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February 17, 2020

Reason Code 37253 and the OASIS Assessment

Submission of an Outcome and Assessment Information Set (OASIS) is a condition of payment for home health periods of care.  OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. 

If the OASIS assessment is not found in the Internet Quality Improvement and Evaluation System (iQIES) system when your final claim is submitted, and the receipt date of the claim is more than 40 days after the assessment completion date, Medicare systems will apply reason code 37253 to the claim and it will be sent to the Return to Provider (RTP) file. 

How to Prevent 37253

Before submitting your claim and the OASIS assessment, ensure the following OASIS items are correct. These items are used to match the claim with the OASIS assessment.

  • Home health agency (HHA) Certification Number (OASIS item M0010)
  • Beneficiary Medicare Number (OASIS item M0063)
  • Assessment Completion Date (OASIS item M0090)
  • Reason for Assessment (OASIS Item M0100) equal to 01, 03, or 04

Note: Effective January 1, 2020, all claims must be submitted with the beneficiary's Medicare Beneficiary Identifier (MBI), regardless of the dates of service.  Therefore, it is important to report the MBI on your OASIS.

If Your Claim Is in RTP (Status/Location T B9997)

  • Review the OASIS and claim and correct any errors to ensure they match and then resubmit (F9) the claim out of the RTP file.
    • It is important that you verify that the OASIS was successfully accepted into the iQIES database. The customer service representatives in the Provider Contact Center (PCC) does not have access to this information. If the OASIS was successfully accepted and verified in iQIES and the required data elements match the claim, but you continue to encounter issues, please contact the PCC at 1.877.299.4500 (option 1) for further assistance.
    • If there is no error and it is determined the services did not meet the condition of payment, submit a claim for denial using the following coding elements:
      • Type of bill 0320, which indicates the expectation of a full denial
      • Occurrence Span Code 77 with span dates matching the From/Through dates of the claim to indicate acknowledgement of liability for the billing period.
      • Condition Code D2 indicating the change in billing the HIPPS code to non-covered.
      • Condition Code 20.
      • DO NOT use condition code 21.

For additional information, refer to the following resources.

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