Home Health

Guidance for MACs expected to address payment error

CMS recently published a new change request to provide Medicare Administrative Contractors (MACs) with guidance on new LUPA add-on amounts for occupational therapy visits under new regulations in the home health final rule. The change request also addresses system issues with the payment grouper process.

With the start of PDGM in 2020, all home health claims are expected to be matched to their associated OASIS data during processing to determine the HIPPS code used for payment. CMS notes that MACs have reported intermittent failures in the claims/OASIS matching process.

“Similarly, on all home health claims, the home health grouper program must calculate the HIPPS code used for payment,” the change request notes. “MACs have reported intermittent cases where home health claims bypass the home health grouper and have paid using the provider-submitted HIPPS code.”

The new guidance for the MACs, effective Jan. 3, 2022, will require the contractors to monitor for certain system errors around these issues.

Read the MLN Matters release, MM12315, at https://www.cms.gov/files/document/mm12315-low-utilization-payment-adjustment-lupa-add-amounts-home-health-hh-occupational-therapy.pdf.