HHAs are required to submit
the following claims detail for final payment under the HHA PPS:
3.1.2.19 Coding
required for a HHA PPS claim is as follows:
3.1.2.19.1 FL 1. (Untitled)
Provider Name, Address, and Telephone Number Required. The minimum
entry is the agency’s name, city, state, and zip code. The post
office number or street name and number may be included. The state
may be abbreviated using standard post office abbreviations. Five
or nine digit zip codes are acceptable. Use this information in
connection with the provider number (FL 51) to verify provider identity.
3.1.2.19.2 FL 2. (Untitled)
Not Required.
3.1.2.19.3 FL 3. Patient
Control Number Required. The patient’s control number may be shown
if you assign one and need it for association and reference purposes.
3.1.2.19.4 FL 4. TOB
Required. This three digit alphanumeric code gives three specific
pieces of information. The first digit identifies the type of facility.
The second classifies the type of care. The third indicates the
sequence of this bill in this particular EOC. It is referred to
as a “frequency” code. The types of bills accepted for HHA PPS RAPs
are any combination of the codes listed below:
3.1.2.19.4.1 Code Structure
(only codes used to bill the TRICARE Program are shown).
3.1.2.19.4.2 First Digit:
Type of Facility
3.1.2.19.4.3 Second
Digit: Bill Classification (Except Clinics and Special Facilities)
• 2 -
Hospital Based or Inpatient
Note: While the bill classification of 3, defined as
“Outpatient,” may also be appropriate to a HHA PPS claim depending
upon a beneficiary’s eligibility, HHAs are encouraged to submit
all claims with bill classification 2.
3.1.2.19.4.4 Third Digit:
Frequency
• 7 -
Replacement of Prior Claim. Used to correct a previously submitted
bill. Apply this code for the corrected or “new” bill. These adjustment
claims may be submitted at any point within the timely filing period
after the payment of the original claim.
• 8 - Void/Cancel
of a Prior Claim. Use this code to indicate this bill is an exact duplicate
of an incorrect bill previously submitted. A replacement RAP and
claim must be submitted for the episode to be paid.
• 9 - Final
Claim for a HHA PPS Episode. This code indicates the home health
bill should be processed as a debit/credit adjustment to the RAP.
This code is specific to home health and does not replace frequency
codes 7 or 8.
• HHA PPS claims are
submitted with the frequency of 9. These claims may
be adjusted with frequency 7 or cancelled with frequency 8.
Late charge bills, submitted with frequency 5, are
not accepted under HHA PPS. To add services within the period of
a paid home health claim, an adjustment must be submitted.
3.1.2.19.5 FL 5. Federal
Tax Number Required.
3.1.2.19.6 FL 6. Statement
Covers Period (From-Through) Required. The beginning and ending dates
of the period covered by this claim. The “From” date must match
the date submitted on the RAP for the episode. For continuous care
episodes, the “Through” date must be 59 days after the “From” date.
The patient status code in FL 22 must be 30 in these cases. In cases
where the beneficiary has been discharged or transferred within
the 60-day episode period, report the date of discharge in accordance
with your internal discharge procedures as the “Through” date. If
a discharge claim is submitted due to change of intermediary, see
FL 22 below. If the beneficiary has died, report the date of death
in the through date. Any NUBC approved patient status code may be
used in these cases. You may submit claims for payment immediately
after the claim “Through” date. You are not required to hold claims
until the end of the 60-day episode unless the beneficiary continues
under care. Submit all dates in the format MMDDYYYY.
3.1.2.19.7 FL 7. Covered
Days Not Required.
3.1.2.19.8 FL 8. Non-covered
Days Not Required.
3.1.2.19.9 FL 9. Coinsurance
Days Not Required.
3.1.2.19.10 FL 10.
Lifetime Reserve Days Not Required.
3.1.2.19.11 FL 12.
Patient’s Name Required. Enter the patient’s last name, first name,
and middle initial.
3.1.2.19.12 FL 13.
Patient’s Address Required. Enter the patient’s full mailing address,
including street number and name, post office box number or RFD,
City, State, and zip code.
