Reason Code U538F

Description
For dates of service with a “from” date after January 1, 2022: For dates of service with a “from” date after January 1, 2022, a home health claim overlaps a home health admission or HH period (episode) for the same or different provider number. Please review the dates of service for input errors or the patient’s eligibility for overlapping home health admissions and if applicable, correct dates of service and resubmit.  If there is an overlap of HH admissions, please contact that HHA for resolution.

For dates of service with a “from” date prior to January 1, 2022: A Request for Anticipated Payment (RAP) or final claim overlaps an existing period/episode with the same provider number and the "from" date equals the period/episode start date or a visit date on a final claim falls within another period/episode established by another home health agency (HHA) or the billing HHA.

HHAs receive this error most often when they submit a second RAP for an episode where the final claim for the same period/episode was previously submitted and rejected (FISS status/location (S/LOC) R B9997). Example: An HHA submits a RAP and final claim for a period/episode from 06/25/YY to 07/23/YY. The final claim rejects to S/LOC R B9997. The HHA submits a second RAP for 06/25/YY – 06/25/YY, which is sent to RTP (T B9997) with reason code U538F.

Billing errors for this reason code may also occur when a home health agency submits a final claim and it contains a visit date (line item date of service — LIDOS) that overlaps another HHA's period/episode or the billing provider's subsequent period/episode. Example: ABC Home Care submits a final claim for period/episode 04/21/YY – 05/19/YY, which contains a LIDOS for 05/08/YY; however, XYZ Home Care has already established a period/episode from 04/30/YY to 05/29/YY, which is posted to Common Working File (CWF) for the beneficiary. ABC Home Care's final claim is sent to RTP with reason code U538F because their 05/08/YY visit falls within XYZ Home Care's 04/30/YY – 05/28/YY period/episode.

HHAs may also receive this error when they submit a final claim with dates of service that overlap two separate periods/episodes established by the HHA. This occurs when HHAs submit multiple RAPs during the same 30-day period or 60-day episode, which creates multiple periods/episodes for the beneficiary on CWF.

Resolution
For dates of service with a “from” date after January 1, 2022: Please review the dates of service for input errors or the patient’s eligibility for overlapping home health admissions and if applicable, correct dates of service and resubmit. If another home health agency (HHA) has an admission that overlaps your HHA’s dates of service, please contact that HHA for resolution.  

If two HHAs submit NOAs in the same 30-day period, the earliest admission will be truncated to the date of the second admission. If the HHA that opened the earlier admission submits a period claim that has a “through” date that overlaps the second HHA’s admission date, the claim will return with U538F. 

If the HHA that billed the later admission cancels their NOA/admission, the truncated period will not automatically reset to 30 days. The earlier admitting HHA will have to cancel (32D TOB) and resubmit their NOA to reset the period to 30 days if their claim “through” date goes past the truncated period end date. CMS has planned a system improvement for implementation in the January 1, 2023, system release to have the truncated period auto reset to 30 days if the later NOA/admission is canceled.

This does not affect sequential billing periods after the admission period. If an HHA cancels an NOA that caused a sequential period claim to return for another HHA, the HHA would just return the claim for processing.

For dates of service with a “from” date prior to January 1, 2022: Submit only one RAP and final claim for each period/episode of care. If the final claim for the period/episode rejects, do not submit a second RAP. The final claim will need to be adjusted or resubmitted. Prior to admission or submitting RAPs/claims to Medicare, check the beneficiary's eligibility file to review established home health periods/episodes, which may impact your dates of service.

If another HHA's episode overlaps your dates of service and you are disputing their period/episode, you must follow the instructions for resolving a transfer dispute prior to contacting Palmetto GBA for assistance. If another HHA's episode overlaps your dates of service and there is no dispute regarding the dates of service, remove the overlapping dates from your claim.

The only time HHAs should submit a second RAP during a period/episode that they have established is when the beneficiary is discharged due to meeting the goals of the plan of care and is readmitted to the agency during that same 30-day period or 60-day episode. More information on this topic is available in the Medicare Claims Processing, Manual Publication 100-04, Chapter 10 (PDF), Section 10.1.5, 10.1.14 and 30.9).