evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
2. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent 60- day recertification and there was a recertification assessment of the patient during days 56- 60 and the patient returns home fr om the inpatient stay on day 61, if the home health resource group (HHRG) remains the same then the 30- day period of care following the inpatient stay would be considered continuous and thus be considered a recertification. However, if the HHRG is different, this would result in a new start of care OASIS and thus be considered a new certification and begins with the new start of care date after inpatient discharge.   3. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent 60- day recertification and there was a recertification assessment of the patient during days 56- 60 and the patient returns home from the inpatient stay after day 61 (after the first day of the next 60- day recertification of care), then a new certification begins with the new start of care date after inpatient discharge.   10.10 - Consolidated Billing                                                                        (Rev. 12382; Issued: 11-28- 23; Effective: 01 -01-24; Implementation:01-02-24)  For individuals under a home health plan of care, payment for all services and supplies, with the exception of certain injectable osteoporosis drugs, DME, and furnishing NPWT using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under  arrangement, and must bill for such covered home health services.  Payment must be made to the HHA.
(Medicare Benefit Policy Manual)
A. Home Health Services Subject to Consolidated Billing Requirements  The home health services included in the consolidated billing governing the HH PPS are:   Part -time or intermittent skilled nursing services;  Part -time or intermittent home health aide services;  Physical therapy;  Speech -language pathology services;  Occupational therapy;  Medical social services;   Routine and nonroutine medical supplies;  Covered osteoporosis drug as defined in 1861(kk) of the Act, but excluding other drugs and biologicals;  Furnishing NPWT using a disposable device as that term is defined in 1834 of the Act, which includes only the device paid separately (specified by the assigned HCPCS code) and does not include payment for the professional services.   Medical services provided by an intern or resident- in-training of the program of the hospital in the case of an HHA that is affiliated or under common control with a hospital with an approved teaching program; and  Home health services defined in 1861(m) of the Act provided under arrangement  at hospitals, SNFs, or rehabilitation centers when they involve equipment too cumbersome to bring to the home or are furnished while the patient is at the  facility to receive such services.   B. Medical Supplies   The law requires that all medical supplies (routine and nonroutine) be provided by the  HHA while the patient is under a home health plan of care. The agency that establishes  the 30- day period is the only entity that can bill and receive payment for medical supplies  during a 30- day period for a patient under a home health plan of care. Both routine and  nonroutine medical supplies are included in the base rates for every Medicare home health patient regardless of whether or not the patient requires medical supplies during the 30- day period  Due to the consolidated billing requirements, CMS provided additional amounts in the  base rates for those nonroutine medical supplies that have a duplicate Part B code that  could have been unbundled to Part B prior to HH PPS. See 50.4 for detailed discussion of medical supplies.   Medical supplies used by the patient, provider, or other practitioners under arrangement  on behalf of the agency (other than physicians) are subject to consolidated billing and bundled into the HHA 30 -day period payment rate. Once a patient is discharged from  home health and not under a home health plan of care, the HHA is not responsible for  medical supplies.
(Medicare Benefit Policy Manual)
DME, including supplies covered as DME, are paid separately from the HH PPS and are  excluded from the consolidated billing requirements governing the HH PPS. The  determining factor is the medical classification of the supply, not the diagnosis of the  patient.   Certain injectable osteoporosis drugs are included in consolidated billing under the home  health benefit. However, payment is not bundled into the HH PPS payment rates. HHAs  must bill for the osteoporosis drug in accordance with billing instructions. Payment is in addition to the HH PPS payment.  Furnishing NPWT using a disposable device is included in consolidated billing under the  home health benefit. However, payment for the device is not bundled into the HH PPS payment rates. HHAs must bill for NPWT using a disposable device in accordance with billing instructions. Payment is in addition to the HH PPS payment.   C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled   The HHA is responsible for the services provided under arrangement on their behalf by other entities. Covered home health services at 1861(m) of the Act (except DME) are included in the baseline HH PPS rates and subject to the consolidated billing require ments while the patient is under a plan of care of the HHA. The time the services are bundled is while the patient is under a home health plan of care.   Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements. The physician would not be acting as a supplier billing the DME Medicare contractor in this situation.
