(Medicare Claims Processing Manual)

If the return code is 05, the claim will be returned to the provider for correction because the principal diagnosis is not assigned to a clinical group.    If the return code is 03, the claim will be returned to the provider for correction because of a diagnosis coding issue that is indicated by the validity flag.   80.2  HH Grouper Decision Logic and Updates  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)  The HH Grouper decision logic, in the form of Java computer software, and related documentation are available to the public on the CMS website at:   www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/HomeHealthPPS/CaseMixGrouperSoftware.html .   The major release of the Home Health Grouper is January 1st each year with changes made as a result of the rulemaking process. There are two other off -cycle updates during the year for new and deleted ICD10 -CM diagnosis codes. These are April 1st and Octob er 1st each year.  Whenever the HH Grouper is updated, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (HHH) about the changes.     90 - Medical and Other Health Services Submitted Using Type of Bill 034x (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  HHAs may submit claims for certain medical and other health services which are paid from the Part B trust fund.  The HHA may receive payment for these services outside of the prospective payment system (see Pub. 100- 02, Medicare Benefit Policy Manual, chap ter 7).   A. Patient Not Under A Home Health Plan Of Care   The HHA submits claims with TOB 034x to bill for certain medical and other health services when there is no home health plan of care.  Specifically the HHA may bill using TOB 034x for the following services.  (There must be a physicians certification on file.):    Surgical dressings, splints, casts, and other devices used for reduction of fractures and dislocations.  (See chapter 20 for billing enteral and parenteral supplies and equipment.)    Rental or purchase of DME.  (See chapter 20 for billing enteral and parenteral supplies and equipment.)    Prosthetic devices.  (See chapter 20 for billing enteral and parenteral supplies and equipment.)    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes.    Outpatient physical therapy services.  (See the Medicare Benefit Policy Manual, chapter 15 and the Medicare Claims Processing Manual, chapter 5.)    Outpatient speech -language pathology services.  (See the Medicare Benefit Policy Manual, chapter 15 and the Medicare Claims Processing Manual, chapter 5.)    Outpatient occupational therapy services.  (See the Medicare Benefit Policy Manual, chapter 15 and the Medicare Claims Processing Manual, chapter 5.)    Diabetes Outpatient Self -Management Training (DSMT).  (See the Medicare Benefit Policy Manual, chapter 15, section 300.5.1)    Bone Mass Measurements.  (See the Medicare Claims Processing Manual, chapter 13, section 140.)    Smoking and Tobacco- Use Cessation Counseling Services.  (See the Medicare Claims Processing Manual, chapter 32, section 12.)   Bills for services not under a home health plan of care should be submitted only after services are delivered.  They should be submitted on a periodic basis, e.g., monthly, without regard to a period of care.  These items are not reimbursed under HH PPS.   B. The Patient is Under a Home Health Plan of Care   If a patient is receiving home health services under a plan of care, the agency may bill for the following services on TOB 034x:    A covered osteoporosis drug,    Pneumococcal pneumonia, influenza virus, and hepatitis B vaccines, and    Disposable negative pressure wound therapy services.   All other services are home health services and should be billed as an HH PPS period of care with Type of Bill 032x.  DME, orthotic, and prosthetics can be billed as a home health service using type of bill 032x or as a medical and other health service using type of bill 034x as appropriate.  Alternately, these services may be provided to HH beneficiaries by a supplier.  Refer to instructions in chapter 20 of this manual for submitting claims under arrangement with suppliers.  C Billing Spanning Two Calendar Years   The agency should not submit a medical and other health services bill paid from the Part B trust fund (TOB 034x only) for an inclusive period beginning in 1 calendar year and extending into the next.  If the agency does not bill on a calendar month basis, it prepares two bills.  The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the new year.  This permits the A/B MAC (HHH) to apply the appropriate  deductible for both years.  HH PPS claims (TOB 032x) may span the calendar year since they represent 30 -day periods of care.   D Billing For Laboratory Services   HHAs may provide laboratory services only if issued a CLIA number and/or having a CLIA certificate of waiver.  HHAs do not report laboratory services, even when on the HH plan of care, to an A/B MAC (A) or (HHH) using an institutional claim format.  These services are always billed to A/B MACs (B) using a professional claim format.  To submit such claims, the HHA must have a CLIA number and a professional billing number.  HHAs should contact the State Survey Agency to obtain a CLIA number.  HHAs should cont act the appropriate MAC to obtain a billing number.  The survey process is used to validate that laboratory services in an HHA facility are being provided in accordance with the CLIA certificate.   90.1 - Osteoporosis Injections as HHA Benefit  (Rev. 10274, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)   A. Billing Requirements   The administration of the drug is included in the charge for the skilled nursing visit billed using TOB 032x.  