HH Billing Basics - Michigan

1 1J6: Home Health Billing Basics1493_10132 National Government Services, Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the medicare Program requirements.

2 Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current medicare regulations can be found on the Centers for medicare & Medicaid Services (CMS) Web site at Government Services, Please access the Acronymspage on the Web site to view any acronym used within this Government Services, Provide an explanation of the HH PPS and educate on basic Billing of the RAP and episode claim for HH providers35 National Government Services, HH PPS Billing the HH RAP Billing the HH Claim Claim Variations References and Resources Questions6 National Government Services.

3 Episode A HH episode is a period of up to 60 days in which a HHA provides care for a medicare beneficiary for whom a HH plan of care has been established by the beneficiary s physician Episodes may be shorter than, but cannot exceed 60 days in length If there is a continuing need for HH care, the beneficiary may receive care for an unlimited number of 60-day episodes47 National Government Services, PPS Pays HHAs a predetermined base payment for each 60-day episode of care for each medicare beneficiary Adjusted for health condition and care needs of the beneficiary Adjusted for geographic difference in wages for HHAs across the country Case-mix adjustment Outliers ensure payment for beneficiaries with expensive care needs and unusually high costs8 National Government Services, PPS Case-mix group assigned to a patient s episode also referred to as an HHRG determined by data from the OASIS HHRG reflected on HHA claim as a HIPPS code HH PPS payment made in two installments RAP (initial payment)

4 Episode claim (final payment)59 National Government Services, HIPPS Coding Position 1: Episode Sequence & Therapy Threshold Position 2-4: Clinical, Functional & Service Domains Position 5: Non-Routine Supply1 A F K S10 National Government Services, Position 1 Position 2 Position 3 Position 4 Position 5 Grouping StepClinical DomainFunctional DomainService DomainSupplies ProvidedSupplies Not ProvidedDomain LevelsEarly Episodes (1st & 2nd)10-13 VisitsAHHRG: C1 FHHRG: F1 KHHRG:S1 SSeverity Level: 11 Severity Level: 1= MIN214-19 VisitsBHHRG: C2 GHHRG: F2 LHHRG:S2 TSeverity Level: 22 Severity Level: 2= LOWLate Episodes (3rd & later)30-13 VisitsCHHRG: C3 HHHRG: F3 MHHRG:S3 USeverity Level: 33 Severity Level: 3= MOD414-19 VisitsNHHRG:S4 VSeverity Level: 44 Severity Level: 4= HIGHE arly or Late Episodes520+ VisitsPHHRG:S5 WSeverity Level: 55 Severity Level: 5= MAXXS everity Level: 66 Severity Level: 6611 National Government Services, Sequence Episode Sequencing Early: First or second episode in a sequence of adjacent episodes* Later.

5 Third or later episode in a sequence of adjacent episodes* * Adjacent Episodes are defined as being separated by no more than 60 days between claims12 National Government Services, Thresholds Number of therapy visits projected on the OASIS at the start of the episode is confirmed by therapy visits entered on final episode claim Three Thresholds 6 Visits 14 Visits 20 Visits Claims will be recoded based on actual number of therapy services provided713 National Government Services, Groups Supplies bundled into HH PPS payment Routine supplies: used in small quantities for patients during usual course of home care Non-routine: needed to treat patient s specific illness or injury according to plan of care Non-routine supplies grouped based on if supplies were (or were not) provided and further scaled down into severity levelsNote: A list of non-routine supplies can be found in the Home Health Consolidated Billing Master Code List on the CMS Web site: Government Services, You Grouper software will always output a code that says supplies are provided.

6 Provider will change 5thposition of HIPPS prior to claim submission, if supplies were not Government Services, Billing HHA must bill for all home health services which includes: Nursing and therapy services Routine and non-routine medical supplies HH aide services Medical social services All home health services paid on a cost basis included in PPS rate Payment made to primary HHA regardless of whether or not items or services were furnished by the HHA16 National Government Services, Requests initial split percentage payment for HH PPS episode Initial episode = 60% split (40% for final claim) Subsequent episode = 50% split (50% for final claim)

7 Submitted after receiving physician s verbal orders and after delivering at least one service to the beneficiary Establishes agency as primary HHA Opens new home health episode on CWF917 National Government Services, HealthProspective Payment System: RAP RAP can be submitted when all of the following conditions are met: OASIS completion Physician s verbal orders Plan of care sent to physician First service delivered Submitted on TOB 32218 National Government Services, You The NUBC maintains the coding information for all medical Billing including the UB-04 data elements. The most common valid values used in home health Billing represented in this presentation do not represent an all-inclusive list of codes that may be used when Billing home health RAPs and claims.

8 Visit the NUBC Web site for subscription to the UB-04: Government Services, 's medicare Health Insurance Claim (HIC) NumberTOB Type of Bill 322 NPIN ational Provider Identifier (NPI) NumberPAT. CNTL#Patient Control Number enter the number assigned to the patient s medical/health DATES FROM and TO (Statement Covers Period "From and "Through")INITIAL RAP: Enter the first medicare billable visit in the "From" field. Enter the same date in the "To" field. MMDDYY formatSUBSEQUENT EPISODE RAP: Enter the first date of the newly certified episode in the From field. Enter the same date in the To field. MMDDYY formatLAST, FIRST, MI, ADDR, DOB, SEXP atient s last name, first name, and middle initial (if applicable), full address, date of birth (MMDDYYYY) and sex code (M/F)Required Fields: RAP Claim Page 120 National Government Services, DATEE nter the effective date of admission, which is the first medicare billable visit and the medicare start of care date (MMDDYY).

9 TYPEE nter the appropriate NUBC code for the admission (Source of Admission)CodeDefinition1 Physician Referral2 Clinic Referral3 medicare Advantage Organization (MAO) Referral4 Transfer from Hospital5 Transfer from SNF (Skilled Nursing Facility)6 Transfer from another health care facility9 Information Not AvailableATransfer from CAH (Critical Access Hospital)Required Fields: RAP Claim Page 11121 National Government Services, Fields: RAP Claim Page 1 FieldDescription/NotesSTATP atient Status Enter patient status code 30. No other patient status code is acceptable on the ZIPF acility Zip Code of the provider or subpart (9 digit code).

10 VALUE CODESE nter Value Code 61 with the appropriate Core Based Statistical Area (CBSA) Code. The five-digit CBSA code must be entered with two trailing zeroes. 22 National Government Services, M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 01SC INST CLAIM ENTRY SV:HIC 123456789A TOB 322S/LOC S B0100 OSCAR XX7 XXX UB-FORMNPI XXXXXXXXXXTRANS HOSP PROV PROCESS NEW #: XXXXXXXXTAX#/SUB: 39 XXXXXXX :STMT DATES FROM 021714 TO 021714 DAYS COV N-C CO LTRLAST DAVISON FIRST JOHN MI DOB 12091929 ADDR 1 12345 HOPE LANE 2 LOS ANGELES CA3 45 6 ZIP 92885 SEX MMS ADMIT DATE 021714HR 00 TYPE 9 SRC 5D HM STAT 30 COND CODES 01 02 03 04 05 06 07 08 09 10 OCC CDS/DATE 01 02 03 04 0506 07 08 09 10 SPAN CODES/DATES 01 02 0304 05