Medicare Claims Processing Manual

1 Medicare Claims Processing Manual chapter 10 - Home Health Agency Billing Table of Contents (Rev. 11502, 07-21-22) Transmittals for chapter 10 10 - General Guidelines for Processing Home Health Agency (HHA) Claims - Home Health Prospective Payment System (HHPPS) - Creation of HH PPS and Subsequent Refinements - Reserved - RESERVED - The HH PPS Unit of Payment - Number, Duration, and Claims Submission of HH PPS Periods of Care - More Than One Agency Furnished Home Health Services - Effect of Election of Medicare Advantage (MA) Organization and Eligibility Changes - RESERVED - Basis of Medicare Prospective Payment Systems and Case-Mix - Coding of HH PPS Case-Mix Groups on HH PPS Claims .

2 HHRGs and HIPPS Codes - Composition of HIPPS Codes for HH PPS - Provider Billing Process Under HH PPS - Grouper Links Assessment and Payment - RESERVED - Submission of the Notice of Admission (NOA) - claim Submission and Processing - Payment, claim Adjustments and Cancellations - RESERVED - Transfer Situation - Payment Effects - Discharge and Readmission Situation Under HH PPS - Payment Effects - Payment Adjustments - Partial Period Payment Adjustment - Payment When Death Occurs During an HH PPS Period - Payment Adjustments - - Low Utilization Payment Adjustments (LUPAs) - RESERVED - Payment Adjustments Applying OASIS Assessment Items to Determine HIPPS Codes - RESERVED - Payment Adjustments - Outlier Payments - RESERVED - Changes in a Beneficiary s Payment Source - Glossary and Acronym List 20 - H ome Health Prospective Payment System (HH PPS)

3 Consolidated Billing - Beneficiary Notification and Payment Liability Under Home Health Consolidated Billing - Responsibilities of Home Health Agencies - Responsibilities of Providers/Suppliers of Services Subject to Consolidated Billing - Responsibilities of Hospitals Discharging Medicare Beneficiaries to Home Health Care - Home Health Consolidated Billing Edits in Medicare Systems - Nonroutine Supply Editing - Therapy Editing - Other Editing Related to Home Health Consolidated Billing - Only Notice of Admission (NOA) Received and Services Fall Within Admission Period - No NOA Received and Therapy Services Rendered in the Home 30 - Common Working File (CWF) Requirements for the Home Health Prospective Payment System (HH PPS)

4 - Eligibility Query to Determine Status - CWF Response to Inquiry - Timeliness and Limitations of CWF Responses - Provider/Supplier Inquiries to MACs Based on Eligibility Responses - National Home Health Prospective Payment Episode History File - Opening and Length of HH PPS Periods of Care - RESERVED RESERVED - Coordination of HH PPS Claims With Inpatient claim Types - RESERVED - Exhibit: Chart Summarizing the Effects of NOA/ claim Actions on the HH PPS Episode File 40 - Completion of Form CMS-1450 for Home Health Agency Billing - Notice of Admission (NOA) - HH PPS Claims - HH PPS Claims When No RAP is Submitted - No-RAP LUPAs - Collection of Deductible and Coinsurance from Patient - RESERVED 50 - Beneficiary-Driven Demand Billing Under HH PPS 60 - No Payment Billing 70 - HH PPS Pricer Program - General - Input/Output Record Layout - RESERVED - Decision Logic Used by the Pricer on Claims - Annual Updates to the HH Pricer 80 - HH Grouper Program - HH Grouper Input/Output Record Layout - HH Grouper Decision Logic and Updates 90 - Medical and Other Health Services Submitted Using Type of Bill 034x - Osteoporosis Injections as HHA Benefit - Billing Instructions for

5 Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines Billing Instructions for Disposable Negative Pressure Wound Therapy Services 100 - Temporary Suspension of Home Health Services 110 - Billing and Payment Procedures Regarding Ownership and CMS Certification Numbers (CCNs) - RESERVED - Payment Procedures for Terminated HHAs 10 - General Guidelines for Processing Home Health Agency (HHA) Claims (Rev. 2977, Issued; 06-20-14, Effective: 09-23-14; ICD-10: Upon Implementation of ICD-10, Implementation: 09-23-14; ICD-10: Upon Implementation of ICD-10) This chapter , in general, describes billing and Claims Processing requirements that are applicable only to home health agencies.

6 For general bill Processing requirements refer to the appropriate other chapters in the Medicare Claims Processing Manual . For a description of home health coverage policies see Pub. 100-02, Medicare Benefit Policy Manual , chapter 7. A. Where and How to Bill Institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare . In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837 institutional claim . The minority of providers that are eligible for an exception to electronic claim submission use the paper Form CMS-1450, also known as the UB-04.

7 Such claim forms are submitted to certain Medicare Administrative Contractors (A/B MACs (HHH)) with jurisdiction over home health and hospice Claims . Some home health agencies may also become approved as Durable Medical Equipment (DME) suppliers, in which case they would submit bills for DMEPOS services to the DME MACs on a professional claim format (the 837professional or paper Form CMS-1500). References to the claim form in this chapter refer to the paper Form CMS-1450 unless otherwise noted. However, the instructions regarding specific data requirements apply also to the electronic 837 institutional claim . B. Services to Include on the claim for Home Health Benefits Effective for all services provided on or after October 1, 2000, all services under the home health plan of care, except the following, are included in the home health PPS payment amount.

8 Services that may be included in the plan of care but excluded from the HH prospective payment system (HH PPS) are: Osteoporosis drugs (although the cost of administration is within the PPS rate); and Durable medical equipment, including prosthetics, orthotics, and oxygen The DMEPOS services may be included on type of bill (TOB) 032x for the home health benefits, and are paid in addition to the PPS payment. See 20 for additional instructions regarding competitively bid DME. Osteoporosis drugs must be billed on type of bill 034x. Other services not under an HH plan of care provided by an HHA are billed using type of bill 034x. See 90 for guidance as to the payment methodologies used by Medicare to reimburse these services, and see in this chapter for information on deductible and coinsurance.

9 - Home Health Prospective Payment System (HH PPS) (Rev. 1, 10-01-03) HH-467, A3-3639 - Creation of HH PPS and Subsequent Refinements (Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21) The HH PPS was initially mandated by law in the Balanced Budget Act of 1997 and legislative requirements were modified in various subsequent laws. Section 1895 of the Social Security Act contains current law regarding HH PPS. The initial implementation of the HH PPS was effective for dates of service on and after October 1, 2000. Refinements to the case-mix system of the HH PPS system were for episodes of care beginning on and after January 1, 2008.

10 Effective for periods of care beginning on and after January 1, 2020, the original HH PPS system was updated to apply the Patient-Driven Grouping Model. Home health Notices of Admission (NOAs) are required for periods of care beginning on and after January 1, 2022. The sections that follow describe billing for services on or after January 1, 2022. - Reserved (Rev. 1348, Issued: 10-05-07, Effective: 01-01-08, Implementation: 11-05-07) - Configuration of the HH PPS Environment (Rev. 2230, Issued: 05-27-11, Effective: 08-28-11, Implementation: 08-28-11) The configuration of Medicare home health claim Processing is similar to previous Medicare Claims Processing systems.