evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If a patient eligible for both Medicare and Medicaid is receiving home health services covered under Medicare and ceases to meet Medicare coverage criteria, the patient should be discharged for Medicare purposes.  Patient status code 06 should not be use d.  This discharge has no payment impact on the Medicare HH PPS period.  If the patient being discharged to Medicaid- only coverage is still receiving skilled services, the HHA should indicate the change in payer source on the OASIS at the next assessment.  10.1.24 - Glossary and Acronym List  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  ABN -  Advance Beneficiary Notice of Non -Coverage   Admission Date -  For HH PPS, the date of the first service delivered by the HHA in a period of care or a series of continuous periods.  It is placed in the Admission/Start of Care Date field on the institutional claim.   Admission Period  The period between the From date of a Notice of Admission and the discharge date.  An admission period may contain several 30- day periods of care and their corresponding claims.   A/B MAC (A) -  A/B MACs processing hospital claims.   A/B MAC (HHH) -  A/B MACs processing all Home Health and Hospice claims.   CBSA -  Core Based Statistical Area   CCN -  CMS certification number   Claim -  The transaction submitted to receive payment for an HH PPS 30- day period of care.   CLIA - Clinical Laboratory Improvement Amendments   CMS -  The Center for Medicare & Medicaid Services, the Federal Agency administering the Medicare program.   CWF -  Common Working File   DCN -  Document Control Number   DME -  Durable Medical Equipment.  DME MAC -  DME Medicare Administrative Contractor -  4 Medicare contractors nationally processing DME on professional claim formats.  DMEPOS -  Durable Medical Equipment, Prosthetics, Orthotics and Supplies.  DOEBA -  Date of Earliest Billing Activity   DOLBA -  Date of Latest Billing Activity
(Medicare Claims Processing Manual)
DOEBA -  Date of Earliest Billing Activity   DOLBA -  Date of Latest Billing Activity   Grouper - A software module that uses claim and assessment information for payment classification.  For HH PPS, this data is grouped to determine HHRGs and corresponding HIPPS codes.   HCPCS Code(s) -  Healthcare Common Procedure Coding System.  Coding for services or items used in the HCPCS/Accommodation Rates/HIPPS Rate Codes field on institutional claim formats.    HH -  Home Health   HHA(s) -  Home Health Agency(ies)   HH PPS -  Home Health Prospective Payment System   HHRG -  Home Health Resource Group.  One of the case -mix groups that determine HH PPS payment rates.   HIPAA -  Health Insurance Portability and Accountability Act   HIPPS -  Health Insurance Prospective Payment System.  Coding used in the HCPCS/ Accommodation Rates/HIPPS Rate Codes field on institutional claim formats to represent case- mix groups in certain prospective payment systems.  ICD - International Classification of Diseases   LUPA -  Low Utilization Payment Adjustment.    MAC -  Medicare Administrative Contractor, one of the contractors processing Medicare claims.   National Standard Per Visit Rates -  National rates for each of the 6 home health disciplines based on historical claims data.  These rates are used in payment of LUPAs.   NOA  Notice of Admission   NUBC -  National Uniform Billing Committee   OASIS -  Outcome and Assessment Information Set.  The HH patient assessment instrument.   Outlier -  An addition to payment in cases where costs of services delivered are estimated to exceed a fixed loss threshold.    PPS -  Prospective Payment System.  Medicare payment for medical care based on pre-determined payment rates or periods, linked to the anticipated intensity of services delivered and/or beneficiary condition.  Pricer -  Software modules in Medicare claims processing systems used to calculate payments under prospective payment systems.  RA -  Remittance Advice   Revenue Code -  Four position payment codes for services or items placed in the Revenue Codes field on institutional claim formats.  An x in the last digit of revenue codes means that value can vary from 0- 9.  TOB -  Type of Bill (e.g., 032x, 034x).  Coding representing the nature of each institutional claim (i.e., type of provider, such as home health; frequency of bill) -  an x in the last digit of the TOB means that value can vary from 0- 9.
