evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
40.1 - Notice of Admission (NOA)                                                            (Rev. 12106; Issued: 06- 29-23, Effective: 01 - 01-24; Implementation:01 -02-24)   HHAs must send the NOA to the A/B MAC (HHH) by mail, electronic data  interchange (EDI), or direct data entry (DDE). EDI submissions require additional data not required by the NOA itself, to satisfy transaction standards. This data is described in a companion guide available on the CMS website. HHAs may voluntarily agree to adopt the companion guide and use it to submit EDI NOAs at any time.  The following data elements are required to submit an NOA under HH PPS.     Provider Name, Address, and Telephone Number   Required -  The minimum entry is the agencys name, city, State, and ZIP Code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five or nine -digit ZIP Codes are acceptable.  This information is used in connection with the CMS Certification Number to verify provider identity.   Type of Bill   Required -    032x -  Home Health Services under a Plan of Treatment   4th Digit  Definition   A Admission/Election Notice   D  Cancellation of Admission/Election Notice   Statement Covers Period (From -Through)   Required  The HHA reports the date of the first visit provided in the admission as the From date.  The Through date on the NOA must always match the From date.    Patient Name/Identifier   Required -  Patients last name, first name, and middle initial.   Patient Address   Required -  Patients full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.  Patient Birth Date   Required -  Month, day, and year of birth of patient.  Left blank if the full correct date is not known.   Patient Sex   Required -  M for male or F for female must be present.  This item is used in conjunction with diagnoses and surgical procedures to identify inconsistencies.  Admission/Start of Care Date   Required -  The Admission date on the NOA must always match the From date.     Condition Codes   Conditional. -   If the NOA is for a patient transferred from another HHA, the HHA enters condition code 47.
(Medicare Claims Processing Manual)
Admission/Start of Care Date   Required -  The Admission date on the NOA must always match the From date.     Condition Codes   Conditional. -   If the NOA is for a patient transferred from another HHA, the HHA enters condition code 47.   Note:  No line item service information is required by the Medicare program to complete a Notice of Admission via DDE.  However, certain line information is required to meet the requirements of the 837I claim format.   See the NOA Companion Guide for details on meeting these  requirements.    Release of Information Certification Indicator   Required -  A Y code indicates the provider has on file a signed statement permitting the provider to release data to other organizations in order to adjudicate the claim.  An R code indicates the release is limited or restricted.  An N code indicates  no release on file.  National Provider Identifier  Billing Provider   Required -  The HHA enters their provider identifier.   Insureds Name   Required -  On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown, record the patients name as shown on the patients HI card or other Medicare notice.   Insureds Unique Identifier   Required  The HHA enters the beneficiarys Medicare Beneficiary Identifier (MBI). Confirm the MBI is active via an eligibility inquiry to avoid delays in the timely receipt or processing of the NOA.   Principal Diagnosis Code   Required to meet the requirements of the 837I claim format.   See the NOA Companion Guide   Attending Provider Name and Identifiers   Required -  The HHA enters the name and provider identifier of the attending physician that has established the plan of care with verbal orders.   40.2 - HH PPS Claims                                                                                        (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)
(Medicare Claims Processing Manual)
40.2 - HH PPS Claims                                                                                        (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  The following data elements are required to submit a claim under home health PPS.  For billing of home health claims not under an HH plan of care (not under HH PPS), see 90.  Home health services under a plan of care are paid based on a 30 -day period of care.  HHAs submit an NOA at the beginning of an admission and then submit one claim for each 30 -day period of care.  Claims submitted before an NOA has been received for the  beneficiary will be returned to the provider.   Billing Provider Name, Address, and Telephone Number   Required  The HHAs minimum entry is the agencys name, city, state, and ZIP Code.  The post office box number or street name and number may be included.  The state may be abbreviated using standard post office abbreviations.  Five or nine -digit ZIP Codes  are acceptable.  A/B MACs (HHH) use this information in connection with the provider identifier to verify provider identity.  Patient Control Number and Medical/Health Record Number   Required -  The patients control number may be shown if the patient is assigned one and the number is needed for association and reference purposes.   The HHA may enter the number assigned to the patients medical/health record.  If this number is entered, the A/B MAC (HHH) must carry it through their system and return it on the remittance record.   Type of Bill   Required -  This 4 -digit alphanumeric code gives two pieces of information.  The first three digits indicate the base type of bill.  The fourth digit indicates the sequence of this bill in this particular period of care.  The types of bill accepted for HH P PS claims are:   032x -  Home Health Services under a Plan of Treatment   4th Digit -  Definition   7 - Replacement of Prior Claim -  HHAs use to correct a previously submitted bill.  Apply this code for the corrected or new bill.  These adjustment claims must be accepted at any point within the timely filing period after the payment of the original claim.
