evekhm/cms_iom_500 huggingface dataset:
(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.)
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
 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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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).   If NPWT using a disposable device is performed during the course of an otherwise covered home health visit (e.g., to perform a catheter change), the visit would be covered as normal.  Performing NPWT using a disposable device will be separately reimbursed the OPPS amount. In this situation, the HHA bills under TOB 034X and this visit is also reported on the HH PPS claim (TOB 032x).  The HHA must not include the time spent performing NPWT in their visit charge or in the length of time reported for the visit on the HH PPS claim.   100 - Temporary Suspension of Home Health Services  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
100 - Temporary Suspension of Home Health Services  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  A physician may suspend visits for a time to determine whether the patient has recovered sufficiently to do without further home health services.  When the suspension is temporary (does not extend beyond the end date of the 60- day certification period) and the physician later determines that the services must be resumed, the resumed services are paid as part of the same or subsequent 30- day period of care and under the same plan of care as before.  The admission date remains the same on any claims.  No special indication need be made on the claim(s) for the period of suspended services.  Explanation of the suspension need be indicated only in the medical record.  If the suspension extends beyond the end of the current 60- day certification, HHAs must submit a discharge claim.  Full payment will be due for the period of care.  If the beneficiary resumes care, the HHA must establish a new plan of care and submit an NO A for a new admission.    110 - Billing and Payment Procedures Regarding Ownership and CMS Certification Numbers (CCNs)  (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)  110.1  RESERVED  (Rev. 4378, Issued:  08- 23-19, Effective: 01 -01-20, Implementation: 11-  27-19)   110.2 - Payment Procedures for Terminated HHAs  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Medicare regulations allow that payment may be made for home health services for up to thirty days after a home health agency (HHA) terminates their Medicare provider agreement.  This payment may be made if the home health services are furnished under a home health plan of care establish ed before the effective date of the termination.   Medicare continues to make full period of care payments for periods which extend beyond a providers termination date if the home health services are provided under a plan of care established prior to that date and if the home health period of care ends within the 30 day period.
(Medicare Claims Processing Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR# R12382CP  11/28/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims -   01/02/2024 13244 R12306CP  10/19/2023 Processing Claims When the Dates of Service Are Beyond the Time Limit for the Patient Assessment   01/24/2024 13402 R12291CP   10/05/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims  Rescinded and Replaced by Transmittal 12 382  01/02/2024 13244  07/20/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims  SENSITIVE CONTROVERSIAL DO NOT POST  Rescinded and Replaced by Transmittal 12291  01/02/2024 13244 R12106CP  06/29/2023 Corrections to Home Health Processing - Claims with Condition DR or Claims Receiving Admission Source Edits   01/02/2024 13225 R11796CP  01/19/2023 Revisions to Processing of Home Health Disaster Related Claims and Contractor -Initiated Adjustments  04/03/2023 13020 R11644CP  10/13/2022 Home Health Claims -  New Grouper Return Code Edits and Informational Unsolicited Response  04/03/2023 12924 R11634CP  10/06/2022 Home Health Claims - New Grouper Return Code Edits and Informational Unsolicited Response - Rescinded and replaced by transmittal 11644  04/03/2023 12924 R11341CP  04/07/2022 Corrections to Home Health Billing for Denial Notices and Calculation of 60-Day Gaps in Services  10/03/2022 12657  R10987CP  09/10/2021 Home Health Notices of Admission -- Additional Manual Instructions   11/10/2021 12424 R10919CP  08/06/2021 Low Utilization Payment Adjustment (LUPA) Add -on Amounts for Home Health (HH) Occupational Therapy Visits and Corrections to Payment Grouping Processes   01/03/2022 12315 R10839CP   06/09/2021 Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA) -- Manual Instructions
(Medicare Claims Processing Manual)
