Home Health Blogger

PDGM Home Health Billing: Significant Change in Condition (SCIC)

Posted by Melissa Cott on Feb 12, 2020

The home health conditions of participation (CoPs) require that agencies update and revise the current OASIS assessment under the following conditions:

(1) The last 5 days of every 60 days if the patient is to be 're-certified', unless there is a beneficiary-elected transfer,

(2) a significant change in condition,

(3) patient discharge and return to the same HHA during the 60-day episode;

(5) at discharge.(4) within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and

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If, during a 30-day billing episode, a patient experiences a significant deterioration which changes the primary diagnosis, the claim for the FOLLOWING 30-day billing period (assuming the patient will receive another 30-day period of care) will reflect the change in diagnosis, the change in HIPPS code, and ultimately a change in payment.

If the patient has a significant change after admission, providers would not change the claim for the first 30-day period. A follow-up assessment would be completed and submitted before the start of the second 30-day period to reflect the change in the functional level and the second 30-day claim would be grouped into its appropriate case-mix group. Accordingly, two 30-day periods would have two different case-mix groups to reflect any changes in patient condition. The case mix group cannot be adjusted within each 30-day period.

Agencies must be sure to update the assessment completion date on the second 30-day claim if a follow-up assessment changes the case-mix group to ensure the claim can be matched to the follow-up assessment. HHAs can submit a claims adjustment if the assessment is received after the claim has been submitted, if the assessment items would change the payment grouping.

HOW TO MANAGE A PATIENT'S SIGNIFICANT CHANGE IN CONDITION

Complete a Followup OASIS (Type 5) Before the Start of 2nd 30-Day Billing Period

Before the start of the second 30-day billing period, a follow-up assessment (type 5) would be completed and submitted before the start of the second 30-day period to reflect the change in the diagnosis and functional level. The second 30-day claim would be grouped into its appropriate case-mix group accordingly.

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