(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 10 - Home Health Agency Billing   Table of Contents  (Rev. 12306, 10- 19-23)    Transmittals for Chapter 10  10 - General Guidelines for Processing Home Health Agency (HHA) Claims  10.1 -  Home Health Prospective Payment System (HHPPS)  10.1.1 -  Creation of HH PPS and Subsequent Refinements  10.1.2 -  Reserved  10.1.3 -  RESERVED  10.1.4 -  The HH PPS Unit of Payment               10.1.5 -  Number, Duration, and Claims Submission of HH PPS                                   Periods   of Care  10.1.5.1 -  More Than One Agency Furnished Home Health Services  10.1.5.2 -  Effect of Election of Medicare Advantage (MA) Organization and Eligibility Changes  10.1.6 -  RESERVED   10.1.7 -  Basis of Medicare Prospective Payment Systems and Case- Mix 10.1.8 -  Coding of HH PPS Case -Mix Groups on HH PPS Claims:                    HHRGs and HIPPS Codes  10.1.9 -  Composition of HIPPS Codes for HH PPS  10.1.10 -  Provider Billing Process Under HH PPS  10.1.10.1 -  Grouper Links Assessment and Payment  10.1.10.2 -  RESERVED  10.1.10.3 -  Submission of the Notice of Admission (NOA)  10.1.10.4 -  Claim Submission and Processing 10.1.11 -  Payment, Claim Adjustments and Cancellations  10.1.12 -  RESERVED  10.1.13 -  Transfer Situation -  Payment Effects  10.1.14 -  Discharge and Readmission Situation Under HH PPS -  Payment Effects  10.1.15 -  Payment Adjustments -  Partial Period Payment Adjustment  10.1.16 -  Payment When Death Occurs During an HH PPS Period  10.1.17 -  Payment Adjustments -   - Low Utilization Payment Adjustments (LUPAs)  10.1.18 -  RESERVED                         10.1.19 -  Payment Adjustments  Applying OASIS Assessment Items to Determine HIPPS Codes  10.1.20 -  RESERVED  10.1.21 -  Payment Adjustments  - Outlier Payments  10.1.22 -  RESERVED   10.1.23 -  Changes in a Beneficiarys Payment Source  10.1.24 -  Glossary and Acronym List  20 - Home Health Prospective Payment System (HH PPS) Consolidated Billing 20.1 -  Beneficiary Notification and Payment Liability Under Home Health Consolidated Billing  20.1.1 -  Responsibilities of Home Health Agencies  20.1.2 -  Responsibilities of Providers/Suppliers of Services Subject to Consolidated Billing  20.1.3 -  Responsibilities of Hospitals Discharging Medicare Beneficiaries to Home Health Care  20.2 -  Home Health Consolidated Billing Edits in Medicare Systems  20.2.1 -  Nonroutine Supply Editing  20.2.2 -  Therapy Editing 20.2.3 -  Other Editing Related to Home Health Consolidated Billing  20.2.4 -  Only Notice of Admission (NOA) Received and Services Fall Within Admission Period   20.2.5 -  No NOA Received and Therapy Services Rendered in the Home   30 - Common Working File (CWF) Requirements for the Home Health Prospective Payment System (HH PPS)  30.1 -  Eligibility Query to Determine Status  30.2 -  CWF Response to Inquiry  30.3 -  Timeliness and Limitations of CWF Responses  30.4 -  Provider/Supplier Inquiries to MACs Based on Eligibility Responses  30.5 -  National Home Health Prospective Payment Episode History File  30.6 -  Opening and Length of HH PPS Periods of Care  30.7 -  RESERVED              30.8-  RESERVED              30.9 -  Coordination of HH PPS Claims With Inpatient Claim Types   30.10 -  RESERVED             30.11 -  Exhibit: Chart Summarizing the Effects of NOA/Claim Actions on the HH PPS Episode File   40 - Completion of Form CMS -1450 for Home Health Agency Billing 40.1 -  Notice of Admission (NOA)  40.2 -  HH PPS Claims  40.3 -  HH PPS Claims When No RAP is Submitted -  No -RAP LUPAs  40.4 -  Collection of Deductible and Coinsurance from Patient  40.5 -  RESERVED  50 - Beneficiary -Driven Demand Billing Under HH PPS  60 - No Payment Billing  70 - HH PPS Pricer Program  70.1 -  General  70.2 -  Input/Output Record Layout  70.3 -  RESERVED  70.4 -  Decision Logic Used by the Pricer on Claims  70.5 -  Annual Updates to the HH Pricer  80 - HH Grouper Program   80.1 -  HH Grouper Input/Output Record Layout   80.2 -  HH Grouper Decision Logic and Updates  90 - Medical and Other Health Services Submitted Using Type of Bill 034x 90.1 -  Osteoporosis Injections as HHA Benefit  90.2 -  Billing Instructions for Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  90.3  Billing Instructions for Disposable Negative Pressure Wound Therapy Services  100 -  Temporary Suspension of Home Health Services  110 -  Billing and Payment Procedures Regarding Ownership and CMS Certification Numbers (CCNs)  110.1 -  RESERVED  110.2 -  Payment Procedures for Terminated HHAs  10 - General Guidelines for Processing Home Health Agency (HHA) Claims (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)  This chapter, in general, describes billing and claims processing requirements that are applicable only to home health agencies.  