DAL-Modifications to the NYS Grouper Due Changes in the OASIS-E Tool

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March 10, 2023

Dear Administrator:

RE:   Modifications to NYS Medicaid Grouper for Certified Home Health Agencies Due
         to Changes to the Federal Outcome & Assessment Information Set-E (OASIS-E) Tool

Beginning January 1, 2023 the Federal OASIS-E tool that collects data for skilled Medicare and Medicaid patients, 18 years and older, was updated by CMS, which caused a disconnect between many of the claims billings systems and the current NYS Medicaid Episodic Payment System (EPS) “Grouper” scoring.

With OASIS-E becoming effective January 1, 2023, certain codes no longer exist and have been replaced with new codes. These new codes and two existing codes have been removed from the Recertification (Recert) and Other Follow-Up forms but they do exist on the Start of Care (SOC) and Resumption of Care (ROC) forms. As a result, the Medicaid grouper is no longer aligned to accurately calculate the patient’s clinical score which is used to determine the proper rate to bill.

In order to facilitate functional billing logic, the Medicaid grouper mapping will remain consistent. If the patient is being recertified, once the Recert OASIS-E is finalized, the billing system should refer to the patient’s latest ROC OASIS and pull all of the missing information from it. If there is no ROC OASIS, then the system should refer to the patient’s latest SOC OASIS (see attachment A for a detailed summary of changes). If there is no ROC or SOC OASIS due to the patient’s recent transition into the current electronic medical record (EMR)/billing system from a legacy EMR/billing system, then the missing information from the legacy system’s most recent ROC or SOC OASIS should be manually obtained and entered into the current system.

In light of the time required by providers and billing agents to update their systems and conduct necessary testing, the 90-day timely filing deadline has been waived through April 2023 date of service claims. Providers using this waiver should complete all claiming by May 31, 2023 (1 month after the conclusion of the waiver) using delay reason code 3.

It is important to note that this waiver does not include any adjustment to the rates for pediatric patients, who continue to be reimbursed on a historical fee-for-service per unit basis in accordance with Part 86-1.13 and who are not assessed with the OASIS-E tool. The list of applicable rate codes is attached (Attachment B). Please email any questions to the email address: CHHA-Rates@health.ny.gov.

Sincerely,

Laura Rosenthal, Director
Bureau of Nursing Home and Long Term Care Rate Setting
Division of Finance and Rate Setting
Office of Health Insurance Programs

Cc:  Amanda Pyskadlo, Deputy Division Director, DMDD
       Thomas Heckert, Pended Claims Unit, DMDD
       Tammy Jessup, Pended Claims Unit, DMDD

OASIS - E Changes - Codes Impacted
Code Replacements
Code Replaced with a New Code in OASIS-C1 Replacement Code in OASIS-E
M1020 Yes M1021
M1022 Yes M1023
Code Changes
Code Code Exists in Start of Care Code Exists in Resumption of Care Code Exists in Recertification (Follow-Up) Code Exist in Other (Follow-Up)
M1021 Yes Yes No No
M1023 Yes Yes No No
M1610 Yes Yes No No
M1620 Yes Yes No No
Impact of Code Changes
Code Correct EPS Rate Code Generated/Billed for Start of Care and Resumption of Care OASIS Correct EPS Rate Code Generated/Billed for Recertification (Follow-Up) and "Other Follow-up" OASIS
M1021 Yes No
M1023 Yes No
M1610 Yes No
M1620 Yes No

A log of changes since the last update between the OASIS forms is available on CMS's web page at: OASIS Data Sets | CMS

Certified Home Health Agencies - New York State Medicaid - Episodic Payment System Rate Codes - Effective May 1, 2012
Rate Code Rate Code Description
4810 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 1
4811 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 2
4812 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 3
4813 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 4
4814 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 5
4815 EPS START OF CARE, CLIN A, FUNC E, AGE GRP 6
4816 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 1
4817 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 2
4818 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 3
4819 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 4
4820 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 5
4821 EPS START OF CARE, CLIN A, FUNC F, AGE GRP 6
4822 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 1
4823 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 2
4824 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 3
4825 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 4
4826 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 5
4827 EPS START OF CARE, CLIN A, FUNC G, AGE GRP 6
4828 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 1
4829 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 2
4830 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 3
4831 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 4
4832 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 5
4833 EPS START OF CARE, CLIN B, FUNC E, AGE GRP 6
4834 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 1
4835 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 2
4836 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 3
4837 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 4
4838 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 5
4839 EPS START OF CARE, CLIN B, FUNC F, AGE GRP 6
4840 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 1
4841 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 2
4842 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 3
4843 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 4
4844 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 5
4845 EPS START OF CARE, CLIN B, FUNC G, AGE GRP 6
4846 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 1
4847 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 2
4848 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 3
4849 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 4
4850 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 5
4851 EPS START OF CARE, CLIN C, FUNC E, AGE GRP 6
4852 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 1
4853 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 2
4854 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 3
4855 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 4
4856 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 5
4857 EPS START OF CARE, CLIN C, FUNC F, AGE GRP 6
4858 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 1
4859 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 2
4860 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 3
4861 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 4
4862 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 5
4863 EPS START OF CARE, CLIN C, FUNC G, AGE GRP 6
4864 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 1
4865 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 2
4866 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 3
4867 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 4
4868 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 5
4869 EPS RECERTIFICATION, CLIN A, FUNC E, AGE GRP 6
4870 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 1
4871 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 2
4872 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 3
4873 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 4
4874 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 5
4875 EPS RECERTIFICATION, CLIN A, FUNC F, AGE GRP 6
4876 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 1
4877 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 2
4878 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 3
4879 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 4
4880 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 5
4881 EPS RECERTIFICATION, CLIN A, FUNC G, AGE GRP 6
4882 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 1
4883 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 2
4884 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 3
4885 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 4
4886 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 5
4887 EPS RECERTIFICATION, CLIN B, FUNC E, AGE GRP 6
4888 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 1
4889 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 2
4890 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 3
4891 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 4
4892 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 5
4893 EPS RECERTIFICATION, CLIN B, FUNC F, AGE GRP 6
4894 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 1
4895 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 2
4896 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 3
4897 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 4
4898 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 5
4899 EPS RECERTIFICATION, CLIN B, FUNC G, AGE GRP 6
4900 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 1
4901 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 2
4902 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 3
4903 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 4
4904 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 5
4905 EPS RECERTIFICATION, CLIN C, FUNC E, AGE GRP 6
4906 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 1
4907 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 2
4908 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 3
4909 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 4
4910 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 5
4911 EPS RECERTIFICATION, CLIN C, FUNC F, AGE GRP 6
4912 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 1
4913 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 2
4914 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 3
4915 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 4
4916 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 5
4917 EPS RECERTIFICATION, CLIN C, FUNC G, AGE GRP 6
4919 ASSESSMENT VISIT WITH NO OASIS - LUPA ONLY
4920 EPS MATERNITY, NO OASIS, 18 AND OLDER