(Medicare Claims Processing Manual)
20 - Home Health Prospective Payment System (HH PPS) Consolidated Billing (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician.  Consequently, Medicare makes payment for all such items and services to a single HHA overseeing that plan.  This HHA is known as the primary HHA for HH PPS billing purposes.  The law states payment will be made to the primary HHA without regard as to whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements exist wi th the primary agency, or otherwise.  Payment for all items is included in the HH PPS payment the primary HHA receives.   Types of services that are subject to the home health consolidated billing provision:    Skilled nursing care;    Home health aide services;    Physical therapy;    Speech -language pathology;    Occupational therapy;    Medical social services;    Routine and nonroutine medical supplies;    Medical services provided by an intern or resident -in-training of a hospital, under an approved teaching program of the hospital, in the case of an HHA that is affiliated or under common control with that hospital; and   Care for homebound patients involving equipment too cumbersome to take to the home.  Exception:  T herapy services are not subject to the home health consolidated billing methodology when performed by a physician.   Medicare periodically publishes Recurring Update Notifications that contain updated lists of nonroutine supply codes and therapy codes that must be included in home health consolidated billing.  Medicare updates the lists annually, effective January 1, as a result of annual changes in HCPCS codes, unless the HCPCS changes do not affect home health services.  The lists may also be updated as frequently as quarterly if this is required by the creation of new HCPCS codes mid- year.
(Medicare Claims Processing Manual)
The HHA that submits an NOA successfully processed by Medicare claims processing systems will be recorded as the primary HHA for a given period in the CWF.  If a beneficiary transfers during a 30- day period of care, then the transfer HHA that establishes t he new plan of care assumes responsibility for consolidating billing for the beneficiary.  A/B MACs (HHH) will reject any claims from providers or suppliers other than the primary HHA that contain billing for the services and items subject to consolidated billing when billed for dates of service within a period of care (see 20.2 for details).   A/B MACs (HHH) will also reject claims subject to consolidated billing when submitted by the primary HHA as services not under an HH plan of care (using TOB 034x) when the primary HHA has already billed other services under an HH plan of care (TOB 032x) for the beneficiary.  Institutional providers may access information on existing periods of care through the home health CWF inquiry process.  See 30.1.  Durable medical equipment is exempt from home health consolidated billing by law.  Therefore, DME may be billed by a supplier or an HHA (including HHAs other than the primary HHA).  Medicare claims processing systems will allow either party to submit DME c laims, but will ensure that the same DME items are not submitted by multiple providers for the same dates of service for the same beneficiary.  In the event of duplicate billing, the first claim received will be processed and paid.  Subsequent duplicate cl aims will be denied.  Medicare claims processing systems will also prevent payment for the purchase and the rental of the same item for the same dates of service.  In this event, the first claim received, regardless of whether for purchase or rental, will be processed and paid.
(Medicare Claims Processing Manual)
The exception to the above, however, is competitive bidding for certain DME.  HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program, must either be awarded a contract to furnish the items in this area or use a contract supplier in the community to furnish these items.  The competitive bidding items are identified by HCPCS codes and the competitive bidding areas are identified based on ZIP Codes where beneficiaries receiving these items maintain their p ermanent residence.  Home health agency claims submitted for HCPCS codes subject to a competitive bidding program will be returned to the provider to remove the affected DME line items and the providers will be advised to submit those charges to the DME MA Cs, who will have jurisdiction over all claims for competitively bid items.   Osteoporosis drugs are subject to home health consolidated billing, even though these drugs continue to be paid on a cost basis in addition to the HH unit of payment.  For more detailed information, refer to 20.2.3 and 90.1.   20.1 - Beneficiary Notification and Payment Liability Under Home Health Consolidated Billing  (Rev. 635, Issued:  08- 05-05; Effective:  10 -01-00; Implementation: 11 -03-05)  20.1.1 - Responsibilities of Home Health Agencies  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Medicare payment for services subject to home health consolidated billing is made to the primary HHA, so separate Medicare payment for these services will never be made.  The primary HHA is responsible for providing these services, either directly or under  arrangement.  This responsibility applies to all services that the physician has ordered on the beneficiarys home health plan of care.
