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Home Health Claims: New Grouper Edits

Home Health Claims: New Grouper Edits


On October 6, 2022, the Centers for Medicare & Medicaid Services (CMS) announced new Grouper edits for home health claims edits. Specifically, CMS will identify error conditions, send new informational responses, and reprocess some Notices of Admission (NOAs).

The update is for home health agencies that bill Medicare Administrative Contractors (MACs) for services they provide to Medicare patients. Providers are advised to make sure their billing staff knows about the update.

New edits will identify various error conditions helpful to providers in improving claims accuracy. If the diagnosis coding issues are identified, CMS returns the claim to the provider for correction. These new Grouper edits apply to Types of Bill 032X (except 032A, 032D, and 0320). With this process, we may return some claims to you 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 identified as a code first code with condition present
  • Primary diagnosis code is not valid for claim dates or is blank

Click here to visit the Resources for Medicare Providers webpage to access the Medicare Learning Network (MLN) article.

Additional Info

Related File(s) : MM12924.pdf

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