CMS To Begin Matching OASIS With Claims

Starting April 1, 2015, Medicare systems will compare the Health Insurance Prospective Payment System (HIPPS) code on a Medicare home health claim to the HIPPS code generated by the corresponding Outcomes and Assessment Information Set (OASIS) assessment before the claim is paid. If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated HIPPS code for payment.

The transmission of assessment data and the submission of claims was an entirely separately process previously. The Fiscal Intermediary Shared System (FISS), which processes all original Medicare home health claims, did not have access to the quality data repository. As a result, FISS could not validate the submitted HIPPS code against the associate OASIS assessment.

For several years, CMS planned to create a file exchange interface with the national quality data repository to provide the infrastructure needed to validate HIPPS codes against OASIS assessments. In 2014, MACs successfully began testing the home health OASIS and claim matching process.

Home health agencies are not required to make any changes to their billing systems.

Claims will be suspended temporarily during processing to allow for the file exchange between FISS and QIES. The claims will be suspended with FISS reason code 37071 in status/locations SMFRX0-SMFRX4 and will occur during the 14 day payment floor period. It should not delay payments to agencies.

If no corresponding OASIS assessment is found, the claim will process normally. CMS expects this will change in the near future.

Click here for more information from CMS.

Click here to read more from NAHC.


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