Frequently Asked Questions for Home Health / Hospice

Where can I find any resources Cahaba has on billing supplies on home health final claims?

Please access to the following Web page references to assist you in understanding and appropriately submitting non-routine home health supplies to Medicare:

HH PPS Claims with Non-Routine Supplies (NRS) Web page
Claims Processing and Reimbursement Changes for Home Health Supplies Web page
Claim Page 02—Entering a RAP or Claim Web page
Supplies Web page
Top Claim Submission Errors for Home Health Providers: Error 31147 Web page
Top Claim Submission Errors for Home Health Providers: Error 32226 Web page

(Oct. - Dec. 2008 FAQ)

With the implementation of the National Provider Identifier, what changes have occurred when home health agencies (HHAs) submit influenza and pneumonia vaccines to Cahaba?

There are two new Web pages available with updated instructions for HHAs that bill vaccination claims to Cahaba:

(Oct. - Dec. 2008 FAQ)

Where can we find contact information for another home health agency if all we know is their Medicare provider number?

The names, provider numbers, and addresses of home health agencies are available on the Centers for Medicare & Medicaid Services (CMS) Web site. It can be accessed from the Cost Report page. To access home health information, click on Home Health Agency and scroll down to the list of downloads. Select “HHA Provider ID Information”. If you are unable to determine the contact information using this resource, call the Cahaba Provider Contact Center at (877) 299-4500.

(Oct. – Nov. 2008 FAQ)

Where can we find the most recent guidance issued regarding signature requirements?

The Centers for Medicare & Medicaid Services (CMS) issued Medicare Learning Network (MLN) article SE0829, which provides clarification regarding the topic.

(July – Sept. 2008 FAQ - Reviewed Nov. 2008)

Can Cahaba provide guidance to us regarding whether we can use specific diagnosis codes as primary on our home health claims?

The diagnosis, whether primary or secondary, must originate with the physician, and be based on the patient's condition. The primary diagnosis must be the chief reason for skilled home health care. Secondary diagnoses should be diagnoses those that are directly related to the home health plan of care, or those that may impact the home health plan of care. There are five allowances for secondary diagnoses in M0240 on the OASIS. If there are more than five secondary diagnoses, these should be included on the plan of care.

Any diagnoses and codes used as the primary (M0230) or secondary (M0240) must follow the ICD-9-CM coding guidelines. Payment does not impact the ICD-9-CM coding process, and Cahaba cannot provide any additional guidance beyond what is found in the ICD-9-CM coding guidelines.

(January – March 2008 FAQ - Reviewed Nov. 2008)

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 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 of 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.

(January – March 2008 FAQ - Reviewed Nov. 2008)

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 included on the final claim when billing home health services to Medicare, they are still bundled (included in the episode payment) under the Home Health Prospective Payment System (HH PPS), and are not separately payable. 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 also 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)

(Oct. – Dec. 2007 FAQ - Reviewed Nov. 2008)

Is it permissible to bill for a denial of skilled home health services using a no-pay bill containing condition code 21?

No. When skilled services will be provided, but Medicare will not pay for them due to the beneficiary not meeting other coverage criteria (not homebound/services not medically necessary), the HHA should complete the Home Health Advance Beneficiary Notice (HHABN) using Option Box 1, educate the beneficiary to authorize the HHA to bill Medicare, and follow appropriate demand billing procedures to submit these services for an official coverage determination by Medicare. More information on this topic can be found in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 50) and the Cahaba quick reference tools, Demand Billing Information Sheet for Home Health Providers and HHABNs and Billing Processes for Denial.

(Oct. – Dec. 2007 FAQ - Reviewed Nov. 2008)

Where can we find a listing of data elements that are required on home health final claims?

The Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 40.2) and the Cahaba quick reference tool, Home Health Medicare Billing Codes Sheet both contain the form locators on the UB-04, which are necessary for appropriately billing home health final claims to Medicare. Cahaba has also recently added Home Health Claims Filing Web pages, which provide screen prints and field descriptions for each FISS claim page and identify which fields are required for final claims. In addition, please access the Cahaba online course, Beginner Home Health Billing, which also provides this information.