(Medicare Claims Processing Manual)
However, providing services either directly or under arrangement requires knowledge of the services provided during the period of care.  An HHA would not be responsible for payment to another provider in the situation in which they have no prior knowledge (e.g., they are unaware of physicians orders) of the services provided by that provider to a patient who is under their home health plan of care.  In certain circumstances where the primary HHA is unaware of services provided during the period of care and the beneficiary is properly notified, the beneficiary may be liable for payment for these services.  In order to protect the beneficiary from unexpected liability in these cases, and in order to comply with Medicare Conditions of Participation, it is important that all providers and suppliers serving a home health patient notify the beneficiary of the possibility that they will be responsible for payment.   Notification about home health consolidated billing must begin with the beneficiarys admission to home health care.  Under the Medicare Home Health Services Conditions of Participation: Patient rights , (42 CFR, 484.10 (c) (i)), the HHA must advise the patient, in advance, of the disciplines (e.g., skilled nursing, physical therapy, home health aide, etc.) that will furnish care, and the frequency of visits proposed to be furnished. It is, therefore, t he responsibility of the HHA to fully inform beneficiar ies that all home health services, including therapies and supplies, will be provided by his/her primary HHA.   In addition, under the Conditions of Participation: Patient liability for payment, (42 CFR, 484.10(e)), HHAs are responsible for advising the patient, in advance, about the extent to which payment is expected from Medicare or other sources , including the patient.  Information regarding patient liability for payment must be provided by the HHA both orally and in writing.  This should assist in alerting the beneficiary to the possibility of payment liability if he/she were to obtain services from anyone othe r than their primary HHA.   HHAs are also responsible for the timely submission of a Notice of Admission (NOA).  This ensures information about their primary HHA status is available to other providers.
(Medicare Claims Processing Manual)
HHAs are also responsible for the timely submission of a Notice of Admission (NOA).  This ensures information about their primary HHA status is available to other providers.    20.1.2 - Responsibilities of Providers/Suppliers of Services Subject to Consolidated Billing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Since Medicare payment for services subject to home health consolidated billing is made to the primary HHA, providers or suppliers of these services must be aware that separate Medicare payment will not be made to them.  Therefore, before they provide services to a Medicare beneficiary, these providers or suppliers need to determine whether or not a home health period of care exists for that beneficiary.  This information may be available to providers or suppliers from a number of sources.  The first avenue a therapy provider or a supplier may pursue is to ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.  Beneficiaries and their representatives s hould have the most complete information as to whether or not they are receiving home health care.  Therapy providers or suppliers may, but are not required to, document information from the beneficiary that states the beneficiary is not receiving home hea lth care, but such documentation in itself does not shift liability to either the beneficiary or Medicare.   Additionally, information about current home health periods of care may be available from MACs.  Institutional providers may access this information electronically through the home health CWF inquiry process (See 30.1).  Independent therapists or suppliers who bill using the professional claim format also have access to a similar electronic inquiry via the HIPAA Eligibility Transaction System (HETS).  They may also, as a last resort, call their A/B MAC (B)s provider t oll free line to request home health eligibility information available on the Common Working File.  The A/B MAC (B)s information is based only on claims Medicare has received from home health agencies at the day of the contact.
(Medicare Claims Processing Manual)
Medicare systems maintain a data file that captures and displays the dates when Medicare paid physicians for the certification or recertification of the beneficiarys HH plan of care.  Physicians submit claims for these services to A/B MACs (B) on the prof essional claim format separate from the HHAs billing their claim on the institutional claim format for the HH services themselves.     There may be instances in which the physician claim for the certification service is received before any HHA billing and this claim is the earliest indication Medicare systems have that HH services will be provided.  As an aid to suppliers and providers subject to HH consolidated billing, Medicare systems display, for each Medicare beneficiary, the code for certification (G0180) or recertification (G0179) and the date of service for either of the two codes.   Suppliers and providers should note that this information is supplementary to the previously existing sources of information about HH periods of care.  Like HH period of care information maintained on CWF, certification information is only as complete and timely as billing by providers allows.  For many periods of care, a physician certification claim may never be billed.  As a result, the beneficiary and their caregivers remain the first and best source of information about the beneficiarys home health status.  If a therapy provider or a supplier learns of a home health period of care from any of these sources, or if they believe they dont have reliable information, they should advise the beneficiary that if the beneficiary decides not to have the services provi ded by the primary HHA and the beneficiary is in an HH period, the beneficiary will be liable for payment for the services.  Beneficiaries should be notified of their potential liability before the services are provided.   If a therapy provider or a supplier learns of a home health period of care and has sufficient information to contact the primary HHA, they may inquire about the possibility of making a payment arrangement for the service with the primary HHA.  Such contact s may foster relationships between therapy providers, suppliers and HHAs that are beneficial both to providers involved and to Medicare beneficiaries.
