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Medicare Return to Provider (RTP) Claims

One of the many challenges that an agency will face is billing. Submitting clean claims is the result of knowledgeable billing staff and efficient processes. When a home health or hospice Medicare claim is submitted for payment, the claim must pass through a series of edits before making it to the payment floor. Before a claim is paid, it is reviewed by the Fiscal Intermediary Standard System (FISS). A Return to Provider (RTP) reason code is assigned to the claim. This reason code lets the agency know the problem with the claim and allows a knowledgeable biller to review and resubmit the claim. Reducing RTPs is your agency’s goal. This will happen when you understand the primary reasons that cause RTP’s, seek out the available resources for follow-up and discuss the multiple ways RTP’s affect your agency.


Top RTP Codes


When reviewing RTP claims, it is important to know what is and is not under your control as an agency. These may include service gaps or misinformation from a patient or referral source. This will allow you to focus your energy on the issues that you can manage. It’s also important to understand the features that are available with your agency’s electronic medical record (EMR) or electronic health record (EHR). Don’t assume you have the correct settings or appropriate features that will prevent RTPs from occurring. If you are unsure about the capabilities of your EMR/EHR software and need help communicating with your vendor, contact a billing consultant like Stromile & Associates.


Some of the top RTPs include:


Home Health


· 37253 No OASIS assessment found

· U538I Overlapping episode of another HHA

· 38200 Duplicate Claim

· U5387 The patient status code is "30" and the through date does not equal the episode end date on file.

· C7010 No condition code 07 to indicate services unrelated to hospice election


Hospice


· 37402 Hospice sequential billing error

· 38200 Duplicate claim

· U5106 NOE falls within current hospice election

· U5181 Occurrence code 27 required when certification date falls within dates of service

· 34952 Service facility NPI not included

· U523A The dates of service on this claim are during both a Hospice election period and Medicare Advantage Plan Period that is Value-Based Insurance Design (VBID) Model. No resolution is required by providers. Refer to the U523A Reason Code Search and Resolution information for details.

· 39929 The hospice claim was rejected due to an untimely Notice of Election (NOE)

· U5194 Hospice claim received for untimely NOE & occurrence span code 77 is missing or invalid

· 31605 The dates of services on the claim cannot be within the span code 77 dates unless the charges are non-covered

· 31503 The total units on the level of care lines (0651, 0652, 0655, 0656) do not equal the number of days in the billing period.


Resources


All home health and hospice agencies submit Medicare claims to a Medicare Administrative Contractor (MAC). The federal government has contracted with these companies to service specific regions of the country. Review your MAC’s website for a list of top RTP codes that are currently generated by home health and hospice agencies contracted with your MAC. CMS.gov has a wealth of information available to you including Medicare Claims Processing Manual – Chapter 10. The staff at Stromile & Associates, LLC are always willing to be a resource for any billing questions that you may have.


RTP’s and Your Agency


There are some key things to remember when discussing the importance of an RTP review with your team. First, acceptance rates outside of the norm for agencies of similar size may send a red flag to your MAC. To understand where your agency’s acceptance rate compares with other agencies, contact knowledgeable billers like the staff at Stromile & Associates. Second, review operational processes with billing personnel who have intimate knowledge of Medicare billing and the proper steps in following up on home health or hospice Medicare claims. Third, document any process improvement plans that have resulted from reviewing your RTPs and include them in your agency’s OIG Compliance Program.


Take charge of your billing by conducting a comprehensive review of your RTPs. Look at the current processes in your agency and determine if changes are needed to prevent an RTP. Use the resources available to you to gain the knowledge needed to be a subject matter expert in RTPs. Make sure your entire staff is aware of their role in ensuring clean claims at your agency.

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