WellSky Home Health Claim Primary Diagnosis Coding Issue
WellSky has identified a software error for their HHA customers that potentially impacted claims submitted between 9/29/2021 and 10/27/2022. The error resulted in the software using diagnosis information from the end of an episode instead of the beginning of an episode when generating, modifying, or updating a claim for a thirty (30) day period of care. This could have resulted in an incorrect diagnosis code, which can have a variable impact on claims, with no impact on reimbursement for some claims. For others, the incorrect diagnosis code may have resulted in an under or overpayment to your agency.
WellSky issued letters and reports to their HHA customers affected by this issue. Questions pertaining to the information or reports shared by Wellsky should be directed to them.
National Government Services is directing HHAs who have identified claims with overpayments or underpayments due to this issue to file a reopening request (TOB XXQ). Please do not use the direction that was provided in Wellsky’s communications.
Reopening requests are used when a claim correction is discovered and the claim is beyond the timely filing limit (1 calendar year from the "through" date on the claim). Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of NGS. Reopenings (TOB XXQ) cannot be submitted with a hardcopy (paper) UB-04. They must be submitted via electronic format or entered directly via DDE.
| Field Name/Requirement | Description |
|---|---|
| TOB (FISS Page 1) | 32Q – home health reopening Once the claim being reopened is selected, you must change the third digit of the TOB field to 'Q' to identify the adjustment claim as a reopening request. |
| COND CODES (FISS Page 1) | Enter the appropriate condition code. R2 – Inaccurate date entry R4 – Computer errors R7 – Correction other than clerical error |
| COND CODES (FISS Page 1) | Enter condition code: D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes |
| COND CODES (FISS Page 1) | Enter "W2" (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process. A reopening request cannot be submitted if an appeal has been requested and a decision is pending or in process. |
| REMARKS (FISS page 4) | Remarks are always helpful in processing a reopening; however, the REMARKS field is required when the R2 or R3 Adjustment Reason Code is submitted. Note: The first 15 characters of the remark must match exactly as shown below. Underline indicates a space. Good_Cause-_C-A TO CORRECT WELLSKY DIAGNOSIS CODING ERROR |
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10.11
- MLN Matters® SE1426: Scenarios and Coding Instructions for Submitting Requests to Reopen Claims that are Beyond the Claim Filing Timeframes – Companion Information to MM8581: Automation of the Request for Reopening Claims Process
Posted 11/28/2023