(Medicare Claims Processing Manual)

If the NOA that corresponds to a claim was filed late and the HHA is requesting an exception to the late -filing penalty (see section 10.1.10.3), append modifier KX to the HIPPS code reported on the revenue code 0023 line.    Service Date   Required -  For initial periods of care, the HHA reports on the 0023 revenue code line the date of the first covered visit provided during the period.  Claims and provider -submitted adjustments where the Admission Date and From Date match but the 0023 revenue code line date does not also match are returned to the provider.  Contractor -submitted adjustments are excluded from this edit.    For subsequent periods, the HHA reports on the 0023 revenue code the date of the first visit provided during the period, regardless of whether the visit was covered or non-covered.   For other line items detailing all services within the period, the HHA reports service dates as appropriate to that revenue code.  For service visits that begin in 1 calendar day and span into the next calendar day, report one visit using the date the visi t ended as the service date.   When the claim Admission Date matches the Statement Covers From Date, Medicare systems ensure that the Service Date on the 0023 revenue code line also matches these dates.   Service Units   Required -  Transaction standards require the reporting of a number greater than zero as the units on the 0023 revenue code line.  However, Medicare systems will disregard the submitted units in processing the claim.  For line items detailing all services w ithin the period, the HHA reports units of service as appropriate to that revenue code.  Coding detail for each revenue code under HH PPS is defined above under Revenue Codes.  For the revenue codes that represent home health visits (042x, 043x, 044x, 055x, 056x, and 057x), the HHA reports as service units a number of 15 minute increments that comprise the time spent treating the beneficiary.  Time spent completing the OASIS assessment in the home as part of an otherwise covered and billable visit and time spent updating medical records in the home as part of such a visit may also be reported.  Visits of any length are to be reported, rounding the time to the nearest 15- minute increment.  If any visits report over 96 units (over 24 hours) on a single line item, Medicare systems return the claim returned to the provider.   Covered and noncovered increments of the same visit must be reported on separate lines.  This is to ensure that only covered increments are included in the per -unit based calculation of outlier payments.   Telehealth services with HCPCS codes G0320 or G0321 are reported with units of 1.    Total Charges   Required -  The HHA must report zero charges on the 0023 revenue code line (the field must contain zero).   For line items detailing all services within the period of care, the HHA reports charges as appropriate to that revenue code.  Coding detail for each revenue code under HH PPS is defined above under Revenue Codes.  Charges may be reported in dollars and ce nts (i.e., charges are not required to be rounded to dollars and zero cents).  Medicare claims processing systems will not make any payments based upon submitted charge amounts.  Non-covered Charges   Required  The HHA reports the total non- covered charges pertaining to the related revenue code here.  Examples of non- covered charges on HH PPS claims may include:    Visits provided exclusively to perform OASIS assessments   Visits provided exclusively for supervisory or administrative purposes   Therapy visits provided prior to the required re -assessments   Payer Name   Required -  See chapter 25.   Release of Information Certification Indicator   Required -  See chapter 25.   National Provider Identifier  Billing Provider   Required -  The HHA enters their provider identifier.   Insureds Name   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Patients Relationship To Insured   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Insureds Unique Identifier   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Insureds Group Name   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Insureds Group Number   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Treatment Authorization Code   Conditional -  Treatment authorization codes are not required on all claims.  The HHA submits a code in this field only if the period is subject to Pre -Claim Review.  In that case, the required tracking number is submitted in the first position of the field in all submission formats.   Document Control Number (DCN)   Required -  If submitting an adjustment (TOB 0327) to a previously paid HH PPS claim, the HHA enters the control number assigned to the original HH PPS claim here.   Employer Name   Required only if MSP involved.  See Pub. 100- 05, Medicare Secondary Payer Manual.   Principal Diagnosis Code   Required -  The HHA enters the ICD code for the principal diagnosis.  The code must be reported according to Official ICD Guidelines for Coding and Reporting, as required by the HIPAA.  The code must be the full diagnosis code, including all five digits for  ICD -9-CM or all seven digits for ICD -10 CM where applicable.  Where the proper code has fewer than the maximum number of digits, the HHA does not fill it with zeros.   Medicare systems may return claims to the provider when the principal diagnosis code is not sufficient to determine the HHRG assignment under the PDGM.   The ICD code and principle diagnosis used for payment grouping is determined from claim coding rather than the OASIS assessment.  As a result, the claim and OASIS diagnosis codes are not expected to match in all cases.    Typically, the codes will match between the first claim in an admission and the start of care (Reason for Assessment RFA 01) assessment and claims corresponding to recertification (RFA 04) assessments.  Second 30- day claims in any 60- day period will not necessarily match the OASIS assessment.  