(Medicare Benefit Policy Manual)
Therapies (physical therapy, occupational therapy, and speech -language pathology services) are covered home health services that are included in the baseline rates and subject to the consolidated billing requirements. In addition to therapies that had been paid on a cost basis under home health, CMS has included in the rates additional amounts for Part B therapies that could have been unbundled prior to PPS. These therapies are subject to the consolidated billing requirements. There are revenue center codes  that reflect the ranges of outpatient physical therapy, occupational therapy, and speech language pathology services and Healthcare Common Procedure Coding System (HCPCS) codes that reflect physician supplier codes that are physical therapy, occupational therapy, and speech -language pathology services by code definition and are subject to the consolidated billing requirements. Therefore, the above -mentioned therapies must be provided directly or under arrangement on behalf of the HHA while a patient is under a home health plan of care and cannot be separately billed to Part B during an open 30- day period of care.   D. Freedom of Choice Issues   A beneficiary exercises his or her freedom of choice for the services under the home health benefit listed in 1861(m) of the Act, including medical supplies, but excluding DME covered as a home health service by choosing the HHA. Once a home health patient chooses a particular HHA, he or she has clearly exercised freedom of choice with respect to all items and services included within the scope of the Medicare home health benefit (except DME). The HHA's consolidated billing role supersedes all other billin g situations the beneficiary may wish to establish for home health services covered under the scope of the Medicare home health benefit during the certified episode.   E. Knowledge of Services Arranged for on Behalf of the HHA
(Medicare Benefit Policy Manual)
E. Knowledge of Services Arranged for on Behalf of the HHA   The consolidated billing requirements governing HH PPS requires that the HHA provide all covered home health services (except DME) either directly or under arrangement while a patient is under a home health plan of care. Providing services either directly or under arrangement requires knowledge of the services provided during the 30- day period. In addition, in accordance with current Medicare conditions of participation and Medicare coverage guidelines governing home health, the patient's plan of care must reflect the physician or allowed practitioner ordered services that the HHA provides either directly or under arrangement. An HHA would not be responsible for payment in the situation in which they have no prior knowledge (unaware of physician or allowed practitioner orders) of the services provided by an entity during a 30-day period to a patient who is under their home health plan of care. An HHA is responsible for payment in the situation in which services are provided to a patient by another entity, under arrangement with the HHA, during a 30-day period in which the patient is under the HHA's home health plan of care. However, it is in the best interest of future business relationships to discuss the situation with any entity that seeks payment from the HHA during a 30-day period in an effort to resolve any misunderstanding and avoid such situations in the future   10.11 - Change of Ownership Relationship to Periods Under HH PPS  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   A.  Change of Ownership With Assignment   When there is a change of ownership and the new owner accepts assignment of the existing provider agreement, the new owner is subject to all the terms and conditions under which the existing agreement was issued.  The provider number remains the same if the new HHA owner accepts assignment of the existing provider agreement.  As long as the new owner complies with the regulations governing home health PPS, billing, and payment for 30-day periods with applicable adjustments for existing patients under an established plan of care will continue on schedule through the change in ownership with assignment.  The 30-day period would be uninterrupted spanning the date of sale.  The former owner is required to file a terminating cost report. Instructions regarding when a cost report is filed are in the Provider Reimbursement Manual, Part 1, 1500.  B.  Change of Ownership Without Assignment
(Medicare Benefit Policy Manual)
When there is a change of ownership, and the new owner does not take the assignment of the existing provider agreement, the provider agreement and provider number of the former owner is terminated.  The former owner will receive partial payment adjusted payments in accordance with the methodology set forth in the Medicare Claims Processing Manual, Chapter 10, "Home Health Agency Billing," 40.2, and 42 CFR 484.235, based on the last billable visit date for existing patients under a home health plan of care ending on or before the date of sale. The former owner is required to file a terminating cost report.  The new owner cannot bill Medicare for payment until the effective date of the Medicare approval.  The new HHA will not be able to participate in the Medicare program without going through the same process as any new provider, which includes an initial survey.  