Home Health Billing FAQs

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1. How do I know how much to charge Medicare for my services/visits?

   • CMS's policy is for providers to bill Medicare the same that they bill other payers. There are four manual references listed below that support this position.

     Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 25, §75.5 states "The CMS policy is for providers to bill Medicare on the same basis that they bill other payers. This policy provides consistency of bill data with the cost report so that bill data may be used to substantiate the cost report. Medicare and non-Medicare charges for the same department must be reported consistently on the cost report."

     Provider Reimbursement Manual, (Pub. 15-1) Part 1, Ch. 22

     Section 2202 defines "charges" as "the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient. All patients' charges used in the development of apportionment ratios should be recorded at the gross value; i.e., charges before the application of allowances and discounts deductions."

     Section 2203 states "To assure that Medicare's share of the provider's costs equitably reflects the costs of services received by Medicare beneficiaries, the intermediary, in determining reasonable cost reimbursement, evaluates the charging practice of the provider to ascertain whether it results in an equitable basis for apportioning costs. So that its charges may be allowable for use in apportioning costs under the program, each facility should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program."

     Section 2204 states "The Medicare charge for a specific service must be the same as the charge made to non-Medicare patients (including Medicaid, CHAMPUS, private, etc.), must be recorded in the respective income accounts of the facility, and must be related to the cost of the service."

     Reviewed: 03.20.17

2. How do HHAs report non-covered visits on Home Health Prospective Payment System (HH PPS) claims? For example, how are non-covered visits reported if we do not get a therapy assessment completed timely?

   • HHAs report (along with covered charges) all non-covered charges, related revenue codes, and HCPCS codes, where applicable. In order to report non-covered visits on HH PPS claims, HHAs enter the total non-covered charges in form locator (FL) 48 (Non-Covered Charges) of the CMS-1450 claim form that pertain to the related revenue code in FL 42 (Revenue Code).

     When billing non-covered home health visits to Medicare using the Fiscal Intermediary Standard System, please be aware that an amount should be entered in both the TOT CHARGE and NCOV CHARGE fields on FISS page 02 for the line item date of service. In addition, no service units should be entered in the "COV UNIT" field for non-covered visits.

     Additional instructions for submitting non-covered visits on HH PPS claims are available in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 40.2 ).

     Reviewed: 03.20.17

3. Can the Request for Anticipated Payment (RAP) be submitted if the face to face encounter hasn't been performed?

   • Please see the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, §10.1.10.3 ) for the conditions that must be met in order for the RAP to be submitted to Medicare.

     Reviewed: 03.20.17

4. If the certification and plan of care are signed by two separate physicians, which one should be the physician submitted on the claim?

   • The Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 40.2 ) states that the home health agency "enters the name and provider identifier of the attending physician that has signed the plan of care" when submitting the final claim for the episode.

     Please see the Medicare Learning Network (MLN) Matters Article SE1305, "Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Request 6417, 6421, 6696, and 6856)" to avoid claim denials for the attending physician information submitted on home health claims.

     For episodes that begin on/after July 1, 2014, Change Request 8441 requires HHAs to report the NPI/name of the physician who signs the plan of care in the "attending physician" field, and the NPI and name of the physician who certified/recertified that patient (if this physician is different) in the "Ordering Physician" field.

     Reviewed: 03.20.17

5. What do we need to do to make sure our home health Medicare Secondary Payer (MSP) claims get paid?

   • Home health agencies should ensure any required MSP data such as condition codes, occurrence codes and dates, and value codes and amounts are present at the time the home health claim is submitted to Medicare. In addition, detailed remarks that will assist with the processing of the MSP claim are also important. As a reminder, Requests for Anticipated Payment (RAPs) billed by home health agencies should never contain MSP data. HHAs should also review the Medicare Secondary Payer (MSP) Billing & Adjustments quick resource tool for assistance in determining if Medicare is the primary or secondary payer. The CGS Medicare Secondary Payer (MSP) Online Tool is also available for providers to use to determine appropriate billing of MSP claims.

