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May 14, 2019

CMS Guidance for No Matching OASIS

The Centers for Medicare & Medicaid Services (CMS) recently issued MM11272External PDF, which includes guidance for home health agencies (HHAs) in cases where a claim is sent to the Return to Provider (RTP) file with reason code 37071 because there is no corresponding OASIS assessment found.  In such cases, the HHA may correct any error in the OASIS or claim information to ensure a match and then re-submit the claim (F9) from the RTP file. 

No Error – Submit Denial
If there was no error and the HHA determines the claim did not meet the condition of payment, the HHA may bill for denial using the following coding:

  • Type of Bill (TOB) 0320 indicating the expectation of a full denial for the billing period
  • Occurrence span code 77 with span dates matching the From/Through dates of the claim, indicating the HHA’s acknowledgement of liability for the billing period
  • Condition code D2, indicating that the HHA is changing the billing for the Health Insurance Prospective Payment System (HIPPS) code to non-covered. 

Note: Do not use condition code 21 in this case, since it would result in inappropriate beneficiary liability.

Please refer to MM11272External PDF for additional information.

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