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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 rules say that the following data elements are required to submit a claim under home health prospective 
payment system (PPS). For billing of home health claims not under a home health (HH) plan of care. Home 
health services under a plan of care are paid based on a 30-day period of care. Home health agencies (HHAs) 
submit a Notice of Admission (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 
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. 
Each service must be reported in line item detail. Each service visit (revenue codes 042x, 043x, 044x, 055x, 
056x and 057x) must be reported as a separate line. Any of the following revenue codes may be used: 
042x Physical Therapy Required detail: One of the physical therapy HCPCS codes defined below in the 
instructions for the HCPCS code field, the date of service, service units which represent the number of 15 
minute increments that comprised the visit, and a charge amount. 
043x Occupational Therapy Required detail: One of the occupational therapy HCPCS codes defined below in 
the instructions for the HCPCS code field, the date of service, service units which represent the number of 15 
minute increments that comprised the visit, and a charge amount. 
HCPCS/Accommodation Rates/HIPPS Rate Codes 
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. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.