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.
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, MM11120, 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 Manual |
OCC CDS/DATES |
11 Onset of symptoms/illness and the date of symptom onset.
17 Date outpatient occupational therapy (OT) plan established or last reviewed. |
REV |
Enter the appropriate revenue code: |
HCPC |
Enter the appropriate HCPCS codes that relates to the therapy service provided. Refer to the "Annual Therapy Update |
MODIFS |
Following the HCPCS code, enter one of the following therapy modifiers. Therapy Modifiers Severity Modifiers (effective for dates of service on or after January 1, 2013, and before January 1, 2019) |
TOT UNIT |
Report the units as the number of times the procedure was performed. 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, 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, 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 |
Enter the national provider identifier (NPI) of the physician certifying the therapy plan of care. |
L |
Enter the last name of the physician certifying the therapy plan of care. |
F |
Enter the first name of the physician certifying the therapy plan of care. |
M |
Enter the middle initial of the physician certifying the therapy plan of care. |
REF PHYS NPI |
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 |
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 |
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 |
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
- Annual Therapy Update
- CGS "Therapy Functional Reporting" Web page
- CGS "Home Health Outpatient Therapies Coverage Guidelines" Web page
- CMS Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions
- CMS "Therapy Cap" Web page
- Medicare Learning Network (MLN) Matters® article, MM11120, Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018
- Medicare Learning Network (MLN) Matters® article, MM7050, "Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services"
- MLN Matters® article, MM7785, "Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012"
- MLN Matters® article, MM8005, "Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services – Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012"
- MLN Matters® article, MM8036, "Manual Medical Review of Therapy Services"
- MLN Matters® article, MM8206, "Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services
- MLN Matters® article, SE1307, "Outpatient Therapy Functional Reporting Requirements"
- Medicare Physician Fee Schedule (MPFS)Fact Sheet
- Search the Medicare Physician Fee Schedule (MPFS)
Refer to the following CMS Internet Only Manuals(IOMs) for coverage and billing regulations for home health outpatient therapy services:
- Medicare Benefit Policy Manual (Pub. 100-02, Ch. 15)
- Medicare Claims Processing Manual (Pub. 100-04, Ch. 5)
- Medicare Claims Processing Manual (Pub. 100-04, Ch. 10)
- Medicare Claims Processing Manual (Pub. 100-04, Ch. 25)
Updated: 12.23.19
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