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February 22, 2021

Reason Codes U5391 and 38107: No RAP or No Matching RAP is Found

An issue related to reason codes U5391 and 38107 was added to the Claims Processing Issues Log (CPIL) web page. However, after completing research, the system is editing claims correctly. Please review the following information, which explains the items that need to match on the RAP and the claim and avoid these reason codes.

Matching Items
Prior to submitting the final claim, ensure that the following items match on the RAP and final claim.

Provider number/identifier of the billing home health agency (FL 56)
"FROM" date (FL 6)
Date of admission (FL 12)
First four positions of the Health Insurance Prospective Payment System (HIPPS) code (FL 44)
Date billed with the HIPPS code 0023 revenue code(FL 45)

Change Request 11855 RAP Exception
With the January 1, 2021, implementation of Change Request 11855, Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation, (see MM11855), there may be some confusion with reporting the HIPPS code and the date reported on the revenue code 0023 line on the initial and subsequent RAPs and final claims.

HIPPS Code

RAP (initial and subsequent)	Submit the HHRG from the OASIS, or submit any valid HIPPS code.
Claim (initial and subsequent)	Submit the same HIPPS code that was submitted on the RAP. The Medicare system will process the claim and determine the actual HIPPS code used for payment.

Date Reported on Revenue Code 0023
CR 11855 implemented a new exception that applies when submitting RAPs for all subsequent periods in calendar year 2021. This exception allows for the submission of RAPs for two 30-day periods of care immediately after the start of a 60-day certification period.

Initial RAP:

The 0023 revenue code line date is the first covered visits provided during the 1st 30-day period.

Subsequent RAPs:

If submitted at the same time the initial RAP is submitted (new exception).
- The 0023 revenue code date is the 1st day of the 2nd 30-day period, which would also match the “From” date of the subsequent RAP.
If submitted any time after the initial RAP is submitted.
- The 0023 revenue code date is the 1st day of the 2nd 30-day period, which would also match the “From” date of the subsequent RAP.
If submitted after the first visit is delivered (if visit is made within the 1st 5 days) in the 2nd 30-day period.
- Submit the 0023 revenue code date as the date of the first visit or the date of the 1st day of the 2nd 30-day period.

Regardless of when the RAP is submitted, the 0023 revenue code date submitted on the RAP and the claim, must match.

The following illustrates an initial RAP/claim and subsequent RAP/claim submission.

Initial RAP

Admit	1/5/2021
DOS	1/5/2021 – 1/5/2021
HIPPS	3IA11
0023 line Date	1/5/2021 = First visit

Claim for the 1st 30-day period in a 60-day certification

Admit	1/5/2021
DOS	1/5/2021 – 2/3/2021
HIPPS	3IA11
0023 line Date	1/05/2021

Subsequent RAP for the 2nd 30-day period in a 60-day certification
(Provider chose not to submit 2nd RAP at the same time as the 1st)

Admit	1/5/2021
DOS	2/4/2021 – 2/4/2021
HIPPS	3IA11
First Visit	2/6/2021
RAP Submit Date	2/7/2021
0023 line Date	Either 2/4/2021 or 2/6/2021

Claim for the 2nd 30-day period in a 60-day certification

Admit	1/5/2021
DOS	2/4/2021 – 3/5/2021
HIPPS	3IA11
0023 line Date	Report the same date as submitted on the RAP. Either 2/4/2021 or 2/6/2021

Remember, to avoid the non-timely RAP submission payment reduction, the RAP for each 30-day period of care must be submitted:

Within 5 calendar days from the start of care date for the 1st 30-day period of care in the 60-day certification period; and
Within 5 calendar days of the “from date” for the 2nd 30-day period of care in the 60-day certification period.

For additional information, please refer to the following CGS resources.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Reason Codes U5391 and 38107: No RAP or No Matching RAP is Found

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