(Medicare Claims Processing Manual)

20.1.2 - Responsibilities of Providers/Suppliers of Services Subject to Consolidated Billing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Since Medicare payment for services subject to home health consolidated billing is made to the primary HHA, providers or suppliers of these services must be aware that separate Medicare payment will not be made to them.  Therefore, before they provide services to a Medicare beneficiary, these providers or suppliers need to determine whether or not a home health period of care exists for that beneficiary.  This information may be available to providers or suppliers from a number of sources.  The first avenue a therapy provider or a supplier may pursue is to ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.  Beneficiaries and their representatives s hould have the most complete information as to whether or not they are receiving home health care.  Therapy providers or suppliers may, but are not required to, document information from the beneficiary that states the beneficiary is not receiving home hea lth care, but such documentation in itself does not shift liability to either the beneficiary or Medicare.   Additionally, information about current home health periods of care may be available from MACs.  Institutional providers may access this information electronically through the home health CWF inquiry process (See 30.1).  Independent therapists or suppliers who bill using the professional claim format also have access to a similar electronic inquiry via the HIPAA Eligibility Transaction System (HETS).  They may also, as a last resort, call their A/B MAC (B)s provider t oll free line to request home health eligibility information available on the Common Working File.  The A/B MAC (B)s information is based only on claims Medicare has received from home health agencies at the day of the contact.   Medicare systems maintain a data file that captures and displays the dates when Medicare paid physicians for the certification or recertification of the beneficiarys HH plan of care.  Physicians submit claims for these services to A/B MACs (B) on the prof essional claim format separate from the HHAs billing their claim on the institutional claim format for the HH services themselves.     There may be instances in which the physician claim for the certification service is received before any HHA billing and this claim is the earliest indication Medicare systems have that HH services will be provided.  As an aid to suppliers and providers subject to HH consolidated billing, Medicare systems display, for each Medicare beneficiary, the code for certification (G0180) or recertification (G0179) and the date of service for either of the two codes.   Suppliers and providers should note that this information is supplementary to the previously existing sources of information about HH periods of care.  Like HH period of care information maintained on CWF, certification information is only as complete and timely as billing by providers allows.  For many periods of care, a physician certification claim may never be billed.  As a result, the beneficiary and their caregivers remain the first and best source of information about the beneficiarys home health status.  If a therapy provider or a supplier learns of a home health period of care from any of these sources, or if they believe they dont have reliable information, they should advise the beneficiary that if the beneficiary decides not to have the services provi ded by the primary HHA and the beneficiary is in an HH period, the beneficiary will be liable for payment for the services.  Beneficiaries should be notified of their potential liability before the services are provided.   If a therapy provider or a supplier learns of a home health period of care and has sufficient information to contact the primary HHA, they may inquire about the possibility of making a payment arrangement for the service with the primary HHA.  Such contact s may foster relationships between therapy providers, suppliers and HHAs that are beneficial both to providers involved and to Medicare beneficiaries.   20.1.3 - Responsibilities of Hospitals Discharging Medicare Beneficiaries to Home Health Care  (Rev. 635, Issued:  08- 05-05; Effective:  10 -01-00; Implementation: 11 -03-05)  A hospital discharging a Medicare beneficiary to home health care can also play an important role in alerting the beneficiary to their potential liability under home health consolidated billing.  Under the Medicare Conditions of Participation (COP) for Hospitals: Discharge planning, (42 CFR, 482.43 (b) (3) and (6)), hospitals must have in effect a discharge planning process that applies to all patients, and the discharge planning evaluation must include an evaluation of the likelihood of a patient needing post -hospital services and of the availability of the services.  The hospital must include the discharge planning evaluation in the patients medical record for use in establishing an appropriate discharge plan and the hospital must discuss the results of the evaluation with the patient or individual acting on his or her behalf.  In addition, under 42 CFR, 482.43 (c) (5), the patient and family members must be counseled to prepare them for post -hospital care and under 42 CFR, 482.43 (d) Transfer or referr al, the hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for followup or ancillary care.   Hospitals, therefore, should counsel beneficiaries being discharged to receive home health services, that his/her primary home health agency; i.e., the agency establishing his/her plan of care, will provide all home health services.  Hospitals should provide a list of home health agencies for beneficiaries to choose from; in addition, when referring the beneficiary to his/her chosen home health agency, the hospital should notify the agency and include any counseling notes, which should serve as a reminder  to the home health agency to also notify the beneficiary that all home health services will be provided by them as the primary home health agency.  Hospitals play a key role in making beneficiaries, and/or their caregivers, aware of Medicare home health coverage policies to help ensure that those services are provided appropriately.   20.2 - Home health Consolidated Billing Edits in Medicare Systems  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  In short, consolidated billing requires that only the primary HHA bill services under the home health benefit, with the exception of DME and therapy services provided by physicians, for the period of that period of care.  