(Oct. – Dec. 2007 FAQ - Updated Nov. 2008)

Is it permissible to submit an OASIS Claim-Matching-Key code of eighteen ones (111111111111111111) 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.

(Oct. – Dec. 2007 FAQ - Reviewed Nov. 2008)

If an OASIS Claim-Matching-Key code of eighteen ones (111111111111111111) 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) when the “FROM” date is prior to January 1, 2008. The Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 60) states in regard to no pay bills, “If no OASIS assessment was done, report the lowest weighted HIPPS code as a proxy (HAEJ1), an 18-digit string of the number 1, "111111111111111111", for the OASIS Claim-Matching-Key in FL 63, and meet other minimum Medicare requirements for processing RAPs. If an OASIS assessment was done, the actual HIPPS code and Matching-Key output should be used.” Please note that for dates of service beginning on or after January 1, 2008, the lowest weighted HIPPS code is 1AFKS and the 18-digit string of 11AA11AA11AAAAAAAA should be reported.

(Oct. – Dec. 2007 FAQ - Reviewed Nov. 2008)

I’m not sure how to submit a demand bill for our home health patient. Where can I find more information about this?

Cahaba has a quick reference tool, Demand Billing Information Sheet for Home Health Providers that provides instructions for submitting demand bills to Medicare, resources providers can access for more information, and examples of FISS claim pages completed with the required data elements for home health demand bills.

(July – Sept. 2007 FAQ - Reviewed Nov. 2008)

Where can I find the Medicare requirements for a home health agency to receive a patient in a beneficiary elected transfer situation?

The regulations for beneficiary elected transfers in the home health setting can be found in the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 7, § 10.8 and 10.8.E) and the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 10.1.15 and 20.1.1).

In addition, please also review the Beneficiary Elected Home Health Transfer and Home Health Discharge/Readmit Web pages for more information on this topic.

(July – Sept. 2007 FAQ - Reviewed Nov. 2008)

How do I add noncovered charges to a previously processed home health claim in a demand bill situation?

In order to add noncovered charges to a previously processed home health claim, an adjustment must be submitted (type of bill 327 or 337) to Medicare. Make sure to enter condition code 20 in FL 18-28, so that the adjustment processes as a demand bill. Key Claim Change Reason Code(CCRC) ‘D9’ into the first available condition code field (FL 18-28). Noncovered charges should be added on claim page 02 of the Fiscal Intermediary Standard System (FISS) in FL 42, 44, 45, 46, 47, and 48. If you submit your adjustment using FISS, you will also need to key 'RM' in the adjustment reason code field on claim page 03. You must also enter remarks on claim page 4 of FISS (FL 80) to explain the reason for the adjustment and demand bill.
Not adjusting existing home health claims can cause billing problems including duplicate billing, overlapping home health episodes, and reduced payment for the previously paid episode due to a partial episode payment (PEP).

(April - June 2007 FAQ – updated Nov. 2008)

How can I find listings of mailing addresses, phone and fax numbers?

Contact information for various Medicare entities can be found on the Contact Us page of the Cahaba Web site.

(April - June 2007 FAQ - Reviewed Nov. 2008)

When can hospices bill Medicare for physician services?

Physician or nurse practitioner (NP) services that are related to the terminal diagnosis and are professional (hands on) in nature are billed to the Regional Home Health Intermediary (RHHI) when the physician or NP is employed, under arrangement (contract), or is a volunteer of the hospice. If the services are provided by an independent attending physician, the physician bills the Medicare Part B Carrier. Cahaba has a quick reference tool available to assist hospices in determining when they should bill physician services to Medicare and the data elements required to bill such services on hospice claims.

(Jan. – March FAQ - Reviewed Nov. 2008)

Is it necessary to complete both the HHABN and “Notice of Medicare Provider Non-Coverage” form when a beneficiary is going to be discharged from Medicare?

