(Medicare Claims Processing Manual)

When a provider is unable to submit a start of care OASIS for an admission period of care, they should submit the HIPPS code weighted closest to 1.  For a period of continuing care, when a provider is unable to submit a follow -up OASIS, they should carry f orward the last HIPPS code generated from the previous OASIS.    If as a result of disaster conditions, OASIS submission timeframes are relaxed, HHAs should submit claims without condition code DR as soon as the OASIS was submitted.  In this case, matching OASIS assessment information and the occurrence code 50 date are required to ensure Medicare pays the claim accurately.   HHAs that are adjusting previously paid claims enter one of the condition codes representing Claim Change Reasons (code values D0 through E0).  If adjusting the claim to correct a HIPPS code, HHAs use condition code D2 and enter Remarks indicating the reason for the HIPPS code change.  HHAs use D9 if multiple changes are necessary.   When submitting an HH PPS claim as a demand bill, HHAs use condition code 20.  See 50 for more detailed instructions regarding demand billing.   When submitting an HH PPS claim for a denial notice, HHAs use condition code 21.  See 60 for more detailed instructions regarding no- payment billing.   Required -  If canceling the claim (TOB 0328), HHAs report the condition codes D5 or D6 and enter Remarks indicating the reason for cancellation of the claim.   Occurrence Codes and Dates   Required  The HHA enters occurrence code 50 and the date the OASIS assessment corresponding to the period of care was completed (OASIS item M0090).   If occurrence code 50 is not reported on a claim or adjustment, the claim will be returned to the provide r for correction, unless condition code DR is present to indicate a waiver of OASIS reporting is in effect.   On claims for initial periods of care (i.e. when the From and Admission dates match), the HHA reports an inpatient admission that ended within 14 days of the From date by using one of the following codes.   Code  Short Descriptor  Long Descriptor  61 Hospital Discharge Date  The Through date of a hospital stay that ended within 14 days prior to the From date this HHA claim.   62  Other Institutional Discharge Date  The Through date of skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long term care hospital (LTCH) or inpatient psychiatric facility (IPF) stay that ended within 14 days prior to this HHA admission.   On claims for continuing periods of care, the HHA reports an inpatient hospital admission that ended within 14 days of the From date by using occurrence code 61.   To determine the 14 day period, include the From date, then count back using the day before the From date as day 1.   For example, if the From date is January 20th, then January 19th is day 1.  Counting back from January 19th,  the 14 day period is J anuary 6 through January 19.  If an inpatient discharge date falls on any date in that period or on the admission day itself (January 20), it is eligible to be reported on the claim.     If more than one inpatient discharge occurs during the 14 day period, the HHA reports only the most recent applicable discharge date.  Claims reporting more than one of any combination of occurrence codes 61 and 62 will be returned to the provider for correction.   Conditional -  The HHA enters any other NUBC approved code to describe occurrences that apply to the claim.   Occurrence Span Code and Dates   Conditional -  The HHA enters any NUBC approved Occurrence Span code to describe occurrences that apply to the claim.  Reporting of occurrence span code 74 is not required to show the dates of an inpatient admission.  Value Codes and Amounts   Required -  Home health payments must be based upon the site at which the beneficiary is served.  For certain dates of service when required by law, payments may be further adjusted if the site is in a rural CBSA or rural county. For periods of care in which the benef iciarys site of service changes from one CBSA or county to another within the period, HHAs should submit the CBSA code or State and County code corresponding to the site of service at the end of the period.   Provider -submitted codes:   Code  Title  Definition  61 Location Where Service is Furnished (HHA and Hospice)  HHAs report the Core Based Statistical Area (CBSA) number (or rural state code) of the location where the home health or hospice service is delivered.  The HHA reports the number in dollar portion of the form locator right justified to the left of the doll ar/cents delimiter, add two zeros to the cents field if no cents.  85 County Where Service is Rendered  Where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered.   Medicare- applied codes: The following codes are added during processing and may be visible in the A/B MAC (HHH)s online claim history. They are never submitted by the HHA.   Code  Title  Definition  17 Outlier Amount  The amount of any outlier payment returned by the Pricer with this code.  