(Medicare Claims Processing Manual)

 ELGH is an inquiry system in CWF available via A/B MAC (HHH) remote access, through which HHAs and other providers can ascertain if a home health episode has already been opened for a given beneficiary by another HHA, and track episodes of beneficiaries fo r whom they are the primary HHA.  HHAs may also access this information via the HIPAA Eligibility Transaction System or HETS.  Refer to 30.1 and 30.2 for a detailed description.  Pricer software is used to process all HH PPS claims and is integrated into the Medicare claims processing systems.  In addition to pricing HIPPS codes for HHRGs, this software maintains national standard visit rate tables to be used in outlier and LUPA determina tions.  Refer to 70 for a detailed description of the Pricer software.  10.1.3 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.4 - The HH PPS - Unit of Payment  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The 30- day period of care is the unit of payment for HH PPS.  The period of care payment is specific to one individual homebound beneficiary.  It pays all Medicare covered home care that is reasonable and necessary for the patients care, including routine and nonroutine supplies used by that beneficiary during the period of care.  It is the only Medicare form of payment for such services, with the exceptions described in 10.B .  See 40 for details on billing these services.    10.1.5 - Number, Duration, and Claims Submission of HH PPS Periods of Care  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The beneficiary can be covered for an unlimited number of nonoverlapping periods of care.  For periods of care beginning on or after January 1, 2020, the duration of a period is 30 days. Periods of care may be shorter than 30 days.   For example, a period may end earlier than the 30th day in the case of a transfer to another HHA, or a discharge and readmission to the same HHA, and payment is pro- rated for these shortened periods, in which more home care is delivered in the same period.  Claims for periods may be submitted prior to the 30th day if the beneficiary has been discharged and treatment goals have been met, though payment will not be pro- rated unless more home health care is subsequently billed in the same period.   Other claims for overlapping periods may also be submitted prior to the end of that period if the beneficiary has been discharged, dies or is transferred to another HHA.  In transfer cases payment for the period of care will be prorated.   The initial period begins with the first service delivered under that plan of care.  A second subsequent period of continuous care would start on the first day after the initial period was completed.   More than one period for a single beneficiary may be opened by the same or different HHAs for different dates of service.  This will occur particularly if a transfer to another HHA, or discharge and readmission to the same HHA, situation exists.  Refer to 10.1.5.1 below for more information on multiple agencies furnishing home health services.  Allowing multiple periods is intended to assure continuity of care and payment.   10.1.5.1 - More Than One Agency Furnished Home Health Services  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The primary HHA bills for all services furnished by both agencies and keeps all records pertaining to the care and other HHAs serving the same beneficiary.  Nonprimary HHAs can receive payment under arrangement only from the primary HHA for services on the  plan of care where prior arrangement exists.  The primary agencys status as primary is established through the submission, receipt and processing of a Notice of Admission (NOA) for the home health care for the beneficiary.  The secondary agency is paid through the primary agency under mutually agreed upon arrangements between the two agencies existing before the delivery of services for services called for under the plan of care.   Two agencies must never bill as primary for the same beneficiary for the same admission period.  When the Common Working File (CWF) indicates an admission period is open for a beneficiary, the A/B MAC (HHH) returns to the provider the NOA of any other agen cy billing unless the NOA indicates a transfer or discharge and readmission situation exists.   In rare cases, a Medicare beneficiary may receive an organ transplant and the organ donors post -operative services are covered by the Medicare program.  Since the donor is frequently not a Medicare beneficiary, services for the donor are billed using the Medicare beneficiarys Medicare number.  If both the organ recipient and organ donor are receiving post -operative home health services, CWF cannot process HH PPS periods for both patients for the same dates of service.  In this case, the HH claim for the organ recipient is accepted by CWF.  The HH claim for the donor is processed by the A/B MAC (HHH) outside CWF.   10.1.5.2 - Effect of Election of Medicare Advantage (MA) Organization and Eligibility Changes on HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  If a Medicare beneficiary is covered under an MA organization during a period of home care, and subsequently decides to change to Medicare fee- for-service coverage, a new OASIS assessment must be completed, as is required any time the Medicare payment source changes.  With that assessment, an NOA may be sent to Medicare to open an HH PPS period.   