Episodic Payment System for Certified Home Health Agencies

Additional Billing Guidance as of July 1, 2012

1. Assessment Dates

In response to provider concerns, the Department has approved changes in the acceptable values for assessment dates reported with Occurrence Code 50 on episodic claims for Certified Home Health Agencies.

An OASIS assessment completion date must be reported with Occurrence Code 50 for all episodic claims which utilize rate codes 4810 through 4917. Code 50 is not required for claims utilizing rate codes 4919 (assessment only) or 4920 (maternity with no OASIS).

Previously, providers were notified that the reported assessment date must be on or before the start date of the episode (the "From" service date) but no more than 60 days prior to the start date. Because Medicare allows a 5-day window for assessments in certain circumstances, agencies were reporting some Medicaid episodes with no assessment in the acceptable date range.

Effective immediately, CHHAs may report assessment dates (Occurrence Code 50) that are up to 5 days after the start date of the Medicaid episode.

In addition, the Department has requested programming changes in the eMedNY billing system that will allow the acceptance of assessment dates up to 65 days prior to the start date of the Medicaid episode. Providers will be notified as soon as this change has been completed.

Both of these changes will be effective for dates of service May 1, 2012, and subsequent. The acceptable date range will apply to Start of Care, Resumption of Care, and Recertification assessments. Discharge assessments should not be used for episodic claims.

Please note that if there is more than one assessment in the acceptable date range, the latest assessment should be used.

If a provider has already submitted a claim with an acceptable assessment date, and this change results in an additional, later acceptable date, the provider is not required to refile the claim.

2. Medical Orders

A question has been raised regarding documentation requirements for Medicaid billing of Interim Claims. In accordance with Department of Health regulations (NYCRR Title 10, Section 763.7), medical orders and nursing diagnoses for a CHHA patient must be "signed by the authorized practitioner within 30 days after admission to the agency, or prior to billing, whichever is sooner."

Please note that submission of an Interim Claim is considered to be Medicaid billing and therefore requires that the agency has obtained signed medical orders.

3. End Date of Partial Episode

Previous instructions indicated that if a patient is discharged, the last day of the episode should be the last day on which a Medicaid-billable service is provided. Providers have expressed concern that when the Discharge Status Code would qualify the episode for a full 60-day payment, but the discharge occurs on a later date than the last Medicaid billable service, they are unable to report the appropriate Discharge Code because the discharge had not yet occurred on the "Through" date of the claim.

To address this issue, providers will be allowed to end a partial episode on the Discharge Date rather than the last billable service date if all of the following criteria are met:

  1. Discharge Date and last Medicaid-eligible service date are not the same.
  2. Episode length is less than 60 days, regardless of whether Discharge Date or last billable service date is used as the end date of the episode.
  3. Discharge Status Code is one of the following: 01, 02, 20, 50, 51.

Providers may rely on these guidelines effective May 1, 2012.

4. Surplus Paid to Other Providers

A question has been raised seeking confirmation that the "surplus" or "spend down" amount that is reported by the CHHA on an episodic claim should include only those amounts which are applicable to services provided by the billing agency.

In some circumstances, amounts paid by the patient to other providers may be used to help satisfy the patient's spend down requirement for a given calendar month. However, these amounts should not be reported on the Medicaid claim submitted by the CHHA.