Once the new owner is Medicare-approved, the HHA may start a new 30 -day period for purposes of payment, OASIS assessment, and certification of the home health plan of care for all new patients in accordance with the regulations governing home health PPS, effective with the date of the new provider certifica tion.  C.  Change of Ownership - Mergers   The merger of a provider corporation into another corporation constitutes a change of ownership. For information on specific procedures, refer to Pub. 100-07, State Operations Manual, chapter 2, section 2202.17.  10.12 - Change of Ownership Relationship to Episodes Under PPS  (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)  A.  Change of Ownership With Assignment   When there is a change of ownership and the new owner accepts assignment of the existing provider agreement, the new owner is subject to all the terms and conditions under which the existing agreement was issued.  The provider number remains the same if the new HHA owner accepts assignment of the existing provider agreement.  As long as the new owner complies with the regulations governing home health PPS, billing, and payment for episodes with applicable adjustments for existing patients under an establish ed plan of care will continue on schedule through the change in ownership with assignment.  The episode would be uninterrupted spanning the date of sale.  The former owner is required to file a terminating cost report. Instructions regarding when a cost report is filed are in the Provider Reimbursement Manual, Part 1, 1500.  B.  Change of Ownership Without Assignment
(Medicare Benefit Policy Manual)
B.  Change of Ownership Without Assignment   When there is a change of ownership, and the new owner does not take the assignment of the existing provider agreement, the provider agreement and provider number of the former owner is terminated.  The former owner will receive partial episode payment adjusted payments in accordance with the methodology set forth in the Medicare Claims Processing Manual, Chapter 10, "Home Health Agency Billing," 40.2, and 42 CFR 484.235, based on the last billable visit date for existing patients under a home health plan of care ending on or before the date of sale. The former owner is required to file a terminating cost report.  The new owner cannot bill Medicare for payment until the effective date of the Medicare approval.  The new HHA will not be able to participate in the Medicare program without going through the same process as any new provider, which includes an initial survey.  Once the new owner is Medicare-approved, the HHA may start a new episode for purposes of payment, OASIS assessment, and certification of the home health plan of care for all new patients in accordance with the regulations governing home health PPS, effective with the date of the new provider certification.  C.  Change of Ownership - Mergers   The merger of a provider corporation into another corporation constitutes a change of ownership. For information on specific procedures, refer to Pub. 100-07, State Operations Manual, chapter 2, section 2202.17.  20 - Conditions To Be Met for Coverage of Home Health Services  (Rev. 1, 10-01-03) A3-3116, HHA-203  Medicare covers HHA services when the following criteria are met:   1. The person to whom the services are provided is an eligible Medicare beneficiary;  2. The HHA that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program;   3. The beneficiary qualifies for coverage of home health services as described in 30;  4. The services for which payment is claimed are covered as described in 40 and 50;  5. Medicare is the appropriate payer; and   6. The services for which payment is claimed are not otherwise excluded from payment.  20.1 - Reasonable and Necessary Services  (Rev. 1, 10-01-03) A3-3116.1. HHA-203.1
(Medicare Benefit Policy Manual)
6. The services for which payment is claimed are not otherwise excluded from payment.  20.1 - Reasonable and Necessary Services  (Rev. 1, 10-01-03) A3-3116.1. HHA-203.1  20.1.1 - Background  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  In enacting the Medicare program, Congress recognized that the physician or allowed practitioner would play an important role in determining utilization of services.  The law requires that payment can be made only if a physician or allowed practitioner certifies the need for services and establishes a plan of care.  The Secretary is respo nsible for ensuring that Medicare covers the claimed services, including determining whether they are "reasonable and necessary."   20.1.2 - Determination of Coverage  (Rev.  208, Issued: 04-22-15, Effective: 01 -01-15, Implementation: 05-11-15)  The Medicare contractors decision on whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS as required by 42 CFR 484.55 or a medical record of the individual patient.  Medicare does not deny coverage solely on the basis of the reviewer's general inferences about patients with similar diagnoses or on data related to utilization generally, but bases it upon objective clinical e vidence regarding the patient's individual need for care.  Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patients potential for improvement from the nursing care or therapy, but rather on the patients need for skilled care.  Skilled care may be necessary to improve a patients current condition, to maintain the patients current condition, to prevent or slow further deterioration of the patients condition.   20.2 - Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services  (Rev.  208, Issued: 04- 22-15, Effective: 01 -01-15, Implementation: 05- 11-15)