(Medicare Claims Processing Manual)
8 - Void/Cancel of a Prior Claim -  HHAs use this code to indicate this bill is an exact duplicate of an incorrect bill previously submitted.  A replacement claim must be submitted for the period of care to be paid.  9 - Final Claim for an HH PPS Period  This code indicates an HH original bill to be processed following the submission of an HH PPS Notice of Admission (TOB 032A)   HHAs must submit HH PPS claims with the 4th digit of 9.  These claims may be adjusted with code 7 or cancelled with code 8.  A/B MACs (HHH) do not accept late charge bills, submitted with code 5, on HH PPS claims.  To add services within the period of a paid HH claim, the HHA must submit an adjustment.   Statement Covers Period   Required -  The beginning and ending dates of the period covered by this claim.  For continuous care periods, the through date must be 29 days after the From date for a 30-day period of care   In cases where the beneficiary has been discharged or transferred within the period, HHAs will report the date of discharge in accordance with internal discharge procedures as the through date.  If the beneficiary has died, the HHA reports the date of de ath in the through date.   The HHA may submit claims for payment immediately after the claim through date.  It is not required to hold claims until the end of the period of care unless the beneficiary continues under care.   Patient Name/Identifier   Required -  The HHA enters the patients last name, first name, and middle initial.   Patient Address   Required -  The HHA enters the patients full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.  Patient Birth Date   Required -  The HHA enters the month, day, and year of birth of patient.  If the full correct date is not known, leave blank.   Patient Sex   Required -  M for male or F for female must be present.  This item is used in conjunction with diagnoses and surgical procedures to identify inconsistencies.  Admission/Start of Care Date
(Medicare Claims Processing Manual)
Patient Sex   Required -  M for male or F for female must be present.  This item is used in conjunction with diagnoses and surgical procedures to identify inconsistencies.  Admission/Start of Care Date   Required -  The HHA enters a date of admission matching the From date on the first period of care in an admission.  On subsequent periods of care, the HHA continues to submit the admission date reported on the first period of care.   Point of Origin for Admission or Visit   Required -  The HHA enters the appropriate NUBC point of origin code.  Patient Discharge Status   Required -  The HHA enters the code that most accurately describes the patients status as of the Through date of the billing period.  Any applicable NUBC approved code may be used.   Patient status code 06 should be reported in all cases where the HHA is aware that the period of care will be paid a partial period payment adjustment.  These are cases in which the agency is aware that the beneficiary has transferred to another HHA within  the 30- day period, or the agency is aware that the beneficiary was discharged with the goals of the original plan of care met and has been readmitted within the period.  Situations may occur in which the HHA is unaware at the time of billing the discharge  that these circumstances exist.  In these situations, Medicare claims processing systems will adjust the discharge claim automatically to reflect the partial period payment adjustment, changing the patient status code on the paid claims record to 06.   In cases where the ownership of an HHA is changing and the CMS certification number (CCN) also changes, the service dates on the claims must fall within the effective dates of the terminating CCN.  To ensure this, all periods of care with from dates before the termination date of the CCN that would extend beyond the termination date must be resolved by the provider submitting claims with through dates on or before the termination date.  The provider must code the claim with patient status 06.  Billing f or the beneficiary is being transferred to the new agency ownership.  In changes of ownership which do not affect the CCN, billing is unaffected.
(Medicare Claims Processing Manual)
In cases where an HHA is aware in advance that a beneficiary will become enrolled in a Medicare Advantage (MA) Organization as of a certain date, the provider should submit a claim for the shortened period prior to the MA Organization enrollment date.  The  provider must code the claim with patient status 06.  Payment responsibility for the beneficiary is being transferred from Medicare fee- for-service to MA Organization, since HH PPS applies only to Medicare fee -for-service.   In cases where an HHA provides care in a 30 -day period of care and then discharges the beneficiary in the next 30 -day period of care, but does not provide any billable visits in the next 30- day period, special handling of the patient status code may be nee ded.  Normally, the patient status code for 30 -day period before the discharge would be 30, since the beneficiary has not yet been discharged.  However, since there will not be a claim for the period in which the discharge occurred, this would result in the HH admission period remaining open in Medicare systems and prevent billing for any later HH services.    In order to close the HH admission period in these cases, the HHA should report patient status 01 on the claim for the last 30- day period in which visits occurred.  This will trigger Medicare systems to close the HH admission period.  If the claim has been submitted with patient status 30 before the discharge occurred, the HHA should adjust the claim to change the patient status to 01.    If the cause of the discharge in the next 30- day period is a transfer to another HHA before any visits were provided, the HHA should take care not to report patient status 06 on the claim.  This would result in an incorrect partial period payment adjustment.  If the cause of the discharge in the next 30- day period is the beneficiarys death, the HHA should take care not to report patient status 20 on the claim.  This would result in an incorrect date of death being recorded in Medicare systems and potential ly affect claims from other providers.   Condition Codes   Conditional  The HHA enters any NUBC approved code to describe conditions that apply to the claim.