3.1.2.19.13 FL 14.
Patient’s Birthdate Required. Enter the month, day, and year of
birth (MMDDYYYY) of the patient. If the full correct date is not
known, leave blank.
3.1.2.19.14 FL 15.
Patient’s Sex Required. M for male or F for
female must be present. This item is used in conjunction with FLs
67-81 (diagnoses and surgical procedures) to identify inconsistencies.
3.1.2.19.15 FL 16.
Patient’s Marital Status Not Required.
3.1.2.19.16 FL 17.
Admission Date Required. Enter the same date of admission that was
submitted on the RAP for the episode (MMDDYYYY).
3.1.2.19.17 FL 18.
Admission Hour Not Required.
3.1.2.19.18 FL 19.
Type of Admission Not Required.
3.1.2.19.19 FL 20.
Source of Admission Required. Enter the same source of admission
code that was submitted on the RAP for the episode.
3.1.2.19.20 FL 21.
Discharge Hour Not Required.
3.1.2.19.21 FL 22.
Patient Status Required. Enter the code that most accurately describes
the patient’s status as of the “Through” date of the bill period
(FL 6).
|
Code
Structure
|
|
Code
|
Definition
|
|
01
|
Discharged to
home or self-care (routine discharge)
|
|
02
|
Discharged/transferred
to another short-term general hospital for inpatient care
|
|
03
|
Discharged/transferred
to SNF
|
|
04
|
Discharged/transferred
to an Intermediate Care Facility (ICF)
|
|
05
|
Discharged/transferred
to another type of institution (including distinct parts)
|
|
06
|
Discharged/transferred
to home under care of another organized home health service organization,
or discharged and readmitted to the same HHA within a 60-day episode
period
|
|
07
|
Left against
medical advice or discontinued care
|
|
20
|
Expired (or
did not recover - Christian Science Patient)
|
|
30
|
Still patient
|
|
40
|
Expired at home
(hospice claims only)
|
|
41
|
Expired in a
medical facility, such a hospital, SNF, ICF or freestanding hospice
(hospice claims only)
|
|
42
|
Expired - place
unknown (hospice claims only)
|
|
50
|
Discharged/transferred
to hospice - home
|
|
51
|
Discharged/transferred
to hospice - medical facility
|
|
61
|
Discharged/transferred
with this institution to a hospital-based Medicare approved swing
bed
|
|
71
|
Discharged/transferred/referred
to another institution for outpatient services as specified by the
discharge POC
|
|
72
|
Discharged/transferred/referred
to this institution for outpatient services as specified by the
discharge POC
|
3.1.2.19.21.1 Patient
status code 06 should be reported in all cases where the HHA is
aware that the episode will be paid as a PEP adjustment. These are
cases in which the agency is aware that the beneficiary has transferred
to another HHA within the 60-day episode, or the agency is aware
that the beneficiary was discharged with the goals of the original
POC met and has been readmitted within the 60-day episode. Situations
may occur in which a HHA is unaware at the time of billing the discharge that
these circumstances exist. In these situations, the contractor claims
systems shall adjust the discharge claim automatically to reflect
the PEP adjustment, changing the patient status code on the paid
claim record to 06.
3.1.2.19.21.2 In cases
where an HHA is changing the contractor to which they submit claims,
the service dates on the claims must fall within the provider’s
effective dates at each intermediary. To ensure this, RAPs for all
episodes with “From” dates before the provider’s termination date
must be submitted to the contractor the provider is leaving. The
resulting episode must be resolved by the provider submitting claims
for shortened periods - the “through” dates on or before the termination date.
The provider must indicate that these claims will be PEP adjustments
by using patient status 06. Billing for the beneficiary is being
“transferred” to the new intermediary.
3.1.2.19.22 FL 23.
Medical Record Number Optional. Enter the number assigned to the
patient’s medical/health record. If you enter a number, the intermediary
must carry it through their system and return it to you.