     In addition, effective for claims received on or after January 1, 2016, Change Request (CR) 8486 implemented changes that allow MSP claims to be entered directly into the Fiscal Intermediary Standard System via direct data entry (DDE). CR 8486 also requires that all MSP claims, submitted via 5010 format or DDE, include Claim Adjustment Segment (CAS) information to ensure proper processing.

     In addition, HHAs should ensure that information normally required on Medicare home health claims is present prior to submitting their MSP claims. Any missing, incorrect or invalid information will cause the claim to be returned for correction or rejected, which will create additional billing issues for HHAs, including the need to correct or resubmit claims multiple times or adjust them in order to receive Medicare payment.

     Reviewed: 03.20.17

6. We have a Request for Anticipated Payment (RAP) that rejected because the dates of service we billed on it overlaps a date the beneficiary was in an inpatient stay. How do we correct our billing error?

   • RAPs will reject if the date submitted on them overlaps a date the beneficiary was in an inpatient stay. In this case, the rejected RAP typically will post the home health episode to the Common Working File (CWF). The only way HHAs can resolve the billing error is to cancel the rejected RAP. Once the cancel RAP (3X8 TOB) has processed (FISS S/LOC P B9997), a new RAP with the correct date of service can be submitted to Medicare.

     To verify whether the RAP posted to CWF, review the TPE-TO-TPE (Tape to Tape) field on MAP171D in FISS. If this field is blank, the information from the rejected RAP posted to CWF, and must be canceled in order to remove it. As a reminder, in order to access the rejected RAP using FISS cancel option "53", you will need to change the "P" that defaults in the S/LOC field to an "R", and add "B9997" in the LOC field. You may also need to change the TOB to "32".

     When submitting an initial (start of care) episode for home health services to Medicare, the "FROM" date (FL 4) and "ADMIT DATE" (FL 12) entered on the RAP must reflect the date of the first Medicare billable visit in the episode, not the date the referral for home health services was received. When billing a subsequent (recertification) episode of care, the "FROM" date reflects the next calendar day in the following episode (day 61, 121, etc.), and the "ADMIT DATE" does not change from the initial episode. The date billed with the 0023 revenue code line on all RAPs and claims must reflect the date of the first Medicare billable visit in the episode. Additional information on submitting cancels is available in Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Guide. Instructions on accessing MAP171D screen in FISS are available in Chapter Three – Inquiry Menu of the FISS Guide.

     Reviewed: 03.20.17

7. My home health claim overlaps an inpatient stay posted to the Common Working File (CWF). How can I resolve this?

   • HHAs should be aware that per the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 30.9 ), "Claims for institutional inpatient services, that is inpatient hospital and skilled nursing facility (SNF) services, will continue to have priority over claims for home health services under HH PPS." To resolve this billing error, access the Top Claim Submission Errors for Home Health Providers: Error C7080 web page. CGS encourages you to use the first Medicare billable visit in the episode as the date of service submitted when billing non-routine supplies or surgical dressing/wound care supplies to avoid errors for overlapping inpatient stays as this is a common reason why this billing error occurs.

     Reviewed: 03.20.17

8. Is there any way to tell which date on our home health final claim overlaps an inpatient stay?

   • If the inpatient facility has submitted their billing, the DOEBA and DOLBA fields may be updated on ELGA Page 1. You may be able to determine which date overlaps the inpatient stay based on this information. Please be aware that the DOEBA and DOLBA dates reflect the first and last billing dates in an inpatient benefit period, and the beneficiary may experience multiple inpatient stays during a single inpatient benefit period. More information about the data fields included on ELGA Page 1 is available in Chapter Two – Checking Beneficiary Eligibility of the Fiscal Intermediary Standard System (FISS) Guide. Please be aware that provider access to ELGA/ELGH will be terminated at some point in the future. See Medicare Learning Network (MLN) Matters® article, MM8248 for more information.