The cost of the drug is billed using TOB 034x, using revenue code 0636.  These drugs are paid on a reasonable cost basis, using the providers submitted charges to make initial payments, which are subject to annual cost settlement.   Coverage requirements for osteoporosis drugs are found in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 50.4.3.  Coverage requirements for the home health benefit in general are found in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 30.   Drugs that have the ingredient calcitonin are billed using HCPCS code J0630.  HCPCS code J0630 is defined as up to 400 units.  Therefore, the provider must calculate units for the bill as follows:  Units Furnished During Billing Period  Units of Service Entry on Bill  100-400 1 401-800 2 801-1200  3 1201 -1600  4 1601 -2000  5 2001 -2400  6  Drugs that have the ingredient teriparatide may be billed using HCPCS code J3110, if all existing guidelines for coverage under the home health benefit are met.  HCPCS code J3110 is defined as 10 mcg.  Providers should report 1 unit for each 10 mcg dose provided during the billing period.   Drugs that have the ingredient denosumab are billed using HCPCS code J0897, if all existing guidelines for coverage under the home health benefit are met.   HCPCS code J0897 is defined as 1 mg.  Providers should report 1 unit for each 1 mg dose provided during the billing period.  Drugs that have the ingredients romosozumab- aqqg are billed using HCPCS code J3111, if all existing guidelines for coverage under the home health benefit are met. HCPCS code J311 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provide d during the billing period.  Drugs that have the ingredient abaloparatide are billed using HCPCS code J3590 (unclassified biologics), if all existing guidelines for coverage under the home health benefit are met.  As an unclassified code, HCPCS code J3590 does have not a standard definition for units.  Providers should report 1 unit for each 80 mcg dose provided during the billing period.  All other osteoporosis drugs that are FDA approved and are awaiting a HCPCS code must use the miscellaneous code of J3490 until a specific HCPCS code is approved for use.  B. Edits   Medicare system edits require that the date of service on a 034x claim for covered osteoporosis drugs falls within the start and end dates of an existing home health PPS episode.  Once the system ensures the service dates on the 034x claim fall within an H H PPS episode that is open for the beneficiary on CWF, CWF edits to assure that the provider number on the 034x claim matches the provider number on the episode file.  This is to reflect that although the osteoporosis drug is paid separately from the HH PP S episode rate it is included in consolidated billing requirements (see 10.1.25 regarding consolidated billing).  Claims are also edited to assure that if the claim is an HH claim (TOB 034x), the beneficiary is female and that the diagnosis code for post -menopausal osteoporosis is present.   90.2 - Billing Instructions for Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  (Rev. 1, 10- 01-03)  Procedures for billing for pneumococcal pneumonia, influenza virus, and Hepatitis B Vaccines is covered in Chapter18.   90.3  Billing Instructions for Disposable Negative Pressure Wound Therapy Services                                                                                        (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  The instructions in this section apply to disposable negative pressure wound therapy (dNPWT ) services provided during home health periods of care ending before January 1, 2024.  Services provided during periods of care ending on or after January 1, 2024 are billed on Type of Bill 032x.  See section 40.2 for billing instructions.   Effective January 1, 2017, Medicare makes a separate payment amount for a disposable negative pressure wound therapy (NPWT) device for a patient under a home health plan of care.  Payment is equal to the amount of the payment that would otherwise be made under the Outpatient Prospective Payment System (OPPS).  Disposable NPWT services are billed using the following HCPCS codes:     97607 -  Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.    97608 -  Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters.   The HHA reports the HCPCS code with one of three revenue codes, depending on the practitioner that provided the service:    Skilled nurse  0559   Physical therapist  042x   Occupational therapy  043x.  When using revenue codes 042x or 043x, the HHA should not use the therapy plan of care modifiers (GO or GP) for NPWT services.   These HCPCS codes include payment for both performing the service and the disposable NPWT device, which is defined as an integrated system comprised of a nonmanual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy.  Services related to the provision of NPWT using a disposable device that do not encompass the provision of the entire integrated system should be billed per existing HH PPS guidelines.  To avoid duplication of payment, for instances where the sole purpose for an HHA visit is to perform NPWT using a disposable device, Medicare will not pay for a skilled nursing or therapy visit under the HH PPS. Rather, performing NPWT using a disposable device for a patient under a home health plan of care is be separately reimbursed the OPPS amount. In this situation, the HHA bills only under TOB 034x.  This visit is not reported on the HH PPS claim (TOB 032x).