3.1.2.19.23 FLs 24,
25, 26, 27, 28, 29 and 30. Condition Codes When Applicable. Enter
any NUBC approved code to describe conditions and apply to the claim.
3.1.2.19.23.1 Required. If adjusting a HHA PPS claim (TOB
3x7), report one of the following:
|
Code
|
Definition
|
|
D0
|
Change to Service
Dates
|
|
D1
|
Change to Charges
|
|
D2
|
Change to Revenue
Codes/HCPCS
|
|
D7
|
Change to Make
TRICARE the Secondary Payer
|
|
D8
|
Change to Make
TRICARE the Primary Payer
|
|
D9
|
Any other Change
|
|
E0
|
Change in Patient
Status
|
3.1.2.19.23.2 If adjusting
the claim to correct a HIPPS code, report condition code D9. Enter “Remarks”
in FL 84 indicating the reason for the HIPPS code change.
3.1.2.19.23.3 Required. If canceling the claim (TOB 3x8),
report one of the following:
|
Code
|
Definition
|
|
D5
|
Cancel to Correct
HICH
|
|
D6
|
Cancel Only
to Repay a Duplicate or OIG Overpayment. Use when D5 is not appropriate
|
3.1.2.19.23.4 Enter “Remarks”
in FL 84 indicating the reason for cancellation of the claim.
3.1.2.19.24 FLs 32,
33, 34, and 35. Occurrence Codes and Dates Optional. Enter any NUBC
approved code to describe occurrences that apply to the claim. Event
codes are two alphanumeric digits, and dates are shown as eight
numeric digits (MM-DD-YYYY). Occurrence code 27 is not required
on HHA PPS RAPs.
3.1.2.19.24.1 Fields
32A-35A must be completed before fields 32B-35B.
3.1.2.19.24.2 Occurrence and occurrence span codes are mutually
exclusive. Occurrence codes have values from 01 through 69 and A0
through L9. Occurrence span codes have values from 70 through 99 and
M0 through Z9.
3.1.2.19.24.3 When FLs
36A and B are fully used with occurrence span codes, FLs 34A and
B and 35A and B may be used to contain the “From” and “Through”
dates of the other occurrence span codes. In this case, the code
in FL 34 is the occurrence span code and the occurrence span “From”
date is in the date field. FL 35 contains the same occurrence span
code as the code in FL 34, and the occurrence span “Through” date
is in the date field.
3.1.2.19.24.4 Other codes
may be required by other payers, and while they are not used by
the TRICARE Program, they may be entered on the bill if convenient.
3.1.2.19.25 FL 36.
Occurrence Span Code and Dates Optional. Enter any NUBC approved
code to describe occurrences that apply to the claim.
3.1.2.19.25.1 Enter code and associated beginning and ending
dates defining a specific event relating to this billing period.
Event codes are two alphanumeric digits. Show dates as MM-DD-YYYY.
3.1.2.19.25.2 Reporting of occurrence span code 74 to show
the date of an inpatient admission within an episode is not required.
3.1.2.19.26 FL 37.
ICN/DCN Required. If submitting an adjustment (TOB 3x7) to a previously
paid HHA PPS claim, enter the control assigned to the original HHA
PPS claim here. Insert the ICN/DCN of the claim to be adjusted here.
Show payer A’s ICN/DCN on line A in FL 37. Similarly, show the ICN/DCN
for Payers B and C on lines B and C, respectively, in FL 37.
3.1.2.19.26.1 Since HHA PPS claims are processed as adjustments
to the RAP, the contractor’s claims systems shall match all HHA
PPS claims to their corresponding RAP and populate this field on
the electronic claim record automatically.
3.1.2.19.26.2 Providers
do not need to submit an ICN/DCN on all HHA PPS claims, only on adjustments
to paid claims.
3.1.2.19.27 FL 38.
(Untitled Except on Patient Copy of the Bill) Responsible Party
Name and Address Not Required. Space is provided for use of a window
envelope if you use the patient’s copy of the bill set. For claims
which involve payers of higher priority than TRICARE Program claims
as defined in FP 58, the address of the other payer may be shown
here or in 84 (Remarks).