     In addition to ELGA and ELGH, the myCGS web portal can also be used to access the inpatient stay dates information by looking at the "Inpatient" tab within the "Eligibility" tab. See the myCGS User Manual for additional information.

     If you are unable to determine the overlapping date by looking at beneficiary's eligibility file, please call the Provider Contact Center at (877) 299-4500 (Option 1) to receive this information.

     Reviewed: 03.20.17

9. My claim rejected and the reason code states that the claims overlaps a hospice election period. How can I tell if a beneficiary has elected the Medicare hospice benefit?

   • If a patient has elected the Medicare hospice benefit, this information will be posted to their eligibility file. Providers can determine this by viewing Page 2 of ELGA, and Page 9 of ELGH. Please be aware that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 for more information.

     In addition to ELGA and ELGH, the myCGS web portal can also be used to access this information by looking at the "Hospice/Home Health" tab within the "Eligibility" tab. See the myCGS User Manual for additional information.

     While a patient has elected the hospice benefit, the hospice agency is responsible for providing all care related to the terminal diagnosis. Medicare will not reimburse services submitted by other providers, such as home health agencies, that are related to the terminal diagnosis while the patient has elected hospice. Medicare will reimburse services that are unrelated to the terminal diagnosis. Providers must indicate the services as unrelated by using a condition code 07 in FL 18-28 on the UB-04 claim form. This field corresponds with the "COND CODES" fields found on FISS Page 01. See the Election of the Medicare Hospice Benefit While Receiving Home Health Services During an MA Plan Enrollment Period Web page for additional information.

     Reviewed: 03.20.17

10. It's our understanding that if a beneficiary elects the hospice benefit, and they are enrolled in a Medicare Advantage (MA) plan all Medicare services are billed to the intermediary. Is this correct? Also, if the hospice election is revoked, when does the MA plan begin to pay for services?

    • Your understanding is correct. When a beneficiary enrolled in an MA plan elects the Medicare hospice benefit, services are billed to the provider's intermediary or Medicare Administrative Contractor (MAC). This includes services not related to the beneficiary's terminal diagnosis that are provided by home health agencies or other Medicare providers. Services furnished after the beneficiary revokes or is discharged from hospice care will continue to be paid by the intermediary or MAC until the first day of the month after the hospice election ends, at which time the MA plan resumes payment responsibility for the beneficiary. (Reference: Pub. 100-04, Ch. 11., § 30.4 )

      Reviewed: 03.20.17

11. Our home health claims are receiving Partial Episode Payments (PEPs) or billing errors for overlapping a Medicare Advantage (MA) plan. How can we get our episodes fully paid by CGS?

    • When a beneficiary under Medicare Fee-For-Service (FFS) coverage elects an MA Plan during a Home Health Prospective Payment System (HH PPS) episode, the episode will end and be proportionally paid according to its shortened length (a partial episode payment (PEP) adjustment). The MA Plan becomes the primary payer effective with the MA Plan enrollment date. CGS cannot make payments under the HH PPS or any other Medicare Part A or Part B payment system for dates of service falling within a beneficiary's enrollment in an MA plan, unless the beneficiary has also elected the Medicare hospice benefit. Review the information found on the Medicare Advantage (MA) Plans — Claim Filing Tips When A Beneficiary Receiving Home Health Services Enrolls / Disenrolls web page for assistance in understanding how home health services are impacted by a Medicare Advantage Plan enrollment. For more on steps HHAs can take to avoid errors due to a beneficiary's enrollment in an MA plan, see the Top Claim Submission Errors for Home Health Providers: Error U5233 and 7CS21 web page. In addition, see the Medicare Claims Processing Manual, (Pub. 100-04, Chapter 10, § 10.1.5.2 & 80 ) for more information about MA plans and their impact on HH PPS episodes

      Reviewed: 03.20.17

12. My home health RAP paid, but I billed incorrect information on it. How can I fix this?

    • If your RAP paid and you determine it contains incorrect information, you will need to cancel it. A provider-cancelled RAP causes the episode established on the Common Working File (CWF) to be removed. RAPs may not be adjusted.