(Medicare Claims Processing Manual)
20.1.3 - Responsibilities of Hospitals Discharging Medicare Beneficiaries to Home Health Care  (Rev. 635, Issued:  08- 05-05; Effective:  10 -01-00; Implementation: 11 -03-05)  A hospital discharging a Medicare beneficiary to home health care can also play an important role in alerting the beneficiary to their potential liability under home health consolidated billing.  Under the Medicare Conditions of Participation (COP) for Hospitals: Discharge planning, (42 CFR, 482.43 (b) (3) and (6)), hospitals must have in effect a discharge planning process that applies to all patients, and the discharge planning evaluation must include an evaluation of the likelihood of a patient needing post -hospital services and of the availability of the services.  The hospital must include the discharge planning evaluation in the patients medical record for use in establishing an appropriate discharge plan and the hospital must discuss the results of the evaluation with the patient or individual acting on his or her behalf.  In addition, under 42 CFR, 482.43 (c) (5), the patient and family members must be counseled to prepare them for post -hospital care and under 42 CFR, 482.43 (d) Transfer or referr al, the hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for followup or ancillary care.   Hospitals, therefore, should counsel beneficiaries being discharged to receive home health services, that his/her primary home health agency; i.e., the agency establishing his/her plan of care, will provide all home health services.  Hospitals should provide a list of home health agencies for beneficiaries to choose from; in addition, when referring the beneficiary to his/her chosen home health agency, the hospital should notify the agency and include any counseling notes, which should serve as a reminder  to the home health agency to also notify the beneficiary that all home health services will be provided by them as the primary home health agency.  Hospitals play a key role in making beneficiaries, and/or their caregivers, aware of Medicare home health coverage policies to help ensure that those services are provided appropriately.
(Medicare Claims Processing Manual)
20.2 - Home health Consolidated Billing Edits in Medicare Systems  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  In short, consolidated billing requires that only the primary HHA bill services under the home health benefit, with the exception of DME and therapy services provided by physicians, for the period of that period of care.  The types of service most affected are nonroutine supplies and outpatient therapies, since these services are routinely billed by providers other than HHAs, or are delivered by HHAs outside of plans of care.   Home health consolidated billing edits are applied when the period of care claim has been received and processed in CWF.  Edits are applied differently depending on whether the HH patient was discharged/transferred at the end of the HH period or not.   If the patient was discharged or transferred, the edits apply to dates of service between the period start date and the last billable service date for the period.  The start date and last service date are excluded.   If the patient is not discharged or transferred (patient status 30, Still Patient), the edits apply to dates of service between the period start date and the period end date.  The start date is excluded but the end date is included.   If any line item services subject to consolidated billing are identified within these dates, CWF sends information to the contractors that enables them to reject or deny those line items.   Claims subject to consolidated billing may be identified in one of two ways.  Claims may be edited when the HH PPS claim had been received before the claim for services subject to consolidated billing.  In these cases, the line items subject to consolidate d billing are rejected or denied prior to payment.  Claims may also be identified when the HH PPS claim is received after the other claims subject to consolidated billing.  In these cases, the claim for services subject to consolidated billing has already been paid.  CWF then notifies the contractor to make a post -payment rejection or denial.   For post -payment rejections of claims billed on institutional claims, recoveries will be made automatically in the claims process.  For post- payment rejections of claims billed on professional claims, those contractors will follow their routine overpayment  identification and recovery procedures.  In the event a denial is reversed upon appeal, an override procedure exists to permit payment to be made.
(Medicare Claims Processing Manual)
The contractor shall use the following remittance advice messages and associated codes when not paying outlier amounts under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.   Group Code: CO  CARC: 97  RARC: N390  MSN: N/A  Since home health consolidated billing is not an ABN situation, coding on incoming claims cannot allow Medicare systems to fully identify the payment liability for any denial.  As described in 20.1, whether the denial is the liability of the primary HHA o r the beneficiary is determined by whether the services are provided under arrangement and whether the beneficiary received notice of their potential liability.  These denials are shown as provider liability on remittance advices (group code CO) to ensure therapy providers or suppliers explore whether a payment arrangement exists or can be made for the services.  Despite this coding limitation, Medicare recognizes that ultimately beneficiaries may be liable for these services.   20.2.1 - Nonroutine Supply Editing  (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)  For home health consolidated billing, nonroutine medical supplies are identified as a list of discrete items by HCPCS code.  Supplies are billed to DME MACs using the professional claim format, in which line items have both a from and to date.  The line item from date is used to enforce consolidated billing of nonrouti ne medical supplies.   Claims submitted by providers using the institutional claim format may include a nonroutine supply HCPCS code in addition to the other services provided.  These supplies are either bundled into the rate paid for the primary service or are otherwise inciden t to the primary service(s) being rendered, therefore these supplies do not fall within the bundling provisions of HH PPS.  As a result, supplies reported on institutional claims are not subject to consolidated billing edits by CWF.   20.2.2 - Therapy Editing (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)