3.1.2.19.28 FLs 39-41.
Value Codes and Amounts Required. Home health episode payments must be
based upon the site at which the beneficiary is served. Claims shall
not be processed with the following value code:
3.1.2.19.28.1 Code 61.
Location Where Service is furnished (HHA and Hospice). MSA or CBSA
number (or rural state code) of the location where the home health
or hospice service is delivered. Report the number in the dollar
portion of the form locator right justified to the left of the dollar/cents
delimiter.
3.1.2.19.28.2 For episodes
in which the beneficiary’s site of service changes from one MSA
or CBSA to another within the episode period, HHAs should submit
the MSA or CBSA code corresponding to the site of service at the
end of the episode on the claim.
3.1.2.19.28.3 Optional.
Enter any NUBC approved value code to describe other values that
apply to the claim. Code(s) and related dollar amount(s) identify
data of a monetary nature necessary for the processing of this claim.
The codes are two alphanumeric digits, and each value allows up
to nine numeric digits (0000000.00). Negative amounts are not allowed
except in FL 41. Whole numbers or non-dollar amounts are right justified
to the left of the dollar and cents delimiter. Some values are reported
as cents, so refer to specific codes for instructions.
3.1.2.19.28.4 If more than one value code is shown for a
billing period, codes are shown in ascending numeric sequence. There
are two lines of data, line a and line b. Use FLs 39a through 41a
before FLs 39b through 41b (i.e., the first line is used before
the second line).
3.1.2.19.29 FL 42 and
43 Revenue Code and Revenue Description Required. Claims must report
a 023 revenue code line matching the one submitted on the RAP for
the episode. If this matching 023 revenue code line is not found
on the claim, the contractor’s claims systems shall reject the claim.
3.1.2.19.29.1 If the claim represents an episode in which
the beneficiary experienced a significant change in condition (SCIC),
report one or more additional 023 revenue code lines to reflect
each change. SCICs are determined by an additional OASIS assessment
of the beneficiary, which changes the HIPPS code that applies to
the episode and requires a change order from the physician to the
POC. Each additional 023 revenue code line will show in FL 44 the
new HIPPS code output from the Grouper for the additional assessment,
the first date on which services were provided under the revised
POC in FL 45 and zero changes in FL 47. In the rare instance when
a beneficiary is assessed more than once in one day, report one
023 line for that date, indicating the HIPPS code derived from the
assessment that occurred latest in the day.
3.1.2.19.29.2 Claims must also report all services provided
to the beneficiary within the episode. Each service must be reported
in line item detail. Each service visit (revenue codes 42X, 43X,
44X, 55X, 56X, and 57X) must be reported as a separate line. Any
of the following revenue codes may be used:
3.1.2.19.29.2.1 27X - Medical/Surgical
Supplies (also see 62X, an extension of 27X). Code indicates the
charges for supply items required for patient care.
• Rationale - Additional
breakdowns are provided for items that hospitals may wish to identify
because of internal or third party payer requirements.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
MED-SUR SUPPLIES
|
|
1 - Nonsterile
Supply
|
NONSTER SUPPLY
|
|
2 - Sterile
Supply
|
STERILE SUPPLY
|
|
3 - Take Home
Supplies
|
TAKEHOME SUPPLY
|
|
4 - Prosthetic/Orthotic
Devices
|
PRSTH/ORTH DEV
|
|
5 - Pace Maker
|
PACE MAKER
|
|
6 - Intraocular
Lens
|
INTR OC LENS
|
|
7 - Oxygen-Take
Home
|
O2/TAKEHOME
|
|
8 - Other Implants
|
SUPPLY/IMPLANTS
|
|
9 - Other Supplies/Devices
|
SUPPLY/OTHER
|
• Required detail: With
the exception of revenue code 274, only service units and a charge
must be reported with this revenue code. If also reporting revenue code
623 to separately identify wound care supplies, not just supplies
for wound care patients, ensure that the charge amounts for the
623 revenue code line and other supply revenue codes are mutually
exclusive. Report only non-routine supply items in this revenue
code or in 623. Revenue code 274 requires a HCPCS code, the date
of service, service units and a charge amount.
