The Situation Report | April 17, 2023
The U.S. Centers for Medicare and Medicaid Services (CMS) has implemented some new Medicare Home Health (HH) Grouper edits that began on April 1, 2023. The HH Grouper program has various data validity edits that make sure it uses consistent and accurate data when calculating payment groups on Medicare HH claims.
With this implementation, CMS finalized the reassignment of 155 additional ICD-10-CM diagnosis codes from their current assigned clinical group to ‘NA’ when the codes are listed as a principal diagnosis. CMS reminds Certified Home Health Agencies (CHHAs) that if a claim cannot be assigned a clinical group (NA), the claim will be returned to the provider (RTPd) for correction. The CY 2023 Final Home Health Clinical Group and Comorbidity Adjustment Diagnosis List provides the clinical grouping of HH diagnosis codes, and all codes identified as NA cannot be used as a principal diagnosis on a HH claim.
These new Grouper edits apply to Types of Bill 032X (except 032A, 032D, and 0320). With this process, National Government Services (NGS), the Medicare Administrative Contractor for home health may return some claims to CHHAs with one of the following messages:
- Unacceptable primary diagnosis, not reportable as primary
- Manifestation code not reportable as primary diagnosis
- Unspecified diagnosis code not acceptable as primary diagnosis
- External cause of injury code not reportable as primary diagnosis
- Primary diagnosis code is not valid for claim dates or is blank
HCA CHHA members can find additional information here.