      To cancel a RAP, access the Claim Correction (Option 03) and Claim Cancels (Option 53) options in FISS. Once the cancel RAP processes (e.g. found in FISS status/location P B9997), re-bill the RAP with the correct information. Additional information on submitting cancels is available in Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Guide.

      Reviewed: 03.20.17

13. What do we need to do to when the dates of service we billed for a beneficiary's home health episode are incorrect?

    • Most often, HHAs will need to cancel and resubmit the Request for Anticipated Payment (RAP) and/or final claim in order to correct episode dates of service that are in error. Review the instructions found on the Correcting Home Health Episode Information Posted to the Common Working File (CWF) web page for more information.

      Reviewed: 03.20.17

14. We are noticing that some of our previously paid home health claims are being adjusted with type of bills 32I. What is causing this?

    • The third digit of "I" in the type of bill indicates that these adjustments are initiated by the Medicare contractor. Home health agencies are seeing these more frequently because of the quarterly reconciliation process that occurs when an outlier, which was previously unable to be paid because it exceeded 10 percent of the HHA's total Home Health Prospective Payment System (HH PPS) payments, is now payable due to the processing of subsequent HH PPS claims over the calendar year.

      Additional information is also available in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10 ), the Home Health Prospective Payment System fact sheet and MLN quick reference information: Home Health Services .

      Reviewed: 03.20.17

15. Some of our patients have a payment source other than Medicare when we begin providing home health services to them and then they become eligible for Medicare while we are seeing them or their Medicare benefits may be subsequently activated. How do we bill Medicare when the patient becomes entitled to Medicare in this situation?

    • There are occasional instances when it is learned that a patient has become entitled to Medicare after the fact, and it is determined that the patient would have qualified for the Medicare home health benefit at the time of entitlement (under a plan of care by a physician, qualifying skilled need/services provided and the patient was homebound). When this occurs, a new start of care Outcome and Assessment Information Set (OASIS) assessment must be completed that reflects the date of the beneficiary's change to this payment source. The OASIS items must be completed based on the beneficiary's condition(s) and needs at the time the patient was eligible for the home health benefit. A new start of care is required any time the payment source changes to Medicare Fee-for-Service (FFS). The OASIS is completed in order to obtain a Health Insurance Prospective Payment System (HIPPS) code and Claims-OASIS Matching Key code, which are needed to bill Medicare. Effective January 1, 2015, the OASIS data must be submitted to the Center for Medicare & Medicaid Services (CMS) via the national OASIS Assessment Submission and Processing (ASAP) system.

      With that assessment, a Request for Anticipated Payment (RAP) may be sent to Medicare to open an HH PPS episode.

      For more information about coverage of Medicare home health services, please see the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 7 )

      Instructions for billing home health services to Medicare can be accessed from the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10 ). You may also need to review the information found in Ch. 25 of this manual.

      Reviewed: 03.20.17

16. Will Medicare Part B reimburse flu or pneumonia (PPV) shots for a beneficiary who is enrolled in a Medicare Advantage (MA) plan?

    • Generally, payment under Fee-For-Service (FFS) Medicare, which includes Part B benefits such as flu and pneumonia vaccines, cannot be made for dates of service falling within a beneficiary's enrollment in an MA plan. The Medicare Managed Care benefits are administered under Medicare Part C by MA plans. Beneficiaries receiving Part C benefits should contact their MA plan in order to determine their coverage for influenza virus and PPV vaccines and which providers are within the MA plan's provider network. Since CGS does not process MA plan claims, we cannot provide any additional information on coverage or billing processes for Medicare Part C.