3.1.2.19.29.2.2 42X - Physical Therapy. Charges for therapeutic
exercises, massage, and utilization of effective properties of light,
heat, cold, water, electricity, and assistive devices for diagnosis
and rehabilitation of patients who have neuromuscular, orthopedic,
and other disabilities.
• Rationale - Permits
identification of particular services.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
|
PHYSICAL THERP
|
|
1 - Visit Charge
|
PHYS THERP/VISIT
|
|
2 - Hourly Charge
|
PHYS THERP/HOUR
|
|
3 - Group Rate
|
PHYS THERP/GROUP
|
|
4 - Evaluation
or Re-evaluation
|
PHYS THERP/EVAL
|
|
9 - Other Physical
Therapy
|
OTHER PHYS THERP
|
• Required detail: HCPCS
code G0151, HCPCS code G0159, the date of service, service units
which represent the number of 15-minute increments that comprised
the visit, and a charge amount.
3.1.2.19.29.2.3 43X - Occupational Therapy (OT). Services provided
by a qualified OT practitioner for therapeutic interventions to
improve, sustain, or restore an individual’s level of function in performance
of activities of daily living and work, including: therapeutic activities;
therapeutic exercises; sensorimotor processing; psychosocial skills
training; cognitive retraining; fabrication and application of orthotic
devices; and training in the use of orthotic and prosthetic devices;
adaptation of environments; and application of physical agent modalities.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
OCCUPATION THER
|
|
1 - Visit Charge
|
OCCUP THERP/VISIT
|
|
2 - Hourly Charge
|
OCCUP THERP/HOUR
|
|
3 - Group Rate
|
OCCUP THERP/GROUP
|
|
4 - Evaluation
or Re-evaluation
|
OCCUP THERP/EVAL
|
|
9 - Other OT
(may include restorative therapy)
|
OTHER OCCUP
THER
|
• Required detail: HCPCS
code G0152, HCPCS code G0160, the date of service, service units
which represent the number of 15-minute increments that comprised
the visit, and a charge amount.
3.1.2.19.29.2.4 44X - Speech-Language Pathology. Charges for
services provided to persons with impaired communications skills.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
SPEECH PATHOL
|
|
1 - Visit Charge
|
SPEECH PATH/VISIT
|
|
2 - Hourly Charge
|
SPEECH PATH/HOUR
|
|
3 - Group Rate
|
SPEECH PATH/GROUP
|
|
4 - Evaluation
or Re-evaluation
|
SPEECH PATH/EVAL
|
|
9 - Other Speech-Language
Pathology
|
OTHER SPEECH
PATH
|
• Required detail: HCPCS
code G0153, HCPCS code G0161, the date of service, service units
which represent the number of 15-minute increments that comprised
the visit, and a charge amount.
3.1.2.19.29.2.5 55X - Skilled Nursing. Charges for nursing
services that must be provided under the direct supervision of a
licensed nurse to assure the safety of the patient and to achieve
the medically desired result. This code may be used for nursing
home services or a service charge for home health billing.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
SKILLED NURSING
|
|
1 - Visit Charge
|
SKILLED NURS/VISIT
|
|
2 - Hourly Charge
|
SKILLED NURS/HOUR
|
|
9 - Other Skilled
Nursing
|
SKILLED NURS/OTHER
|
• Required detail: the
date of service, service units which represent the number of 15-minute
increments that comprised the visit, and a charge amount, and:
• HCPCS
code G0154 on or before December 31, 2015; or
• HCPCS
code G0299 or G0300 on or after January 1, 2016; or
• HCPCS
code G0162 -G0164 on or after January 1, 2016; or
• HCPCS
codes G0493-G0496 on or after January 1, 2017.
3.1.2.19.29.2.6 56X - Medical Social Services. Charges for
services such as counseling patients, interviewing patients, and
interpreting problems of a social situation rendered to patients
on any basis.