Typically, you will not need to complete both forms in this situation. A “Notice of Medicare Provider Non-Coverage” form should be given to the beneficiary when they are being discharged from all Medicare-covered services. The only reason an HHABN needs to be given is if non-covered care were to continue after the beneficiary’s discharge. For example, the beneficiary has met the goals of the plan of care and is being discharged. However, they want homemaker services to continue. The “Notice of Medicare Provider Non-Coverage” form is given to the beneficiary to notify them they are being discharged from home care. The agency would also give the HHABN to notify the beneficiary that Medicare does not cover the homemaker services they are requesting; therefore, the beneficiary or another payer would be liable for payment of services. Please refer to the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 30, §60.2.B) for more information about this question.

(October - December 2006 FAQ - Reviewed Nov. 2008)

What is the most current guidance on use of the Home Health Advance Beneficiary Notice (HHABN) for instances where visits are decreased to the client but are within the ordered range that is on the POC?

When the initial instructions for the HHABN were first issued, it was our understanding that if visits decreased within the ranges ordered, an HHABN was not needed. However, the Centers for Medicare & Medicaid Services (CMS) has since clarified how ordered ranges impact the provision and administration of the HHABN. If the anticipated number of visits are clearly communicated in the original plan of care with the beneficiary, the HHA documents the conversation in the medical record and the course of treatment conforms exactly to the plan, then no HHABN is needed. Please see the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 30, § 60.2 & 60.3)

(Oct. - Dec. 2006 FAQ - Reviewed Nov. 2008)

With the changes being implemented by CR 5245 (reporting hospice services in greater detail), is the HCPC code used based on the type of facility where the patient resides or the type of care they are receiving?

The HCPC reported with the level of care the patient receives needs to reflect the type of facility where the patient resides, not the type of care that is received/provided.

(Oct. - Dec. 2006 FAQ - Reviewed Nov. 2008)

Which HCPC is used when a hospice patient’s place of residence isn’t detailed out in the HCPC listing?

HCPC Q5009 (Place not otherwise specified (NOS)) should be used when the patient’s place of residence isn’t indicated in the HCPC listing.

(Oct. - Dec. 2006 FAQ - Reviewed Nov. 2008)

Explain how the therapy caps affect home health patients.

The Centers for Medicare & Medicaid Services (CMS) implemented annual financial limitations for outpatient therapy services rendered on or after January 1, 2008, through December 31, 2008. The limit on the allowed amount for outpatient physical therapy (PT) and speech language pathology (SLP) combined is $1,810.00. There is a separate limit for occupational therapy (OT), which is also $1,810.00.

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. These services are billed to Medicare on a 34X type of bill (TOB). Therapy services billed under the Home Health Prospective Payment System (HH PPS) using TOB 329 or 339 are not impacted by the therapy cap limits. The amount a beneficiary has “to be met (TBM)” for the calendar year can be verified by checking page 1 of the beneficiary eligibility screens, ELGH or ELGA.

(Jan. – March 2006 FAQ - Reviewed Nov. 2008)

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.

For more information, review the Claims Correction section of the FISS Reference Guide for instructions on completing a cancellation electronically. You can also use the computer based training (CBT), Adjusting and Canceling Claims for more information.

(Sept. 2005 FAQ - Reviewed Nov. 2008)

When submitting a final claim for a beneficiary who revoked hospice, I forgot to include the occurrence code 42. Is this a problem, and how do I fix this?

Yes, it is a problem. When an occurrence code 42 is omitted from the claim, the hospice benefit period screens on ELGA/ELGH show the patient is still receiving hospice care, which prevents other providers from getting paid for services. To fix this, you can do an adjustment to the claim by accessing the Claim Correction (Option 03) and Claim Adjustment (Option 35) options in FISS. Add the occurrence code 42, and use condition code D9 and adjustment reason code RM on the claim. Make sure to include remarks that the occurrence code 42 was inadvertently omitted.

(July-Sept. 2005 FAQ - Reviewed Nov. 2008)

Page last updated: December 12, 2008