For general bill processing requirements refer to the appropriate other chapters in the Medicare Claims Processing Manual.  For a description of home health coverage policies see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7.   A. Where and How to Bill   Institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare.  In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transactio n, the 837 institutional claim.  The minority of providers that are eligible for an exception to electronic claim submission use the paper Form CMS -1450, also known as the UB -04.  Such claim forms are submitted to certain Medicare Administrative Contractor s (A/B MACs (HHH)) with jurisdiction over home health and hospice claims.  Some home health agencies may also become approved as Durable Medical Equipment (DME) suppliers, in which case they would submit bills for DMEPOS services to the DME MACs on a profe ssional claim format (the 837professional or paper Form CMS -1500).  References to the claim form in this chapter refer to the paper Form CMS -1450 unless otherwise noted.  However, the instructions regarding specific data requirements apply also to the electronic 837 institutional claim.   B. Services to Include on the Claim for Home Health Benefits   Effective for all services provided on or after October 1, 2000, all services under the home health plan of care, except the following, are included in the home health PPS payment amount.  Services that may be included in the plan of care but excluded from  the HH prospective payment system (HH PPS) are:    Osteoporosis drugs (although the cost of administration is within the PPS rate); and   Durable medical equipment, including prosthetics, orthotics, and oxygen   The DMEPOS services may be included on type of bill (TOB) 032x for the home health benefits, and are paid in addition to the PPS payment.  See 20 for additional instructions regarding competitively bid DME.  Osteoporosis drugs must be billed on type of bill 034x.  Other services not under an HH plan of care provided by an HHA are billed using type of bill 034x.  See 90 for guidance as to the payment methodologies used by Medicare to reimburse these services, and see 40.4 in this chapter for information on deductible and coinsurance.   10.1 - Home Health Prospective Payment System (HH PPS)  (Rev. 1, 10- 01-03) HH- 467, A3- 3639  10.1.1 - Creation of HH PPS and Subsequent Refinements  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The HH PPS was initially mandated by law in the Balanced Budget Act of 1997 and legislative requirements were modified in various subsequent laws. Section 1895 of the Social Security Act contains current law regarding HH PPS.   The initial implementation of the HH PPS was effective for dates of service on and after October 1, 2000.  Refinements to the case -mix system of the HH PPS system were for episodes of care beginning on and after January 1, 2008.   Effective for periods of care beginning on and after January 1, 2020, the original HH PPS system was updated to apply the Patient -Driven Grouping Model.  Home health Notices of Admission (NOAs) are required for periods of care beginning on and after January 1, 2022.   The sections that follow describe billing for services on or after January 1, 2022.  10.1.2 - Reserved  (Rev. 1348, Issued: 10- 05-07, Effective: 01 -01-08, Implementation: 11- 05-07)  10.1.3 - Configuration of the HH PPS Environment (Rev. 2230, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)  The configuration of Medicare home health claim processing is similar to previous Medicare claims processing systems.  The flow from the HHA at the start of billing, to the receipt or remittances and electronic funds transfer (EFT) by the agency, to the recording of payment in either billing or accounting systems (bill/acct software) can be envisioned as follows:    CWF  SS/Contractor  Front End  SS/Contractor  Back End  PRICER  PS&R  Grouper  Billing  Software  Bank Bill./ Acct. Software  At HHA  At HHA  At Contractor  At CWF Host  Inquiries  RAP/Cl aim Batches  Inquiries  Claims  EFT Payment  Remittances  Checks  RAPs   Subsystems, also known as drivers or software applications or modules, have been created for HH PPS for Medicare home health claims processing.    Grouper determines HHRGs for claims at HHAs by inputting OASIS data.  (OASIS is the clinical data set that currently must be completed by HHAs for patient assessment.)  OASIS software was updated to integrate the Grouper from the advent of HH PPS, and CMS has made Grouper specifications available on its Web site for those designing their own software.    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)