(Medicare Claims Processing Manual)

C. Custodial Care under HH PPS, or Termination of the Benefit during a Period  In certain cases, Medicare allows the use of no payment claims in association with an ABN involving custodial care and termination of a benefit during a period of care.  This does not apply to cases in which a determination is being requested as to the beneficiarys homebound status at the beginning of a period of care; there an ABN must be used assuming a triggering event occurs (i.e., the initiation of c ompletely noncovered care).  However, in cases where the HH plan of care prescribes only custodial care, or if the benefit has terminated during a previous period, and the physician, beneficiary, and provider are all in agreement the benefit has terminated  or does not apply, home health agencies (HHAs) can use:   1. The ABN for notification of the beneficiary, and,   2. A condition code 21 no- payment claim to bill all subsequent services.   70 - HH PPS Pricer Program  (Rev. 1, 10- 01-03) HH- 475.4  70.1 - General  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Home health services billed on TOB 032x are reimbursed based on calculations made by the HH Pricer.  The HH Pricer is a module within Medicare claims processing systems.  The HH Pricer makes all payment calculations applicable under HH PPS, including claim payments for full periods of care, and all payment adjustments, including low utilization payment adjustments (LUPAs), partial period payment adjustments, and outlier payments.  Medicare claims processing systems send an input record to Pricer for all claims with covered visits, and Pricer will return an output record to the shared systems.  The following sections describe the elements of HH PPS claims that are used in the HH PPS Pricer and the logic that is used to make payment determinations.  No part of the Pricer logic is required to be incorporated into an HHAs billing system in order to bill Medicare.  The following is presented for A/B MACs (HHH) and as information for the HHAs, in order to help HHAs understand their HH PPS payments and how they are determined.   70.2 - Input/Output Record Layout  (Rev. 10919, Issued:08- 06-21, Effective:01 -01-22, Implementation: 01- 03-22)  The required data and format for the HH Pricer input/output record for periods of care beginning on or after January 1, 2021 are shown below:    File Position  Format  Title  Description  1-10 X(10)  NPI Input item:  The National Provider Identifier, copied from the claim form.  11-22 X(12)  HIC Input item:  The Health Insurance Claim number of the beneficiary, copied from the claim form.  23-28 X(6)  PROV -NO Input item:  The six -digit CMS certification number, copied from the claim form.  29 X INIT -PAY -QRP -INDICATOR   Input item: A single character to indicate whether payment should be reduced under the Quality Reporting Program.  Medicare systems move this value from field 18 of the provider specific file. Valid values:  0 = Make normal percentage payment  2 = Make final payment reduced by 2%  30-35 9V9(5)   PROV -VBP -ADJ-FAC  Input item: Medicare systems move this information from from field 30 of the provider specific file.   36-45 9(8)V99  PROV -OUTL -PAY- TOT  Input item:  The total amount of outlier payments that have been made to this HHA for periods of care ending during the current calendar year.    46-56 9(9)V99  PROV -PAYMENT -TOTAL  Input item: The total amount of HH PPS payments that have been made to this HHA for periods of care ending during the current calendar year.  57-59 X(3)  TOB  Input item:  The type of bill code, copied from the claim form.  60-64 X(5)  CBSA  Input item:  The core based statistical area (CBSA) code, copied from the value code 61 amount on the claim form.  File Position  Format  Title  Description  65-69 X(5)  COUNTY -CODE  Input item: The FIPS State and County Code copied from the value code 85 amount on the claim form.  70-77 X(8)  SERV -FROM -DATE  Input item:  The statement covers period From date, copied from the claim form.  Date format must be CCYYMMDD.  78-85 X(8)  SERV -THRU DATE  Input item:  The statement covers period through date, copied from the claim form.  Date format must be CCYYMMDD.  86-93 X(8)  ADMIT -DATE  Input item:  The admission date, copied from claim form.  Date format must be CCYYMMDD.  94 X LUPA -SRC -ADM  Input Item:  Medicare systems set this indicator to B when condition code 47 is present on the claim.  