01/03/2022 12315 R10839CP   06/09/2021 Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA) -- Manual Instructions   08/11/2021 12256 R10758CP  05/11/2021 Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA) -- Manual Instructions  Rescinded and replaced by transmittal 10839    08/11/2021 12256 R10696CP  03/31/2021 Penalty for Delayed Request for Anticipated Payment (RAP) Submission  Implementation   01/04/2021 11855 R10403CP   10/27/2020 Penalty for Delayed Request for Anticipated Payment (RAP) Submission  Implementation - Rescinded and replaced by transmittal 10696  01/04/2021 11855 R10369CP  09/24/2020 Penalty for Delayed Request for Anticipated Payment (RAP) Submission  Implementation - Rescinded and replaced by transmittal 10403  01/04/2021 11855 R10274CP  08/07/2020 Update to Osteoporosis Drug Codes Billable on Home Health Claims  01/04/2021 11846 R10254CP  07/31/2020 Penalty for Delayed Request for Anticipated Payment (RAP) Submission  Implementation - Rescinded and replaced by transmittal 10369 01/04/2021 11855 R4489CP  01/09/2020 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Split Implementation  07/01/2019 11081 R4482CP  12/20/2020 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Split Implementation -Rescinded and Replaced by Transmittal # 4489  07/01/2019 11081  R4466CP  11/22/2019 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020  01/06/2020 11536 R4453CP
(Medicare Claims Processing Manual)
R4466CP  11/22/2019 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020  01/06/2020 11536 R4453CP   11/08/2019 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020 -- Rescinded and Replaced by Transmittal # 4466 01/06/2020 11536 R4378CP  08/23/2019 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Revised and Additional Manual Instructions  11/27/2019 11395 R4312CP  05/23/2019 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Additional Manual Instructions  08/16/2019 11272 R4294CP  05/03/2019 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Additional Manual Instructions -- Rescinded and Replaced by Transmittal # 4312 08/07/2019 11272 R4244CP  02/15/2019 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Split Implementation -  Rescinded and Replaced by Transmittal # 4482 07/01/2019 11081 R4228CP  02/01/2019 Home Health (HH) Patient- Driven Groupings Model (PDGM) -  Split Implementation -- Rescinded and Replaced by Transmittal # 4244 07/01/2019 11081 R4210CP  01/25/2019 Update to Pub. 100- 04 Chapter 10 to Provide Language -Only Changes for the New Medicare Card Project  02/26/2019 11077 R4190CP  12/31/2018 Home Health Rural Add -on Payments Based on County of Residence  01/07/2019 10782 R4148CP  10/19/2018        Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2019  01/07/2019 10992 R4106CP  08/03/2018 Home Health Rural Add -on Payments Based on County of Residence - Rescinded and Replaced by Transmittal # 4190 01/07/2019 10782 R3948CP  01/05/2018 Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial
(Medicare Claims Processing Manual)
07/02/2018 10372 R3933CP  12/07/2017 Revisions to the Home Health Pricer to Support Value -Based Purchasing and Payment Standardization  01/02/2018 10167 R3888CP  10/20/2017   Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2018  01/02/2018 10310 R3829CP  08/04/2017 Revisions to the Home Health Pricer to Support Value -Based Purchasing and Payment Standardization - Rescinded and Replaced by Transmittal 3933
(Medicare Claims Processing Manual)
01/02/2018 10167 R3655CP  11/10/2016 Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment System  01/03/2017 9736 R3630CP  10/27/2016 Correcting Editing for Condition Code 54 and Updating Remittance Advice Messages on Home Health Claims  04/03/2017 9826 R3629CP  10/27/2016 Denial of Home Health Payments When Required Patient Assessment Is Not Received  04/03/2017 9585 R3624CP  10/14/2016 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2017  01/03/2017 9820 R3585CP  08/12/2016 Implementation of Policy Changes for the CY 2017 Home Health Prospective 01/03/2017 9736 Payment System - Rescinded and replaced by Transmittal 3655 R3553CP  06/28/2016 New Condition Code for Reporting Home Health Episodes With No Skilled Visits  07/05/2016 9474 R3533CP  05/27/2016 Payments to Home Health Agencies That Do Not Submit Required Quality Data  08/30/2016 9651 R3457CP  02/05/2016 New Condition Code for Reporting Home Health Episodes With No Skilled Visits -  Rescinded and replaced by Transmittal 3553  07/05/2016 9474 R3378CP  10/16/2015 Additional G -Codes Differentiating RNs and LPNs in the Home Health and Hospice Settings  01/01/2016 9369 R3268CP  05/29/2015 Corrections to the 2015 Home Health (HH) Pricer Program  10/05/2015 9198 R3176CP  01/30/2015 Preventing Inappropriate Payments on Home Health Low Utilization Payment Adjustment (LUPA) Claims  07/06/2015 9027 R3151CP  12/17/2014 Correction to Remittance Information When HIPPS Codes are Re- coded by Medicare Systems  04/06/2014 8950 R3104CP  11/06/2014 Correction to Remittance Information When HIPPS Codes are Re- coded by Medicare Systems  Rescinded and replaced by Transmittal 3151 04/06/2014 8950 R3021CP  08/08/2014 Update to Pub. 100- 04, Chapter 10 to Provide Language -Only Changes for Updating ASC X12 09/08/2014 8606 R3010CP  08/01/2014 Preventing Payment