Claims Updated 10/1

In Home Health, Hospice, News by Lisa Selman-Holman5 Comments

The 2021 ICD-10-CM codes are to be used for discharges occurring from October 1, 2020 through September 30, 2021 and for patient encounters occurring from October 1, 2020 through September 30, 2021. The updates based on discharge dates apply only to hospitals.
The HIPAA requirement for medical code sets is any date of service after the code effective date. This has been effective since October 2015.

My question to CMS: So if any days 10/1 or later were included in the billing period, the applicable codes would need to change on the claim. Since the diagnoses on the RAP no longer have to match the diagnoses on the claim, then the diagnoses on the RAP could be the 2020 codes and diagnoses on the claim could be the 2021 codes. Do I have that right for the transition?
Answer from CMS:  Yes

What does that mean for home health?

Let's use the change to N18.3 effective on 10/1 as an example. It gets an extra digit on October 1.
We have a billing period that runs 9/4 to 10/4, the RAP will include the N18.3 for CKD stage 3. If we try to update the RAP to the new code, the RAP will not process. At claim time, the N18.3 will no longer process and will have to be changed to N18.30 (or other depending on the provider's documentation).
Is the change based on Start of Episode (SOE)? No
Is the change based on start of billing period? No
Is the change based on EOE or end of billing period? No
Is the change based on M0090? No

This transition is a lot of work. Codes that will change that are likely to be on a home health claim:
* This code will still be valid but will need to change to M80.0Ax-

First, I would run a list of patients with the code to see which claims will need the update. Second, run a report or develop a spreadsheet to include claim dates.

When it is claim date time, change the code. Refer to DDE or software instructions on how to change the code on the claim.

What does that mean for hospice?

Just like home health, the transition to the 2021 codes occurs with dates of service October 1 or later. Unlike home health, hospice coders/billers do not have to worry about RAPs. If a monthly or benefit period claim includes any dates of October 1 or later, the new codes will need to be placed on that claim. The most common changes for home health (above) also apply to hospice.

If you need assistance with this transition, do not hesitate to contact Selman-Holman & Associates!

Lisa Selman-Holman, JD, BSN, RN
President | Selman-Holman, A Briggs Healthcare Company


  1. Lisa. So when billing occurs at 30 day mark under PDGM, this 30 day claim would need to include the updated code? Or is it only on the final claim once the patient has been discharged?

  2. We are getting initial claims rejected because the dx codes do not match the RAP. SOC done in late sept 2020, claim sent in october 2020. We use kinnser and it will not allow us to input or change dx codes manually. What could we be doing wrong?

    1. Author

      The codes on the RAP do not have to match the codes on the claim. If any dates of service are 10/1 or later then the new code set must be used on the claim. Wellsky does have a workaround in the code edit.

  3. If a billing period ends on 10/1 but there was no visit completed on 10/1 , do we still use the new code? I think CMS’ terminology “patient encounter” confuses me. Thank you.

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