The implementation of PDGM has brought about major changes in the reimbursement structure, primarily the shift from 60-day billing periods to 30-day billing periods. The pressure is certainly on as the billing process will now be completed twice as often (every 30 days). Obtaining the required documentation in a timely manner is essential for maintaining a consistent cash flow.
If the pressure of becoming familiar with the changes of PDGM is just not enough, there is the additional inconvenience of making sure the new patient MBI number is correct on both the clinical side for the OASIS and on the financial side for the final claims. While timely submission of the OASIS is a key factor in the reimbursement process, accuracy of the OASIS plays a crucial role as well. Not only does the clinical information determine reimbursement, but the demographic information on the patient and the episode must match the information on the claims before payments can be made. Having to make corrections on the OASIS can cause significant delays in receiving payments since the OASIS will need to be reopened, corrected and exported again before the claim can be updated for payment.
Aside from an invalid patient ID number, the most common claim code error results from an incorrect episode start date or first visit date required on the claims. It is important to keep in mind that the Start of Care episode’s RAP should always contain a matching admission date, from date, and first billable visit (0023 revenue line) date. This error typically occurs when there is a change in the scheduled visit date (clinician or patient had to change it), but the new visit date was not updated to carry over to the OASIS. This must be fixed by reopening the OASIS, updating with the corrected visit date and exporting again. Once those steps are complete, the claim can be updated with the corrected dates.
The 0023 revenue line date on the RAP must also match the first billable visit date and corresponding line found on the final claim. If the first billable date needs to be corrected, this could result in a RAP being submitted with the incorrect visit date resulting in a delay of payment for the final. In that case, the biller must cancel the RAP once it has paid. Once the cancel is complete, the RAP must be resubmitted as a new claim with the corrected visit dates. Once the corrected RAP has paid and matches the final, the biller can have the final claim updated for payment (F9 in the DDE system).
All of these delays, corrections, and resubmissions are problematic enough on a 60-day basis. Now we face the potential for twice as many of these issues under PDGM. Taking a moment at the front end to ensure that dates and ID numbers are correct for the billing periods will save a lot of time and work now that the workload has already increased without a comparable increase to reimbursement. Clinical and clerical staff must be working in sync to succeed.
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