PDGM

PDGM, Billing and Occurrence Codes

Under PDGM, claims are the source of most patient information.  Even the ICD-10 diagnosis codes come from the claim and not the OASIS.  The functional score is the only information that will come from the OASIS.  Providers need to make sure their EMRs have the ability to input all the needed information into the billing screens. EMRs also need to have the ability to populate information from other areas to ensure everything is captured for billing.

Occurrence codes 61 and 62 could be added to the claim if the patient has been in an institution within the 14 days prior to the home health admission. CMS states they will automatically add these codes and adjust your payment if needed.  Providers have the option to include these codes on the final claim to help ensure proper payment.

  • Code 61 could be reported but not required on final claims for a hospital admission
  • Code 62 could be reported but not required on final claims for a SNF, IRF, LTCH or IPF admission

On their August MLN call, CMS reviewed another occurrence code that is not optional but required for payment.  It’s occurrence code “50”- Assessment Date.  It is required on all final claims, not on RAPs.  If this code is missing, the claim will not be paid but returned to the provider.

Providers are instructed to use the date in OASIS item M0090 “Date Assessment Completed” for the SOC, ROC, RC or other follow-up OASIS occurring most recently before the claim “from” date.

CMS will use this date to match the OASIS record for payment in the iQIES and will no longer require a treatment authorization code.

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