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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)External Website.

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 MenuPDFof 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.

NOTE: Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.  Refer to Medicare Learning Network (MLN) Matters® article, MM11120External PDF, Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018 for additional information.

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 ManualExternal Website)

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 ManualExternal Website

HCPC

Enter the appropriate HCPCS codes that relates to the therapy service provided. Refer to the "Annual Therapy UpdateExternal Website" Web page on the CMS website and the Medicare Claims Processing Manual, Pub. 100-04, Ch. 5, §10.6External PDFfor more information .

MODIFS

Following the HCPCS code, enter one of the following therapy modifiers. 

Therapy Modifiers
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.

Severity Modifiers (effective for dates of service on or after January 1, 2013, and before January 1, 2019)
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

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, and before January 1, 2019, for the G code line, enter 1 unit.

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

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, and before January 1, 2019. for the G code line, enter 1 unit.

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

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, and before January 1, 2019, for the G code line, enter a nominal charge (example - $0.01)

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

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 ManualsExternal Website(IOMs) for coverage and billing regulations for home health outpatient therapy services:

Updated: 12.23.19

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