(Medicare Claims Processing Manual)
Condition Codes   Conditional  The HHA enters any NUBC approved code to describe conditions that apply to the claim.   If the claim is for a patient transferred from another HHA, the HHA enters condition code 47.  If the claim is for a period of care in which there are no skilled HH visits in the billing period, but a policy exception that allows billing for covered services is documented at the HHA, the HHA enters condition code 54.  As a result of disaster conditions (such as hurricane or wildfire) that render submission of OASIS assessments impossible, Medicare may issue a waiver indicating OASIS submission is waived.  In this case, HHAs should report condition code DR on their claim  to indicate billing under the waiver.  Since the OASIS assessment cannot be submitted, the HHA cannot report occurrence code 50 to show the assessment completion date.  Claims without occurrence code 50 will be accepted if condition code DR is present.   When a provider is unable to submit a start of care OASIS for an admission period of care, they should submit the HIPPS code weighted closest to 1.  For a period of continuing care, when a provider is unable to submit a follow -up OASIS, they should carry f orward the last HIPPS code generated from the previous OASIS.    If as a result of disaster conditions, OASIS submission timeframes are relaxed, HHAs should submit claims without condition code DR as soon as the OASIS was submitted.  In this case, matching OASIS assessment information and the occurrence code 50 date are required to ensure Medicare pays the claim accurately.   HHAs that are adjusting previously paid claims enter one of the condition codes representing Claim Change Reasons (code values D0 through E0).  If adjusting the claim to correct a HIPPS code, HHAs use condition code D2 and enter Remarks indicating the reason for the HIPPS code change.  HHAs use D9 if multiple changes are necessary.   When submitting an HH PPS claim as a demand bill, HHAs use condition code 20.  See 50 for more detailed instructions regarding demand billing.   When submitting an HH PPS claim for a denial notice, HHAs use condition code 21.  See 60 for more detailed instructions regarding no- payment billing.   Required -  If canceling the claim (TOB 0328), HHAs report the condition codes D5 or D6 and enter Remarks indicating the reason for cancellation of the claim.   Occurrence Codes and Dates
(Medicare Claims Processing Manual)
Required -  If canceling the claim (TOB 0328), HHAs report the condition codes D5 or D6 and enter Remarks indicating the reason for cancellation of the claim.   Occurrence Codes and Dates   Required  The HHA enters occurrence code 50 and the date the OASIS assessment corresponding to the period of care was completed (OASIS item M0090).   If occurrence code 50 is not reported on a claim or adjustment, the claim will be returned to the provide r for correction, unless condition code DR is present to indicate a waiver of OASIS reporting is in effect.   On claims for initial periods of care (i.e. when the From and Admission dates match), the HHA reports an inpatient admission that ended within 14 days of the From date by using one of the following codes.   Code  Short Descriptor  Long Descriptor  61 Hospital Discharge Date  The Through date of a hospital stay that ended within 14 days prior to the From date this HHA claim.   62  Other Institutional Discharge Date  The Through date of skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long term care hospital (LTCH) or inpatient psychiatric facility (IPF) stay that ended within 14 days prior to this HHA admission.   On claims for continuing periods of care, the HHA reports an inpatient hospital admission that ended within 14 days of the From date by using occurrence code 61.   To determine the 14 day period, include the From date, then count back using the day before the From date as day 1.   For example, if the From date is January 20th, then January 19th is day 1.  Counting back from January 19th,  the 14 day period is J anuary 6 through January 19.  If an inpatient discharge date falls on any date in that period or on the admission day itself (January 20), it is eligible to be reported on the claim.     If more than one inpatient discharge occurs during the 14 day period, the HHA reports only the most recent applicable discharge date.  Claims reporting more than one of any combination of occurrence codes 61 and 62 will be returned to the provider for correction.   Conditional -  The HHA enters any other NUBC approved code to describe occurrences that apply to the claim.   Occurrence Span Code and Dates
(Medicare Claims Processing Manual)
