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Payment for Home Health to Be Contingent on OASIS Starting in April

December 1, 2016:

Effective April 1, 2017, Medicare payers will deny payment for home health claims lacking an Outcome and Assessment Information Set (OASIS). Although the assessment is a condition for payment under the Code of Federal Regulations, Medicare has been lax in enforcing the requirement, and payers currently take no action on claims submitted without the OASIS.

Reporting regulations stipulate that an OASIS must be transmitted to payers within 30 days of being completed for the beneficiary. This means that the OASIS would have to be submitted by the time a 60-day episode of care for home health services has ended. Come April 1, if the OASIS is in the Quality Information Evaluation System (QIES) when the payer receives the final claim for an HH episode of care and the receipt date is more than 40 days after the OASIS was completed (Medicare is allowing an extra 10 days in its initial implementation of the edit), the Medicare payer will deny the claim. The resulting remittance message will contain group code CO and claim adjustment reason code 272.

Home health agencies use OASIS to collect and report performance data on outcomes and processes. The assessment, which must be performed for all adult patients covered by Medicare or Medicaid, has been a requirement of Medicare certification for home health agencies since 1999. The data are used to generate quality reports that help direct home health improvement. CMS has posted a subset of this information on the Medicare.gov website since 2003 called “Home Health Compare.” This report puts outcome measures of various home health agencies side by side to compare how well they help patients regain and maintain function.

Note that the final rule for the home health prospective payment system for 2017 details four of the measures included in OASIS:

  • Discharge to community (Post Acute Care Home Health Quality Reporting Program)
  • Drug regimen review conducted with follow-up on identified issues (Post Acute Care Home Health Quality Reporting Program)
  • Measure of 30-day post-discharge readmissions that could have been prevented (Home Health Quality Reporting Program)
  • Ulcer measure that calculates the percentage of residents or patients with new ulcers or ulcers that have gotten worse


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