evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
See 40 for details on billing these services.    10.1.5 - Number, Duration, and Claims Submission of HH PPS Periods of Care  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The beneficiary can be covered for an unlimited number of nonoverlapping periods of care.  For periods of care beginning on or after January 1, 2020, the duration of a period is 30 days. Periods of care may be shorter than 30 days.   For example, a period may end earlier than the 30th day in the case of a transfer to another HHA, or a discharge and readmission to the same HHA, and payment is pro- rated for these shortened periods, in which more home care is delivered in the same period.  Claims for periods may be submitted prior to the 30th day if the beneficiary has been discharged and treatment goals have been met, though payment will not be pro- rated unless more home health care is subsequently billed in the same period.   Other claims for overlapping periods may also be submitted prior to the end of that period if the beneficiary has been discharged, dies or is transferred to another HHA.  In transfer cases payment for the period of care will be prorated.   The initial period begins with the first service delivered under that plan of care.  A second subsequent period of continuous care would start on the first day after the initial period was completed.   More than one period for a single beneficiary may be opened by the same or different HHAs for different dates of service.  This will occur particularly if a transfer to another HHA, or discharge and readmission to the same HHA, situation exists.  Refer to 10.1.5.1 below for more information on multiple agencies furnishing home health services.  Allowing multiple periods is intended to assure continuity of care and payment.   10.1.5.1 - More Than One Agency Furnished Home Health Services  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
10.1.5.1 - More Than One Agency Furnished Home Health Services  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The primary HHA bills for all services furnished by both agencies and keeps all records pertaining to the care and other HHAs serving the same beneficiary.  Nonprimary HHAs can receive payment under arrangement only from the primary HHA for services on the  plan of care where prior arrangement exists.  The primary agencys status as primary is established through the submission, receipt and processing of a Notice of Admission (NOA) for the home health care for the beneficiary.  The secondary agency is paid through the primary agency under mutually agreed upon arrangements between the two agencies existing before the delivery of services for services called for under the plan of care.   Two agencies must never bill as primary for the same beneficiary for the same admission period.  When the Common Working File (CWF) indicates an admission period is open for a beneficiary, the A/B MAC (HHH) returns to the provider the NOA of any other agen cy billing unless the NOA indicates a transfer or discharge and readmission situation exists.   In rare cases, a Medicare beneficiary may receive an organ transplant and the organ donors post -operative services are covered by the Medicare program.  Since the donor is frequently not a Medicare beneficiary, services for the donor are billed using the Medicare beneficiarys Medicare number.  If both the organ recipient and organ donor are receiving post -operative home health services, CWF cannot process HH PPS periods for both patients for the same dates of service.  In this case, the HH claim for the organ recipient is accepted by CWF.  The HH claim for the donor is processed by the A/B MAC (HHH) outside CWF.   10.1.5.2 - Effect of Election of Medicare Advantage (MA) Organization and Eligibility Changes on HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
If a Medicare beneficiary is covered under an MA organization during a period of home care, and subsequently decides to change to Medicare fee- for-service coverage, a new OASIS assessment must be completed, as is required any time the Medicare payment source changes.  With that assessment, an NOA may be sent to Medicare to open an HH PPS period.   If a beneficiary under fee -for-service receiving home care elects an MA organization during an HH PPS period of care, the period will end and be proportionally paid according to its shortened length (a partial period payment adjustment).  The MA organizati on becomes the primary payer upon the MA organization enrollment date.   . 10.1.6 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.7 - Basis of Medicare Prospective Payment Systems and Case -Mix  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21) There are multiple prospective payment systems (PPS) for Medicare for different provider types.  Before 1997, prospective payment was a term specifically applied to inpatient hospital services.  In 1997, with passage of the Balanced Budget Act, prospective  payment systems were mandated for other provider groups/bill types:    Skilled nursing facilities;   Outpatient hospital services;  Home health agencies;   Rehabilitation hospitals; and  Others.   While there are commonalities among these systems, there are also variations in how each system operates and in the payment units for these systems.    Case- mix is an underlying concept in prospective payment.  With the creation of inpatient hospital PPS, the first Medicare PPS, there was a recognition that the differing characteristics of hospitals, such as teaching status or number of beds, contributed to substantial cost differences, but that even more cost impact was linked to the characteristics of the patient populations of the hospitals.  Other Medicare PPS systems, where research is applied to adjust payments for patients requiring more complex or costly care, use this concept of case- mix complexity, meaning that patient characteristics affect the complexity, and therefore, cost of care.  HH PPS considers a patients clinical and functional condition in determining case -mix for home health care.