      Reviewed: 03.20.17

17. My RAP/home health claim needs correction and the reason code states that the episode overlaps an existing episode with the same or different provider number. How can I tell if a beneficiary is in a current home health episode?

    • ELGA and ELGH, the patient eligibility screens, can provide information on billing periods established by other providers. Using information found in these screens can assist you in resolving claim errors that occur due to overlapping dates of service with another provider. Page 3 of ELGH and Page 4 of ELGA will help you determine if the patient is in a current home health episode. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 for more information.

      REMINDER: If you need to review older episode information, ensure that you enter the first calendar day of the episode in the APP DATE field when accessing the beneficiary's eligibility information. If your dates of service overlap an existing episode, you may need to call the other agency. The provider number of the agency can be accessed from the PROV NUM field on Page 3 of ELGH.

      In addition to ELGA and ELGH, the myCGS web portal can also be used to access this information by looking at the "Hospice/Home Health" tab within the "Eligibility" tab. In order to view all home health episodes that may impact your dates of service, CGS recommends, at a minimum, entering your 60-day episode dates in the "Date Range" field when using myCGS® for eligibility checks. See the myCGS User Manual for additional information.

      Once you have reviewed the home health episode information posted to the beneficiary's eligibility file, access the CGS quick resource tool, Avoiding Billing Errors Caused By Overlapping Home Health Episodes to determine the action that should be taken. If you are unable to resolve the overlapping issue after reviewing the eligibility information and using the quick resource tool, call the CGS Provider Contact Center at (877) 299-4500 (Option 1) for assistance.

      Reviewed: 03.20.17

18. We admitted a patient who is in a current home health episode. I need to know how to contact the other home health agency to figure out if they discharged the patient. Where can we find contact information for another home health agency if all we know is their Medicare provider number?

    • The names, Provider Transaction Access Numbers (PTANs), and addresses of home health agencies are available on the Centers for Medicare & Medicaid Services (CMS) website. It can be accessed from the Cost Report Web page. To access home health information, click on the Home Health Agency link and scroll down to the list of downloads. Select the "HHA-REPORTS (Supplemental Files and counts)" link under the "Downloads" header to open a zip file containing the listing of HHAs. The document named "HHA_PROVIDER_ID_INFO" contains the HHA listing.

      If using myCGS to verify beneficiary home health eligibility, please be aware that a National Provider Identifier (NPI) may display for the home health agency providing care to the beneficiary, rather than a PTAN. HHAs will need to use the NPI Registry housed on the National Plan & Provider Enumeration System (NPPES) website. You will need to click on the link to "Search for an Organizational Provider" to enter the NPI displayed in the "Provider Number" field. See the myCGS User Manual for additional information.

      If you are unable to determine the contact information after using this resource, call the CGS Provider Contact Center at (877) 299-4500 (Option 1).

      Reviewed: 03.20.17

19. Our home health patient received supplies covered under consolidated billing from another supplier, who is now demanding payment from us because they cannot bill the item separately. Are we liable for payment for this supply?

    • It is the intent of consolidated billing for home health episodes of care to include all services and supplies needed to carry out the plan of care (POC). Therefore, if the following conditions are met, the HHA would not be liable for payment:

      The service or supply is not on POC or Consolidated Billing Master Supply List .

      The HHA does not have an existing arrangement with supplier/provider.

      The HHA is unaware that the beneficiary received home health related services/supplies from another provider.

      The Medicare Claims Processing Manual (Pub. 100-04, Ch. 10 § 20.1.1 ) states that HHAs "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 during an episode to a patient who is under their home health plan of care." However, it is the HHA's responsibility to "fully inform beneficiaries that all home health services, including therapies and supplies, will be provided by his/her primary HHA." This would include advising the beneficiary to contact the HHA when needing supplies or medical care while under the home health agency's care.