(Medicare Benefit Policy Manual)
Where the Medicare criteria for coverage of home health services are met, patients are entitled by law to coverage of reasonable and necessary home health services.  Therefore, a patient is entitled to have the costs of reasonable and necessary services reimbursed by Medicare without regard to whether there is someone available to furnish the services.  However, where a family member or other person is or will be providing services that adequately meet the patient's needs, it would not be reasonable and nec essary for HHA personnel to furnish such services.  Ordinarily it can be presumed that there is no able and willing person in the home to provide the services being rendered by the HHA unless the patient or family indicates otherwise and objects to the provision of the services by the HHA, or unless the HHA has first hand knowledge to the contrary.   Similarly, a patient is entitled to reasonable and necessary Medicare home health services even if the patient would qualify for institutional care (e.g., hospital care or skilled nursing facility care) and Medicare payment should be made for reasonable and necessary home health services where the patient is also receiving supplemental services that do not meet Medicares definition of skilled nursing care or home health aide services.   EXAMPLE 1:   A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage of home health services, requires the assistance of a home health aide for bathing and assistance with an exercise program to improve endurance.  The daughter is unwil ling to bathe her elderly father and assist him with the exercise program.  Home health aide services would be reasonable and necessary.   EXAMPLE 2:   A patient who is being discharged from a hospital with a diagnosis of osteomyelitis and requires continuation of the I.V. antibiotic therapy that was begun in the hospital was found to meet the criteria for Medicare coverage of skilled nursing facility ser vices.  If the patient also meets the qualifying criteria for coverage of home health services, payment may be made for the reasonable and necessary home health services the patient needs, notwithstanding the availability of coverage in a skilled nursing f acility.   EXAMPLE 3:
(Medicare Benefit Policy Manual)
EXAMPLE 3:   A patient who needs skilled nursing care on an intermittent basis also hires a licensed practical (vocational) nurse to provide nighttime assistance while family members sleep.  The care provided by the nurse, as respite to the family members, does not require the skills of a licensed nurse (as defined in 40.1 ) and therefore has no impact on the beneficiary's eligibility for Medicare payment of home health services even though another third party insurer may pay for that nursing care.  20.3 - Use of Utilization Screens and "Rules of Thumb"  (Rev. 1, 10-01-03) A3-3116.3, HHA-203.3  Medicare recognizes that determinations of whether home health services are reasonable and necessary must be based on an assessment of each beneficiary's individual care needs.  Therefore, denial of services based on numerical utilization screens, diagnost ic screens, diagnosis or specific treatment norms is not appropriate.  30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  To qualify for the Medicare home health benefit, under 1814(a)(2)(C) and 1835(a)(2)(A)  of the Act, a Medicare beneficiary must meet the following requirements:    Be confined to the home;   Under the care of a physician or allowed practitioner;   Receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner;   Be in need of skilled nursing care on an intermittent basis or physical therapy or speech -language pathology; or    Have a continuing need for occupational therapy.  For purposes of benefit eligibility, under 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, "intermittent" means skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or l ess (with extensions in exceptional circumstances when the need for additional care is finite and predictable).   A patient must meet each of the criteria specified in this section.  Patients who meet each of these criteria are eligible to have payment made on their behalf for services discussed in 40 and 50.
(Medicare Benefit Policy Manual)
A patient must meet each of the criteria specified in this section.  Patients who meet each of these criteria are eligible to have payment made on their behalf for services discussed in 40 and 50.  30.1 - Confined to the Home  (Rev. 1, 10-01-03) A3-3117.1, HHA-204.1  30.1.1 - Patient Confined to the Home  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  For a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician or allowed practitioner certify in all cases that the patient is confined to his/her home.  For purposes of the statute, an individual shall be considered confined to the home (homebound) if the following two criteria are met:   1. Criterion One:   The patient must either:   - Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence   OR  - Have a condition such that leaving his or her home is medically contraindicated.   If the patient meets one of the criterion one conditions, then the patient must ALSO meet two additional requirements defined in criterion two below.   2. Criterion Two:   - There must exist a normal inability to leave home;  AND   - Leaving home must require a considerable and taxing effort.