(Medicare Claims Processing Manual)
For individual Medicare inpatient acute care hospital bills, diagnosis related groups (DRGs) are produced by claim information, which includes data elements such as procedure and diagnoses, through Grouper software that reads these pertinent elements on the claim and groups services into appropriate DRGs.  DRGs are then priced by a separate Pricer software module at the A/B MAC (A).  Processing for HH PPS is built on this model, using home health resources groups (HHRGs), instead of DRGs.  In HH PPS, paymen ts are case -mix adjusted using claim information and elements of the patient assessment.   Since 1999, HHAs have been required by Medicare to assess potential patients, and reassess existing patients, incorporating the OASIS (Outcome and Assessment Information Set) tool as part of the assessment process.  The total case -mix adjusted payment is based on elements of the OASIS data set and other information provided on the claim.  Payments made for the period are case -mix adjusted based on Grouper run in Medicare systems.  Pricer software run by the A/B MAC (HHH) processing home health claims perfor ms pricing including wage index adjustment and other factors.  10.1.8 - Coding of HH PPS Case -Mix Groups on HH PPS Claims: HHRGs and HIPPS Codes  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Under the home health prospective payment system as refined by the Patient -Driven Groupings Model, a case -mix adjusted payment for a 30- day period of care is made using one of 432 HHRGs.  On Medicare claims, these HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) codes.    HIPPS code rates represent specific characteristics (or case- mix) on which Medicare payment determinations are made.  HIPPS codes are used in association with special revenue codes used on institutional claims submitted to A/B MACs (HHH).  One revenue code  is defined for every Medicare prospective payment system that uses HIPPS codes.  For home health claims, this is revenue code 0023.  HIPPS codes are placed in HCPCS/Accommodation Rates/HIPPS Rate Codes field of the claim.
(Medicare Claims Processing Manual)
10.1.9 - Composition of HIPPS Codes for HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  For HH PPS periods of care, the distinct 5- position, alphanumeric home health HIPPS codes are created as follows:   The first position represents a combination of the referral source (community or institutional) and the period timing (early or late).    The second and third positions represent the clinical and functional domains of the HHRG coding system.   The fourth position represents the co- morbidity category that applies to the patient.    The fifth position is a placeholder for future use, required only because the field used to report HIPPS codes requires five positions.  Position #1  Position #2  Position #3  Position #4  Position #5  Source & Timing  Clinical Group  Functional Level  Co-Morbidity  Placeholder  1 - Community Early  A -  MMTA Other  A - Low 1 - None  1 2 - Institutional Early  B -  Neuro Rehab  B - Medium  2 - Low  3 - Community Late  C -   Wounds  C - High  3 - High   4 - Institutional Late  D -    Complex   Nursing Interv.        Using this structure, a second period for a patient with a hospital inpatient stay during the period, in the Wounds group, high functional severity and no co- morbidity would be coded 4CC11. HIPPS codes created using this structure are valid only on claim lines with revenue code 0023.  10.1.10 - Provider Billing Process Under HH PPS  (Rev. 1, 10- 01-03) HH- 467.15, A3- 3639.15  The next four sections describe the basic HH PPS billing process, not including payment adjustments.  Payment adjustment follows in subsequent sections.  10.1.10.1 - Grouper Links Assessment and Payment  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Position #1  Position #2  Position #3  Position #4  Position #5  Source & Timing  Clinical Group  Functional Level  Co-Morbidity  Placeholder   E -  MS Rehab      F   Behavioral Health      G  MMTA Surgical Aftercare      H  MMTA Cardiac & Circulatory      I  MMTA Endocrine      J  MMTA GI/GU      K  MMTA Infectious Disease
(Medicare Claims Processing Manual)
E -  MS Rehab      F   Behavioral Health      G  MMTA Surgical Aftercare      H  MMTA Cardiac & Circulatory      I  MMTA Endocrine      J  MMTA GI/GU      K  MMTA Infectious Disease      L  MMTA Respiratory     The home health Grouper software is incorporated in Medicare claims processing systems.  The Grouper uses claims data and OASIS data from the CMS quality data repository to assign the HIPPS code used for payment on the claim.   In the event of a temporary failure of the file transfer process that connects the claims and quality data systems, the MACs may resubmit claims to the quality system to ensure matching OASIS data is found.   This action may occur in response to notificati on from CMS or at the discretion of the MAC.   10.1.10.2 - Reserved  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.10.3 - Submission of the Notice of Admission (NOA)  (Rev. 12106; Issued: 06- 29-23, Effective: 01 - 01-24; Implementation:01 -02-24)   For each admission to home health, the HHA notifies Medicare systems via submission of a Notice of Admission (NOA).   HHAs shall 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 compa nion 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 HHA can submit an NOA to Medicare when:    The HHA has obtained a verbal or written order from the physician that contains the services required for the initial visit, and   The HHA has conducted an initial visit at the start of care.