A/B MACs (HHH) always Code  Title  Definition  place condition code 61 on the claim along with this value code.  62 HH Visits - Part A  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3)  of the Social Security Act.  63 HH Visits - Part B  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act.  64 HH Reimbursement - Part A  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act. 65 HH Reimbursement - Part B  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act. QF Late-filed NOA penalty amount  The dollar amount that the claim payment was reduced due to the NOA being filed more than 5 days after the HH From date.  QV Value -based purchasing adjustment amount  The dollar amount of the difference between the HHAs value -based purchasing adjusted payment and the payment amount that would have otherwise been made.   May be a positive or a negative amount.   If information returned from the CWF indicates all visits on the claim are Part A, the shared system must place value codes 62 and 64 on the claim record, showing the total visits and total PPS payment amount as the values, and send the claim to CWF with RIC code V.   If information returned from CWF indicates all visits on the claim are Part B, the shared system must place value codes 63 and 65 on the claim record, showing the total visits and total PPS payment amount as the values, and send the claim to CWF with RIC c ode W.   If information returned from CWF indicates certain visits on the claim are payable from both Part A and Part B, the shared system must place value codes 62, 63, 64, and 65 on the claim record.  The shared system also must populate the values for code 62 an d 63 based on the numbers of visits returned from CWF and prorate the total PPS reimbursement amount based on the numbers of visits to determine the dollars amounts to be associated with value codes 64 and 65.  The shared system will return the claim to CWF wit h RIC code U.   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.  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:    027x  Medical/Surgical Supplies (Also see 062x, an extension of 027x)   Required detail:  With the exception of revenue code 0274 (prosthetic and orthotic devices), only service units and a charge must be reported with this revenue code.  If also reporting revenue code 0623 to separately identify specific wound care supplies, not just supplies for wound care patients, ensure that the charge amounts for revenue code 0623 lines are mutually exclusive from other lines for supply revenue codes reported on the claim.  Report only nonroutine supply items in this revenue code or in 0623.  Revenue code 0274 requires an HCPCS code, the date of service units and a charge amount.   NOTE:  Revenue Codes 0275 through 0278 are not used for Medicare billing on HH PPS claims.  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.  044x  Speech -Language Pathology   Required detail:  One of the speech -language pathology 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. 055x  Skilled Nursing   Required detail:  One of the skilled nursing 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.  056x  Medical Social Services   Required detail:  The medical social services HCPCS code 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.  057x  Home Health Aide (Home Health)   Required detail:  The home health aide HCPCS code 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.   NOTE:  A/B MACs (HHH) will return claims to the provider if revenue codes 058x or 059x are submitted with covered charges on Medicare home health claims.  They also return to the provider if revenue code 0624, investigational devices is reported on HH claims   Revenue Codes for Optional Billing of DME   Billing of DME provided in the period of care is not required on the HH PPS claim.  Home health agencies retain the option to bill these services to their A/B MAC (HHH) processing home health claims or to have the services provided under arrangement with a  supplier that bills these services to the DME MAC.  Agencies that choose to bill DME services on their HH PPS claims must use the revenue codes below.  These services will be paid separately in addition to the HH PPS amount, based on the applicable Medica re fee schedule.  For additional instructions for billing DME services see chapter 20 of this manual.   0274  Prosthetic/Orthotic Devices   Required detail: The applicable HCPCS code for the item, a date of service, a number of service units, and a charge amount. 029x  Durable Medical Equipment (DME) (Other Than Renal)   Required detail:  The applicable HCPCS code for the item, a date of service indicating the purchase date or the beginning date of a monthly rental, a number of service units, and a charge amount.  Monthly rental items should be reported with a separate lin e for each months rental and service units of one.  Revenue code 0294 is used to bill drugs/supplies for the effective use of DME.  060x  Oxygen (Home Health)   Required detail:  The applicable HCPCS code for the item, a date of service, a number of service units, and a charge amount.  Revenue Code for Optional Reporting of Wound Care Supplies   0623  Medical/Surgical Supplies - Extension of 027x