The indicator is set to 1 in all other cases.  95 X ADJ-IND Input Item:  Medicare systems set the adjustment indicator to 2 when a LUPA add- on claim is identified as not being the first or only period in a sequence.  The indicator is set to 0 in all other cases.  96 X PEP-IND   Input item: A single Y/N character to indicate if a claim must be paid a partial period payment adjustment. Medicare claims processing systems set a Y if the patient discharge status code of the claim is 06. An N is set in all other cases.  97-101 X(5)  HRG -INPUT -CODE  Input item:  Medicare claims processing systems must copy the HIPPS code from the 0023 revenue code line.   102-104 9(3) HRG -NO-OF - DAYS  Input item:  A number of days calculated by the shared systems for each HIPPS code.  The number is determined by the span of days from and including the first line item service date provided under that HIPPS code to and including the last line item service  date provided under that HIPPS code.  105-110 9(2)V9(4)  HRG -WGTS  Output item:  The weight used by the Pricer to determine the payment amount on the claim.  111-119 9(7)V9(2)  HRG -PAY  Output item:  The payment amount calculated by the Pricer for the HIPPS code.  120-123 X(4)  REVENUE - CODE  Input item:  One of the six home health discipline revenue codes (042x, 043x, 044x, 055x, 056x, 057x).  All six revenue codes must be passed by the Medicare claims processing systems even if the revenue codes are not present on the claim.  File Position  Format  Title  Description  124-126 9(3) REVENUE -QTY -  COV-VISITS  Input item:  A quantity of covered visits corresponding to each of the six revenue codes.  Medicare claims processing systems must count the number of covered visits in each discipline on the claim.  If the revenue codes are not present on the claim, a zer o must be passed with the revenue code.  127-131 9(5) REVENUE -QTY -  OUTLIER -UNITS  Input item: The sum of the units reported on all covered lines corresponding to each of the six revenue codes. Medicare claims processing systems accumulate the number of units in each discipline on the claim, subject to a limit of 32 units per date of ser vice.  If any revenue code is not present on the claim, a zero must be passed with that revenue code.  132-139 9(8) REVENUE -EARLIEST -DATE  Input item:  The earliest line item  date for the corresponding revenue code.  Date format must be CCYYMMDD.  140-148 9(7)V9(2)  REVENUE -DOLL -RATE  Output item:  The dollar rates used by the Pricer to calculate the payment for the visits in each discipline if the claim is paid as a LUPA.   149-157 9(7)V9(2)  REVENUE - COST  Output item:  The dollar amount determined by the Pricer to be the payment for the visits in each discipline if the claim is paid as a LUPA.   158-166 9(7)V9(2)  REVENUE -ADD- ON-VISIT -AMT  Output item:  The add -on amount to be applied to the earliest line item date with the corresponding revenue code.   If revenue code 055x, then this is the national per -visit amount multiplied by 1.8451.  If revenue code 042x, then this is the national per -visit amount multiplied by 1.6700.  If revenue code 043x and the Through date is on or after January 1, 2022, then this is the national per-visit amount multiplied by 1.6700.  If revenue code 044x, then this is the national per -visit amount multiplied by 1.6266.  168-401 Defined above  Additional REVENUE data Five more occurrences of all REVENUE related data defined above.  File Position  Format  Title  Description  402-403 9(2) PAY -RTC  Output item:  A return code set by Pricer to define the payment circumstances of the claim or an error in input data.     Payment return codes:     00 Final payment where no outlier applies  01 Final payment where outlier applies  02 Final payment where outlier applies, but is not payable due to limitation.  03 Not used.  04 Not used.  05 Not used.  06 LUPA payment only     07 Not used.     08 Not used.     09 Final payment, partial period payment     11 Final payment, partial period payment with outlier     12 Not used.     13 Not used.     14  LUPA payment, add -on payment applies     Error return codes:     10 Invalid TOB  15 Invalid PEP days  16 Invalid HRG days, greater than 30  20 PEP indicator invalid  25 Med review indicator invalid  30 Invalid CBSA code  31 Invalid/missing County Code  35 Invalid Initial Payment Indicator  40 Dates before January 2020 or invalid  70 Invalid HRG code  75 No HRG present in 1st occurrence  80 Invalid revenue code