(Medicare Claims Processing Manual)
 The HHA has obtained a verbal or written order from the physician that contains the services required for the initial visit, and   The HHA has conducted an initial visit at the start of care.   Only one NOA is required for any series of HH periods of care beginning with admission to home care and ending with discharge.  After a discharge has been reported to Medicare, a new NOA is required before the HHA submits any additional claims.   NOAs must be submitted timely.  A timely -filed NOA is submitted to and accepted by the A/B MAC (HHH) within five calendar days after admission date.    In instances where an NOA is not timely -filed, Medicare shall reduce the payment for a period of care, including outlier payment, by the number of days from the home health admission date to the date the NOA is submitted to, and accepted by, the A/B MAC (HHH), divided by 30. No LUPA per -visit payments shall be made for visits that occurred on days that fall within the period of care prior to the submission of the NOA.  This reduction shall be a provider liability, and the provider shall not bill the benefic iary for it.    If an HHA fails to file a timely -filed NOA, it may request an exception, which, if approved, waives the consequences of late filing.  The four circumstances that may qualify the HHA for an exception are as follows:   1. fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHAs ability to operate;  2. an event that produces a data filing problem due to a CMS or A/B MAC (HHH) systems issue that is beyond the control of the HHA;   3. a newly Medicare -certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its A/B MAC (HHH); or,   4. other circumstances determined by the A/B MAC (HHH) or CMS to be beyond the control of the HHA.
(Medicare Claims Processing Manual)
4. other circumstances determined by the A/B MAC (HHH) or CMS to be beyond the control of the HHA.   When an NOA is submitted within the five day timely filing period, but the NOA contains inadvertent errors (such as a beneficiary identifier that has recently changed), the error may not trigger the NOA to be immediately returned to the HHA for correction. In these instances, the HHA must wait until the incorrect information is fully processed by Medicare systems before the NOA is returned for correction. Such delays in Medicare systems could cause the NOA to be late. Delays due to Medicare system constrain ts are outside the control of the HHA and may qualify for an exception to the timely filing requirement.   HHAs can reduce the number of errors and exception requests related changes to the beneficiary identifier by performing an eligibility check immediately before admission.  This can confirm that the Medicare Beneficiary Identifier (MBI) is active and accurate since the eligibility inquiry system contains an MBI End Date field.    If there is a date in that field, the MBI is not valid after that date.  The HHA can contact the beneficiary or use the MBI Lookup tool to determine the current MBI to use on the NO A.   Since correct beneficiary identifier information is available to the HHA, only changes that occur shortly before the admission are beyond the HHAs control.  A/B MAC (HHH) MACs will not grant exceptions based on MBI changes that were accessible to the HHA more than two weeks prior to the admission date.   An admission period will be opened on CWF with the receipt and processing of the NOA.  NOAs are submitted using TOB 032A.  After this admission period is recorded, the HHA can submit claims for HH periods of care in the admission.   See section 40.1 for detailed submission instructions and required information for the NOA.    10.1.10.4 - Claim Submission and Processing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
10.1.10.4 - Claim Submission and Processing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Payment due to an HHA for a period of care will be made based on a claim submitted at the end of the 30- day period, or after the patient is discharged, whichever is earlier.  HHAs may not submit this claim until after all services are provided for the period and the physician has signed the plan of care and any subsequent verbal order.    All HH PPS claims must be submitted with TOB 0329.  The HH PPS claim will include line item detail describing all the services provided in the period of care.  At a providers option, any durable medical equipment, oxygen or prosthetics, and orthotics provided may also be billed on the HH PPS claim, and this equipment will be paid in addition to the period of care payment.  However, osteoporosis drugs and disposable negative pressure wound therapy (dNWPT) services must be billed separately on TOB 034x claims, even when an admission period is open.  See section 90.   Claims for periods of care may span calendar and fiscal years.  Payment rates are determined for all services on the claim using the Statement Covers Period Through date on the claim.   Once the payment for a period of care is calculated, Medicare claims processing systems determine whether the claim should be paid from the Medicare Part A or Part B trust fund.  This A -B shift determination does not affect HHA payment amounts.  Informatio nal value codes for A and B visits (value codes 62 and 63) and dollar amounts (64 and 65) may be visible to HHAs on electronic claim remittance records, but providers do not submit these value codes.   10.1.11 - Payment, Claim Adjustments and Cancellations (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