      In addition, HHAs must also advise "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 other than their primary HHA."

      If the beneficiary is properly notified, the beneficiary may be held liable for payment. However, CMS further states that "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." The Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 20.1.2 ) outlines the responsibilities of providers and suppliers for services subject to home health consolidated billing, including their responsibility to "determine whether or not a home health episode of care exists" for a beneficiary before providing services to them.

      Reviewed: 03.20.17

20. How do we know which supplies are routine or non-routine for a home health episode?

    • A supply is considered non-routine when the item:

      • Is directly identifiable for an individual patient;
      • Can be identified and accumulated in a separate cost center; and
      • Is ordered by the patient's physician and is specifically identified in the plan of care (POC)

      In addition, an item meets the criteria for non-routine supplies when the HHA follows a consistent charging practice for Medicare and non-Medicare beneficiaries receiving the item.

      Please note that even though non-routine supplies are line item billed on the final claim when submitting home health services to Medicare, they are still included in the total episode payment under the Home Health Prospective Payment System (HH PPS), and are not separately payable. The supply severity level (which is indicated by the fifth position of the HIPPS code) determines the payment amount HHAs receive for non-routine supplies. HHAs receive the supply severity payment amount regardless of whether non-routine supplies were provided to the beneficiary during the episode.

      For a listing of nonroutine supplies that are included in HH PPS consolidated billing, please review the Consolidated Billing Master Supply List . Supplies not on the list, but needed to carry out the plan of care, are bundled under consolidated billing for home health. For more information, please refer to the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 7, § 50.4.1 ), as well as the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 10.1.4 )

      Reviewed: 03.20.17

21. If we bill a RAP with a HIPPS code indicating that we will be providing supplies, should we cancel and re-bill it if we didn't provide the supplies during the episode?

    • No. If you will only be changing the fifth position of the HIPPS code to a number to indicate your HHA did not provide supplies to the beneficiary, you do not need to cancel and re-bill the RAP. HHAs should ensure that they do not change the supply severity level when updating the fifth position of the HIPPS code on the final claim to reflect whether or not supplies were provided during the episode. Please see the "Billing HH PPS Claims With Non-Routines Supplies (NRS)" web page for more information.

      Reviewed: 03.20.17

22. Is it permissible to submit a generic OASIS Claim-Matching-Key code (11AA11AA11AAAAAAAA) as the treatment authorization code on a home health demand bill?

    • No. Home health agencies should use the OASIS Claim-Matching-Key output, along with the HIPPS code that is generated through the Grouper software from their OASIS assessment for the 60-day episode when a demand bill (which must contain condition code 20) needs to be submitted to Medicare. Review the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 50 ), Demand Billing Information Sheet for Home Health Providers quick resource tool and Home Health Demand Denials (Condition Code 20) web page for additional information on home health demand bills.

      Reviewed: 03.20.17

23. If generic OASIS Claim-Matching-Key code (11AA11AA11AAAAAAAA) cannot be used as the treatment authorization code on home health demand bills, when can it be used?

    • This can be used as the treatment authorization code on a no-pay bill (submitted with condition code 21). Review the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 60 ) and Home Health No-Payment Billing (Condition Code 21) Web page for additional information on home health no-pay bills.

      Reviewed: 03.20.17

24. If we provide more therapy visits than were anticipated at the beginning of the episode, should we cancel the RAP and re-bill it with a higher HIPPS code?

    • No. The Fiscal Intermediary Standard System (FISS) will adjust the HIPPS code to reflect the actual number of therapy visits submitted on the claim, thereby ensuring appropriate payment for the HHA. If more therapy visits were provided than were reflected by the HIPPS code, FISS will "upcode" the claim and change the HIPPS code to indicate the increase in the beneficiary's service utilization. HHAs are reminded that the first four positions of the HIPPS code submitted on the final claim must match the first four positions of the HIPPS code submitted on the episode's RAP.

