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Home Health Outpatient Therapy Billing

Outpatient therapy services may be furnished by a home health agency (HHA) to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC). These services are not paid under the Home Health Prospective Payment System (HH PPS). Instead, the home health agency's reimbursement for outpatient therapy services is calculated using the Medicare Physician's Fee Schedule (MPFS).

HHA outpatient therapy claims can be entered into the Fiscal Intermediary Standard System (FISS) Home Health Claims Entry option 26 (accessible from FISS Main Menu option 02). See Chapter 4 – Claims and Attachments Menu of the Fiscal Intermediary Standard System (FISS) Guide for information on entering Medicare claims using FISS. In addition to the usual information that is required on Medicare claims, the following identifies specific information required for HHA outpatient therapy claims.

Field Name Description
TOB 34X — HHA visits provided on an outpatient basis. ('X' denotes the frequency of bill. Frequency indicators are accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual)
OCC CDS/DATES 11 Onset of symptoms/illness and the date of symptom onset.

  • When appropriate, enter one of the following occurrence codes and corresponding date:
17 Date outpatient occupational therapy (OT) plan established or last reviewed.
29 Date outpatient physical therapy (PT) plan established or last reviewed
30 Date outpatient speech-language pathology (SLP) plan established or last reviewed
35 Date treatment started for PT
44 Date treatment started for OT
45 Date treatment started for SLP
REV Enter the appropriate revenue code:
042X — Physical therapy
043X — Occupational therapy
044X — Speech-language pathology
Please note that "X" is a placeholder which indicates the value can vary from 0-9. A complete list of revenue codes is available from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual
HCPC Enter the appropriate HCPCS codes that relates to the therapy service provided.  For the current therapy code list, refer to the “Annual Therapy Update” web page on the CMS website.

Note: Functional data reporting is effective for claims with dates of service on or after January 1, 2013, which requires providers to report a non-payable Functional G-code(s) on their claim.  Refer to the Medicare Claims Processing Manual, Pub. 100-04, Ch. 5, §10.6 for more information and a list of function-related G-codes.
MODIFS Following the HCPCS code, enter one of the following severity modifiers (CH – CN) followed by the appropriate modifier related to the therapy service being provided.

Severity Modifiers (effective for dates of service on or after January 1, 2013)
CH — 0 percent impaired, limited or restricted
CI — At least 1 percent but less than 20 percent impaired, limited or restricted
CJ — At least 20 percent but less than 40 percent impaired, limited or restricted
CK — At least 40 percent but less than 60 percent impaired, limited or restricted
CL — At least 60 percent but less than 80 percent impaired, limited or restricted
CM — At least 80 percent but less than 100 percent impaired, limited or restricted
CN — 100 percent impaired, limited or restricted

Therapy Modifiers
CN — 100 percent impaired, limited or restricted
GN — Services personally provided by a speech-language therapist.
GO — Services personally provided by an occupational therapist
GP — Services personally provided by a physical therapist
KX — Outpatient therapy services when the beneficiary is qualified for exception to the therapy caps.
TOT UNIT Report the units as the number of times the procedure was performed.

Effective for dates of service on or after January 1, 2013, for the G code line, enter 1 unit.
COV Unit Key the number of covered units for the services billed.  Ensure the appropriate increment is reflected for the therapy being billed.

Effective for dates of service on or after January 1, 2013, for the G code line, enter 1 unit.
TOT CHARGE Key the total charge per revenue code.  The decimal point is optional (i.e., $1500.00 can be keyed as 1500.00 or 150000).  However, you must key two zeroes (00) for the cents amount.

Effective for dates of service on or after January 1, 2013, for the G code line, enter a nominal charge (example - $0.01)
SERV DATE Enter the line item date for the service provided.
ATT PHYS NPI
Required
Enter the national provider identifier (NPI) of the physician certifying the therapy plan of care.
L
Required
Enter the last name of the physician certifying the therapy plan of care.
F
Required
Enter the first name of the physician certifying the therapy plan of care.
M
Optional
Enter the middle initial of the physician certifying the therapy plan of care.
REF PHYS NPI
Conditionally Required
Enter the NPI of the physician certifying the therapy plan of care only in cases where different professionals certify the occupational therapy (OT), physical therapy (PT), or speech-language pathology (SLP) plan of care.
L
Conditionally Required
Enter the last name of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.
F
Conditionally Required
Enter the first name of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.
M
Optional
Enter the middle initial of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.

Additional Resources

Refer to the following CMS Internet Only Manuals (IOMs) for coverage and billing regulations for home health outpatient therapy services:

Updated: 1.15.14


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