Conditional -  The HHA enters any other NUBC approved code to describe occurrences that apply to the claim.   Occurrence Span Code and Dates   Conditional -  The HHA enters any NUBC approved Occurrence Span code to describe occurrences that apply to the claim.  Reporting of occurrence span code 74 is not required to show the dates of an inpatient admission.  Value Codes and Amounts   Required -  Home health payments must be based upon the site at which the beneficiary is served.  For certain dates of service when required by law, payments may be further adjusted if the site is in a rural CBSA or rural county. For periods of care in which the benef iciarys site of service changes from one CBSA or county to another within the period, HHAs should submit the CBSA code or State and County code corresponding to the site of service at the end of the period.   Provider -submitted codes:   Code  Title  Definition  61 Location Where Service is Furnished (HHA and Hospice)  HHAs report the Core Based Statistical Area (CBSA) number (or rural state code) of the location where the home health or hospice service is delivered.  The HHA reports the number in dollar portion of the form locator right justified to the left of the doll ar/cents delimiter, add two zeros to the cents field if no cents.  85 County Where Service is Rendered  Where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered.   Medicare- applied codes: The following codes are added during processing and may be visible in the A/B MAC (HHH)s online claim history. They are never submitted by the HHA.
(Medicare Claims Processing Manual)
Medicare- applied codes: The following codes are added during processing and may be visible in the A/B MAC (HHH)s online claim history. They are never submitted by the HHA.   Code  Title  Definition  17 Outlier Amount  The amount of any outlier payment returned by the Pricer with this code.  A/B MACs (HHH) always Code  Title  Definition  place condition code 61 on the claim along with this value code.  62 HH Visits - Part A  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3)  of the Social Security Act.  63 HH Visits - Part B  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act.  64 HH Reimbursement - Part A  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act. 65 HH Reimbursement - Part B  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments from the Part A to the Part B trust fund as mandated by 1812 (a)(3) of the Social Security Act. QF Late-filed NOA penalty amount  The dollar amount that the claim payment was reduced due to the NOA being filed more than 5 days after the HH From date.  QV Value -based purchasing adjustment amount  The dollar amount of the difference between the HHAs value -based purchasing adjusted payment and the payment amount that would have otherwise been made.   May be a positive or a negative amount.   If information returned from the CWF indicates all visits on the claim are Part A, the shared system must place value codes 62 and 64 on the claim record, showing the total visits and total PPS payment amount as the values, and send the claim to CWF with RIC code V.
(Medicare Claims Processing Manual)
If information returned from CWF indicates all visits on the claim are Part B, the shared system must place value codes 63 and 65 on the claim record, showing the total visits and total PPS payment amount as the values, and send the claim to CWF with RIC c ode W.   If information returned from CWF indicates certain visits on the claim are payable from both Part A and Part B, the shared system must place value codes 62, 63, 64, and 65 on the claim record.  The shared system also must populate the values for code 62 an d 63 based on the numbers of visits returned from CWF and prorate the total PPS reimbursement amount based on the numbers of visits to determine the dollars amounts to be associated with value codes 64 and 65.  The shared system will return the claim to CWF wit h RIC code U.   Revenue Code and Revenue Description  Required   HH PPS claims must report a 0023 revenue code line which contains a HIPPS code.  HHAs enter only one 0023 revenue code per claim in all cases.   Claims must also report all services provided to the beneficiary within the period of care.  All services must be billed on one claim for the entire period.  The A/B MAC (HHH) will return to the provider TOB 0329 when submitted without any visit charges.  Each service must be reported in line item detail.  Each service visit (revenue codes 042x, 043x, 044x, 055x, 056x and 057x) must be reported as a separate line.  Any of the following revenue codes may be used:    027x  Medical/Surgical Supplies (Also see 062x, an extension of 027x)   Required detail:  With the exception of revenue code 0274 (prosthetic and orthotic devices), only service units and a charge must be reported with this revenue code.  If also reporting revenue code 0623 to separately identify specific wound care supplies, not just supplies for wound care patients, ensure that the charge amounts for revenue code 0623 lines are mutually exclusive from other lines for supply revenue codes reported on the claim.  Report only nonroutine supply items in this revenue code or in 0623.  Revenue code 0274 requires an HCPCS code, the date of service units and a charge amount.