10.1.11 - Payment, Claim Adjustments and Cancellations (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)   HHAs may cancel or adjust claims.  Type of bill 0328 is used to cancel an HH PPS claim.  A cancellation is needed to change the beneficiary identifier or the HHAs provider number, if originally submitted incorrectly.  Type of bill 0327 is used to adjust a n HH PPS claim.  Adjustments are used to correct information that may change payment.    10.1.12 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.13 - Transfer Situation - Payment Effects  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  By law under the HH PPS system, beneficiaries must be able to transfer among HHAs, and payments must be pro- rated to reflect these changes.  To accommodate this requirement, HHAs submit an NOA with condition code 47 to indicate a transfer when an admission  period may already be open for the same beneficiary at another HHA.    In order for a receiving HHA to accept a beneficiary elected transfer, the receiving HHA must document that the beneficiary has been informed that the initial HHA will no longer receive Medicare payment on behalf of the patient and will no longer provide M edicare covered services to the patient after the date of the patients elected transfer in accordance with current patient rights requirements at 42 CFR 484.10(e) .  Documentation of these notifications may be needed if the transfer is disputed and verification is required as described in the Medicare Benefit Policy Manual, chapter 7, section 10.8.E. The receiving HHA must also document in its records that it access ed a Medicare inquiry system to determine whether or not the patient was under an established home health plan of care and contacted the initial HHA on the effective date of transfer.
(Medicare Claims Processing Manual)
In such cases, the previously open admission period will be automatically closed in Medicare claims processing systems as of the date services began at the HHA the beneficiary transferred to, as reported in the NOA.  The new admission period for the trans fer to agency will begin on that same date.  Payment will be pro- rated for the last claim in the closed admission period of the transferred from agency.    10.1.14 - Discharge and Readmission Situation Under HH PPS - Payment Effects  (Rev. 10758; Issued: 05 -11-21; Effective: 01 -01-22; Implementation: 08 -11-21)   Under HH PPS, HHAs may discharge beneficiaries before the period of care has closed if all treatment goals of the plan of care have been met.  Cases may occur in which an HHA has discharged a beneficiary during a period of care, but the beneficiary is readmitted to the same agency in the same 30 days.  Since no portion of the period can be paid twice, the first payment must be pro- rated to reflect the shortened period (see 10.1.15).  A new admission period can be opened by the HHA.  Medicare systems will allow this in cases where the CMS certification number (CCN) on the new NOA matches the CCN on the prior period.  The next period of care will begin the date the first service is s upplied under readmission (setting a new 30- day clock).
(Medicare Claims Processing Manual)
Note that beneficiaries do not have to be discharged within the period because of admissions to other types of health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such cases.  If an agency chooses not to discharge and the patient returns to the agency in the same 30- day period, the same period of care continues.  However, if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same period, the discharge is not recognized for Medicare payment purposes.  All the HH services provided in the complete period of care, both before and after the inpatient stay, should be billed on one claim. When discharging, full payment would still be made unless the beneficiary received more home care later in the same period.   Discharge is not required if the beneficiary has an inpatient stay that spans the end of the first 30 -day period of care in a 60- day certification period.  The HHA should submit the claim for the period following the discharge as if the 30- day periods were contiguous  submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge.  Medicare systems will a llow the HH claim to overlap the inpatient claim for dates in which there are no HH visits.   10.1.15 - Payment Adjustments - Partial Period Payment Adjustment  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Both transfer situations and discharge and readmission to the same agency in a 30- day period result in shortened periods of care.  In such cases, payment will be pro- rated.    Partial period payment adjustments occur as a result of the two following situations:   a. When a patient has been discharged and readmitted to home care within the same 30 -day period of care; or   b. When a patient transfers to another HHA during a 30- day period of care.