      Reviewed: 03.20.17

25. Explain how the therapy caps affect home health patients.

    • Beneficiaries who are not homebound or under a plan of care, and are receiving outpatient Part B therapy services from a home health agency (HHA) are affected by the therapy caps. The limit on the allowed amount for outpatient physical therapy (PT) and speech language pathology (SLP) combined is $1,920 for calendar year 2014 ($1.940 for 2015). There is a separate limit for occupational therapy (OT) which is also $1,920 ($1.940 for 2015). These services are billed to Medicare on a 34X type of bill (TOB).

      The dollar amount that has been applied to the beneficiary's therapy caps for the calendar year can be verified by checking the "PT APL" and "OT APL" fields found on Page 1 of the beneficiary eligibility screens, ELGH or ELGA. The myCGS web portal can also be used to access this information by looking at the "Deductible/Caps" tab within the "Eligibility" tab. See the myCGS User Manual for additional information. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 for more information.

      Therapy services billed and paid under the Home Health Prospective Payment System (HH PPS) using TOB 329 are not impacted by the therapy cap limits.

      For more information regarding the therapy cap, please see the CMS Therapy Cap Web page. Coverage guidelines for home health outpatient therapies are available at the Home Health Outpatient Therapies Coverage Guidelines page . Requirements and resources for home health outpatient therapy billing are available on the Home Health Outpatient Therapy Billing page .

      In addition, effective December 9, 2013, HHAs are required to issue an Advance Beneficiary Notice (ABN) to beneficiaries before providing them therapy that is not medically reasonable and necessary, regardless of the therapy cap. For additional information, refer to the MLN Matters® article MM8404 .

      Reviewed: 03.20.17

26. Why does FISS change the HIPPS code submitted on a final claim?

    • The Pricer program in FISS will change the HIPPS code if the Common Working File (CWF) determines that the beneficiary's episode history is different from what is indicated by the first position of the HIPPS code. In addition, if the number of therapy visits billed on the final claim is different than what is indicated by the HIPPS code billed on the claim, FISS will also change the HIPPS code to match the number of therapy visits actually billed by the HHA. CGS has a quick resource tool, Understanding Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) Code Changes , that is available for HHAs to use in determining how FISS modifies the original HIPPS code submitted on home health final claims.

      Reviewed: 03.20.17

27. How is an "early" episode defined?

    • An early episode is the first or second episode in a series of continuous covered home health episodes of care received by the beneficiary. If there is a span of more than 60 calendar days between the "END DATE" of a prior episode and the "START DATE" of the next episode, the home health care is not continuous; therefore, the next episode would be considered early. Additional information about home health episode timing is available in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 10.1.19.2 ).

      Reviewed: 03.20.17

28. If the episode is paid as a Low Utilization Payment Adjustment (LUPA), how are adjacent episodes determined?

    • Since LUPAs reflect the services that were provided during a full 60-day episode, HHAs should use the "END DATE" of the prior episode to determine whether the subsequent episode is adjacent. If there is more than 60 days between the end date of the LUPA episode and the start date of the next episode, it would not be considered adjacent.

      Reviewed: 03.20.17

29. If the previous episode was paid as a Partial Episode Payment (PEP), how are adjacent episodes determined?

    • The "Date of Latest Billing Action" (DOLBA) is used when determining whether an episode that follows the PEP is adjacent.

      Reviewed: 03.20.17

30. What is the impact of an auto-canceled RAP posted to a beneficiary's home health episode history?

    • A RAP that auto-cancels does not remove the episode from a beneficiary's home health episode history; therefore, it will impact adjacent episodes submitted for the beneficiary.

      Reviewed: 03.20.17

31. When a claim comes in out of order, will this generate an auto adjustment to all claims that have been processed?

    • Yes. System adjustments will occur when a new episode is received and the date of service (DOS) cause previously processed claims to move within the episode series.

      Reviewed: 03.20.17