When diagnosis codes change between one 30- day claim and the next, there is no absolute requirement for the HHA to complete an other follow -up (RFA 05) assessment to ensure that diagnosis coding on the claim matches to the assessment. However, the HHA would be required to complete an other follow -up (RFA 05) assessment when such a change would be considered a major decline or improvement in the patients health status.     Other Diagnosis Codes   Required -  The HHA enters the full diagnosis codes for additional conditions if they coexisted at the time of the establishment of the plan of care.  These codes may not duplicate the principal diagnosis as an additional or secondary diagnosis.   In listing the diagnoses, the HHA places them in order to best reflect the seriousness of the patients condition and to justify the disciplines and services provided in accordance with the Official ICD Guidelines for Coding and Reporting.  The sequence of  codes should follow ICD guidelines for reporting manifestation codes.  Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in ICD guidelines.  The claim and OASIS diagnosis codes may vary as described under Principal Diagnosis.   Diagnosis codes that reflect the patients condition as of the start of a period of care are reflected on the claim for the current period of care.   Diagnosis codes that reflect a change in the patients condition during a period of care should be reflect ed on the claim for the next period.     Attending Provider Name and Identifiers   Required - The HHA enters the name and national provider identifier (NPI) of the attending physician who signed the plan of care.   Other Provider (Individual) Names and Identifiers   Required -  The HHA enters the name and NPI of the physician who certified/re -certified the patients eligibility for home health services.   NOTE:  Both the attending physician and other provider fields should be completed unless the patients designated attending physician is the same as the physician who certified/re -certified the patients eligibility.  When the attending physician is also the certifying/re -certifying physician, only the attending physician is required to be reported.   Remarks   Conditional  If the NOA that corresponds to a claim was filed late and the HHA is requesting an exception to the late -filing penalty (see section 10.1.10.3), enter information supporting the exception category that applied to the NOA.   The HHA shall provide sufficient information in the Remarks section of its claim to  allow the contractor to research the case. If the remarks are not sufficient, Medicare  contractors shall request documentation. Documentation should consist of printouts or  screen images of any Medicare systems screens that contain the information shown  above.   Medicare contractors shall not grant exceptions if:   the HHA can correct the NOA without waiting for Medicare systems actions   the HHA submits a partial NOA to fulfill the timely -filing requirement, or   HHA with multiple provider identifiers submit the identifier of a location that did not actually provide the service   In the great majority of cases, the five day timely filing period allows enough time to  submit NOAs on a day when Medicare systems are available (i.e.  the period allows for  ("dark days"). Additionally, the receipt date is typically applied to the NOA immediately  upon submission to Medicare systems, so subsequent dark days would not affect the  determination of timeliness. However, if the HHA can provide documentation showing an NOA is submitted on the day before a dark day period and the NOA does not receive a  receipt date until the day following the dark days, the contractor shall grant an exception to the timely filing requirement. CMS expects these cases to be very rare.   Remarks are otherwise required only in cases where the claim is cancelled or adjusted.  adjusted.  40.5  RESERVED  (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  50 - Beneficiary -Driven Demand Billing Under HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Demand billing is a procedure through which beneficiaries can request Medicare payment for services that: (1) their HHAs advised them were not medically reasonable and necessary, or that (2) they failed to meet the homebound, intermittent or noncustodial care requirements, and therefore would not be reimbursed if billed.  The HHA must inform the beneficiary of this assessment in an Advance Beneficiary Notice of Noncoverage (ABN), which also must be signed by the beneficiary or appropriate representative.  I nstructions for the ABN are found in chapter 30 of this manual.  Beneficiaries pay out of pocket or third party payers cover the services in question, but HHAs in return, upon request of the beneficiary, are required to bill Medicare for the disputed services.  If, after its review, Medicare decides some or all the disp uted services received on the demand bill are covered and pays for them, the HHA would refund the previously collected funds for these services.  If the Medicare determination upholds the HHAs judgment that the services were not medically reasonable and necessary, or that the beneficiary failed to meet the homebound or intermittent care requirements, the HHA keeps the funds collected, unless the A/B MAC (HHH) determines the ABN notification was not properly executed, or some other factor changed liabilit y for payment of the disputed services back to the HHA.    A. Interval of Billing   The Medicare payment unit for home care under the home health prospective payment system (HH PPS) is a period of care, usually 30 days in length.  A Notice of Admission (NOA) must be submitted for a beneficiary before any claims can be processed.  A claim is submitted for every 30 days of HH services.  This does not change in demand bill situations.   B. Timeliness of Billing   Medicare requests that HHAs submit demand bills promptly.  Timely filing requirements apply to HH PPS claims in the same manner as other claims (see chapter 1 for information on timely filing).  Medicare has defined promptly for HH PPS to mean submission at the end of the period of care in question.  The beneficiary must also be given either a copy of the claim or a written statement of the date the claim was submitted.   C. Claim Requirements