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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 providers must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that a case-mix methodology adjusts the 30-day payment rate based on characteristics of the 
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other 
factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from 
home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information 
Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into 
their case-mix groups. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
Benefit Policy Manual, Chapter 7, Section 10.2. 
 
The rules say that Home Health Resource Groups (HHRGs) and HIPPS Codes, Under the home health 
prospective payment system as refined by the Patient- Driven Groupings Model, a case-mix adjusted payment 
for a 30-day period of care is made using one of 432 HHRGs. On Medicare claims, these HHRGs are 
represented as Health Insurance Prospective Payment System (HIPPS) codes. HIPPS code rates represent 
specific characteristics (or case-mix) on which Medicare payment determinations are made. You can find this 
rule in the Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual Chapter 10, 
Section 10.1.8. 
 
The rules say that Required - On the 0023 revenue code line, the HHA may submit the HIPPS code they expect 
will be used for payment if they choose to run grouping software at their site for internal accounting purposes. 
If not, they may submit any valid HIPPS code in order to meet this requirement. HHAs enter only one HIPPS code per claim in all cases. Claims submitted with additional HIPPS codes will be 
returned to the provider. 
Medicare will determine the appropriate HIPPS code for payment based on claims and OASIS data and will 
replace the provider-submitted HIPPS code as necessary. If the HIPPS code further changes based on medical 
review or other processes, the code used for payment is recorded in the APC-HIPPS field of the electronic 
claim record. 
For revenue code lines other than 0023, the HHA reports HCPCS codes as appropriate to that revenue code. 
 
The rules also say that 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. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, 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.