The types of service most affected are nonroutine supplies and outpatient therapies, since these services are routinely billed by providers other than HHAs, or are delivered by HHAs outside of plans of care.   Home health consolidated billing edits are applied when the period of care claim has been received and processed in CWF.  Edits are applied differently depending on whether the HH patient was discharged/transferred at the end of the HH period or not.   If the patient was discharged or transferred, the edits apply to dates of service between the period start date and the last billable service date for the period.  The start date and last service date are excluded.   If the patient is not discharged or transferred (patient status 30, Still Patient), the edits apply to dates of service between the period start date and the period end date.  The start date is excluded but the end date is included.   If any line item services subject to consolidated billing are identified within these dates, CWF sends information to the contractors that enables them to reject or deny those line items.   Claims subject to consolidated billing may be identified in one of two ways.  Claims may be edited when the HH PPS claim had been received before the claim for services subject to consolidated billing.  In these cases, the line items subject to consolidate d billing are rejected or denied prior to payment.  Claims may also be identified when the HH PPS claim is received after the other claims subject to consolidated billing.  In these cases, the claim for services subject to consolidated billing has already been paid.  CWF then notifies the contractor to make a post -payment rejection or denial.   For post -payment rejections of claims billed on institutional claims, recoveries will be made automatically in the claims process.  For post- payment rejections of claims billed on professional claims, those contractors will follow their routine overpayment  identification and recovery procedures.  In the event a denial is reversed upon appeal, an override procedure exists to permit payment to be made.   The contractor shall use the following remittance advice messages and associated codes when not paying outlier amounts under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.   Group Code: CO  CARC: 97  RARC: N390  MSN: N/A  Since home health consolidated billing is not an ABN situation, coding on incoming claims cannot allow Medicare systems to fully identify the payment liability for any denial.  As described in 20.1, whether the denial is the liability of the primary HHA o r the beneficiary is determined by whether the services are provided under arrangement and whether the beneficiary received notice of their potential liability.  These denials are shown as provider liability on remittance advices (group code CO) to ensure therapy providers or suppliers explore whether a payment arrangement exists or can be made for the services.  Despite this coding limitation, Medicare recognizes that ultimately beneficiaries may be liable for these services.   20.2.1 - Nonroutine Supply Editing  (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)  For home health consolidated billing, nonroutine medical supplies are identified as a list of discrete items by HCPCS code.  Supplies are billed to DME MACs using the professional claim format, in which line items have both a from and to date.  The line item from date is used to enforce consolidated billing of nonrouti ne medical supplies.   Claims submitted by providers using the institutional claim format may include a nonroutine supply HCPCS code in addition to the other services provided.  These supplies are either bundled into the rate paid for the primary service or are otherwise inciden t to the primary service(s) being rendered, therefore these supplies do not fall within the bundling provisions of HH PPS.  As a result, supplies reported on institutional claims are not subject to consolidated billing edits by CWF.   20.2.2 - Therapy Editing (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x.  These revenue codes are subject to cons olidated billing when submitted on types of bill 013x, 023x, 034x, 074x, 075x or 085x.  Consolidated billing edits do not apply on TOB 034x when the HHA is billing for disposable negative pressure wound therapy services during an HH period of care.   On claims submitted by practitioners using the professional claim format, CWF enforces consolidated billing for outpatient therapies using a list of HCPCS codes which represent therapy services.   Therapy services on professional claims are not subject to the home health consolidated billing methodology when performed by a physician.  Therefore, CWF bypasses the therapy edit if the HCPCS code is a therapy code subject to home health consolidated billing but the specialty code on the claim indicates a physician.   The following specialty codes indicate a physician for purposes of this edit:   Code   Physician Specialty  01  General Practice  02  General Surgery  03  Allergy/Immunology  04  Otolaryngology  05  Anesthesiology  06  Cardiology  07  Dermatology  08  Family Practice  09  Interventional Pain Management  10  Gastroenterology  11  Internal Medicine  12  Osteopathic Manipulative Therapy  13  Neurology  14  Neurosurgery  16  Obstetrics/Gynecology  18  Ophthalmology  19  Oral Surgery (dentists only)  20  Orthopedic Surgery  22  Pathology  24  Plastic and Reconstructive Surgery  25  Physical Medicine and Rehabilitation  26  Psychiatry  28  Colorectal Surgery (formerly proctology)  29  Pulmonary Disease  Code   Physician Specialty  30  Diagnostic Radiology  33  Thoracic Surgery  34  Urology  35  Chiropractic  36  Nuclear Medicine  37  Pediatric Medicine  38  Geriatric Medicine  39  Nephrology  40  Hand Surgery  41  Optometry  44  Infectious Disease  46  Endocrinology  48  Podiatry  66  Rheumatology  70 Single or Multispecialty Clinic or Group Practice  72  Pain Management  76  Peripheral Vascular Disease  77  Vascular Surgery  78  Cardiac Surgery  79  Addiction Medicine  81  Critical Care (Intensivists)  82  Hematology  83  Hematology/Oncology  84  Preventive Medicine  85  Maxillofacial Surgery  86  Neuropsychiatry  90  Medical Oncology  91  Surgical Oncology  92  Radiation Oncology  93  Emergency Medicine  94  Interventional Radiology  Code   Physician Specialty  98  Gynecological/Oncology  99  Unknown Physician Specialty