If a beneficiary under fee -for-service receiving home care elects an MA organization during an HH PPS period of care, the period will end and be proportionally paid according to its shortened length (a partial period payment adjustment).  The MA organizati on becomes the primary payer upon the MA organization enrollment date.   . 10.1.6 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.7 - Basis of Medicare Prospective Payment Systems and Case -Mix  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21) There are multiple prospective payment systems (PPS) for Medicare for different provider types.  Before 1997, prospective payment was a term specifically applied to inpatient hospital services.  In 1997, with passage of the Balanced Budget Act, prospective  payment systems were mandated for other provider groups/bill types:    Skilled nursing facilities;   Outpatient hospital services;  Home health agencies;   Rehabilitation hospitals; and  Others.   While there are commonalities among these systems, there are also variations in how each system operates and in the payment units for these systems.    Case- mix is an underlying concept in prospective payment.  With the creation of inpatient hospital PPS, the first Medicare PPS, there was a recognition that the differing characteristics of hospitals, such as teaching status or number of beds, contributed to substantial cost differences, but that even more cost impact was linked to the characteristics of the patient populations of the hospitals.  Other Medicare PPS systems, where research is applied to adjust payments for patients requiring more complex or costly care, use this concept of case- mix complexity, meaning that patient characteristics affect the complexity, and therefore, cost of care.  HH PPS considers a patients clinical and functional condition in determining case -mix for home health care.   For individual Medicare inpatient acute care hospital bills, diagnosis related groups (DRGs) are produced by claim information, which includes data elements such as procedure and diagnoses, through Grouper software that reads these pertinent elements on the claim and groups services into appropriate DRGs.  DRGs are then priced by a separate Pricer software module at the A/B MAC (A).  Processing for HH PPS is built on this model, using home health resources groups (HHRGs), instead of DRGs.  In HH PPS, paymen ts are case -mix adjusted using claim information and elements of the patient assessment.   Since 1999, HHAs have been required by Medicare to assess potential patients, and reassess existing patients, incorporating the OASIS (Outcome and Assessment Information Set) tool as part of the assessment process.  The total case -mix adjusted payment is based on elements of the OASIS data set and other information provided on the claim.  Payments made for the period are case -mix adjusted based on Grouper run in Medicare systems.  Pricer software run by the A/B MAC (HHH) processing home health claims perfor ms pricing including wage index adjustment and other factors.  10.1.8 - Coding of HH PPS Case -Mix Groups on HH PPS Claims: HHRGs and HIPPS Codes  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  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.  HIPPS codes are used in association with special revenue codes used on institutional claims submitted to A/B MACs (HHH).  One revenue code  is defined for every Medicare prospective payment system that uses HIPPS codes.  For home health claims, this is revenue code 0023.  HIPPS codes are placed in HCPCS/Accommodation Rates/HIPPS Rate Codes field of the claim.   10.1.9 - Composition of HIPPS Codes for HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  For HH PPS periods of care, the distinct 5- position, alphanumeric home health HIPPS codes are created as follows:   The first position represents a combination of the referral source (community or institutional) and the period timing (early or late).    The second and third positions represent the clinical and functional domains of the HHRG coding system.   The fourth position represents the co- morbidity category that applies to the patient.    The fifth position is a placeholder for future use, required only because the field used to report HIPPS codes requires five positions.  Position #1  Position #2  Position #3  Position #4  Position #5  Source & Timing  Clinical Group  Functional Level  Co-Morbidity  Placeholder  1 - Community Early  A -  MMTA Other  A - Low 1 - None  1 2 - Institutional Early  B -  Neuro Rehab  B - Medium  2 - Low  3 - Community Late  C -   Wounds  C - High  3 - High   4 - Institutional Late  D -    Complex   Nursing Interv.        Using this structure, a second period for a patient with a hospital inpatient stay during the period, in the Wounds group, high functional severity and no co- morbidity would be coded 4CC11. HIPPS codes created using this structure are valid only on claim lines with revenue code 0023.  10.1.10 - Provider Billing Process Under HH PPS  (Rev. 1, 10- 01-03) HH- 467.15, A3- 3639.15  The next four sections describe the basic HH PPS billing process, not including payment adjustments.  Payment adjustment follows in subsequent sections.  10.1.10.1 - Grouper Links Assessment and Payment  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Position #1  Position #2  Position #3  Position #4  Position #5  Source & Timing  Clinical Group  Functional Level  Co-Morbidity  Placeholder   E -  MS Rehab      F   Behavioral Health      G  MMTA Surgical Aftercare      H  MMTA Cardiac & Circulatory      I  MMTA Endocrine      J  MMTA GI/GU      K  MMTA Infectious Disease