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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The Medicare guidelines say "The following data elements are required to submit a claim under home 
health PPS. For billing of home health claims not under an HH plan of care (not under HH PPS), see 
90. Home health services under a plan of care are paid based on a 30- day period of care. HHAs submit 
an NOA at the beginning of an admission and then submit one claim for each 30-day period of care. 
Claims submitted before an NOA has been received for the beneficiary will be returned to the provider. 
Revenue Code and Revenue Description Required. 
 
HH PPS claims must report a 0023 revenue code line which contains a HIPPS code. HHAs enter only one 0023 
revenue code per claim in all cases. Claims must also report all services provided to the beneficiary within the 
period of care. All services must be billed on one claim for the entire period. The A/B MAC (HHH) will return 
to the provider TOB 0329 when submitted without any visit charges. For revenue code lines other than 0023, 
the HHA reports HCPCS codes as appropriate to that revenue code. 
To report HH visits, the HHA reports one of the following HCPCS codes to represent a visit by each HH care 
discipline: Physical Therapy (revenue code 042x) G0151 Services performed by a qualified physical therapist 
in the home health or hospice setting, each 15 minutes. G0157 Services performed by a qualified physical 
therapist assistant in the home health or hospice setting, each 15 minutes. G0159 Services performed by a 
qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective 
physical therapy maintenance program, each 15 minutes. G2168 Services performed by a physical therapist 
assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance 
program, each 15 minutes. Occupational Therapy (revenue code 043x) G0152 Services performed by a 
qualified occupational therapist in the home health or hospice setting, each 15 minutes. G0158 Services 
performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 
minutes. G0160 Services performed by a qualified occupational therapist, in the home health setting, in the 
establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. 
G2169 Services performed by an occupational therapist assistant in the home health setting in the delivery of a 
safe and effective occupational therapy maintenance program, each 15 minutes. Speech-Language Pathology 
(revenue code 044x) G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. G0161 Services performed by a qualified speech-language pathologist, in 
the home health setting, in the establishment or delivery of a safe and effective speech-language pathology 
maintenance program, each 15 minutes. Note that modifiers indicating services delivered under a therapy plan 
of care (modifiers GN, GO or GP) are not required on HH PPS claims. 
Skilled Nursing (revenue code 055x) General skilled nursing: 
G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting 
G0300 Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting. 
Care plan oversight: 
G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 
15 minutes (the patients underlying condition or complication requires an RN to ensure that essential non-
skilled care achieves its purpose in the home health or hospice setting). 
G0493 Skilled services of a registered nurse (RN) for the observation and assessment of the patients condition, 
each 15 minutes (the change in the patients condition requires skilled nursing personnel to identify and 
evaluate the patients need for possible modification of treatment in the home health or hospice setting). 
G0494 Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patients 
condition, each 15 minutes (the change in the patients condition requires skilled nursing personnel to identify 
and evaluate the patients need for possible modification of treatment in the home health or hospice setting). 
Training: 
G0495 Skilled services of a registered nurse (RN), in the training and/or education of a patient or family 
member, in the home health or hospice setting, each 15 minutes.  
G0496 Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient 
or family member, in the home health or hospice setting, each 15 minutes. 
Medical Social Services (revenue code 056x) 
G0155 Services of a clinical social worker under a home health plan of care, each 15 minutes. Home Health 
Aide (revenue code 057x) 
G0156 Services of a home health aide under a home health plan of care, each 15 minutes. Regarding all skilled 
nursing and skilled therapy visits. 
In the course of a single visit, a nurse or qualified therapist may provide more than one of the nursing or 
therapy services reflected in the codes above. HHAs must not report more than one G-code for each visit 
regardless of the variety of services provided during the visit. In cases where more than one nursing or therapy 
service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician 
spent most of his/her time. 
For instance, if direct skilled nursing services are provided, and the nurse also provides training/education of a 
patient or family member during that same visit, Medicare would expect the HHA to report the G-code which 
reflects the service for which most of the time was spent during that visit. Similarly, if a qualified therapist is 
performing a therapy service and also establishes a maintenance program during the same visit, the HHA 
should report the G-code that reflects the service for which most of the time was spent during that visit. In all 
cases, however, the number of 15-minute increments reported for the visit should reflect the total time of the 
visit. 
HHAs must report where home health services were provided. The following codes are used for this reporting: 
Q5001: Hospice or home health care provided in patients home/residence Q5002: Hospice or home health care 
provided in assisted living facility Q5009: Hospice or home health care provided in place not otherwise 
specified 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes as described above, HHAs must report an 
additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, 
Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were 
provided changes during the period of care, the new location should be reported with an additional line 
corresponding to the first visit provided in the new location. You can find this guidance in the Medicare Claims 
Processing Manual Chapter 10 - Home Health Agency Billing, 40.2 -HH PPS Claims. 
 
The Medicare guidelines say "The A/B MACs (A) must provide a listing of the required data elements, including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the 
distinction between submissions which are not considered claims, but which are returned to provider (RTP) and 
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted 
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected 
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected 
and resubmitted." You can find this guidance in the Medicare Claims Processing Manual Chapter 1 - General 
Billing Requirements Section 70.2.3.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.