• Rationale: Necessary
for TRICARE Program home health billing requirements. May be used
at other times as required by hospital.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
MED SOCIAL SVS
|
|
1 - Visit charge
|
MED SOC SERV/VISIT
|
|
2 - Hourly charge
|
MED SOC SERV/HOUR
|
|
9 - Other Med.
Soc. Service
|
MED SOC SERV/OTHER
|
• Required detail: HCPCS
code G0155, the date of service, service units which represent the
number of 15-minute increments that comprised the visit, and a charge
amount.
3.1.2.19.29.2.7 57X - Home
Health Aide (Home Health). Charges made by an HHA for personnel that
are primarily responsible for the personal care of the patient.
• Rationale:
Necessary for TRICARE Program home health billing requirements.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
AIDE/HOME HEALTH
|
|
1 - Visit Charge
|
AIDE/HOME HLTH/VISIT
|
|
2 - Hourly Charge
|
AIDE/HOME HLTH/HOUR
|
|
9 - Other Home
Health Aide
|
AIDE/HOME HLTH/OTHER
|
• Required detail: HCPCS
code G0156, the date of service, service units which represent the
number of 15-minute increments that comprised the visit, and a charge
amount.
Note: Revenue codes
58X and 59X may no longer be reported as covered on TRICARE Program home
health claims under HHA PPS. If reporting these codes, report all
charges as non-covered. Revenue code 624, IDEs, may no longer be
reported on TRICARE Program home health claims under HHA PPS.
3.1.2.19.29.2.8 Optional: Revenue codes for optional billing
of DME: Billing DME provided in the episode is not required on the
HHA PPS claim. HHAs retain the option to bill these services to
their contractor or to have the service provided under arrangement
with a supplier that bills these services to the DME Regional Carrier.
Agencies that choose to bill DME services on their HHA PPS claims
must use the revenue codes below.
3.1.2.19.29.2.8.1 29X - DME
(Other Than Rental). Code indicates the charges for medical equipment that
can withstand repeated use (excluding rental equipment).
• Rationale:
The TRICARE Program requires a separate revenue center for billing.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
MED EQUIP/DURAB
|
|
1 - Rental
|
MED EQUIP/RENT
|
|
2 - Purchase
of New DME
|
MED EQUIP/NEW
|
|
3 - Purchase
of Used DME
|
MED EQUIP/USED
|
|
4 - Supplies/Drugs
for DME Effectiveness (HHAs Only)
|
MED EQUIP/SUPPLIES/DRUGS
|
|
9 - Other Equipment
|
MED EQUIP/OTHER
|
• Required detail: The
applicable HCPCS code for the item, a date of service indicating
the purchase date or the beginning date of a monthly rental, number
of service units, and a charge amount. Monthly rental items should
be reported with a separate line for each month’s rental and for
service units of one.
3.1.2.19.29.2.8.2 60X - Oxygen
(Home Health). Code indicates charges by an HHA for oxygen equipment
supplies or contents, excluding purchased equipment. If a beneficiary
has purchased a stationary oxygen system, an oxygen concentrator
or portable equipment, current revenue codes 292 or 293 apply.
• Rationale:
The TRICARE Program requires detailed revenue coding.
|
Subcategory
|
Standard
Abbreviation
|
|
0 - General
Classification
|
02/HOME HEALTH
|
|
1 - Oxygen -
State/Equip/Suppl or Cont
|
02/EQUIP/SUPPL/CONT
|
|
2 - Oxygen -
State/Equip/Suppl Under LPM
|
02/STATE EQUIP//UNDER
1 LPM
|
|
3 - Oxygen -
State/Equip/Over 4 LPM
|
02/STATE EQUIP/OVER
4 LPM
|
|
4 - Oxygen -
Portable Add-on
|
02/STATE EQUIP/PORT
ADD-ON
|
• Required detail: The
applicable HCPCS code for the item, a date of service, number of
service units, and charge amount.
3.1.2.19.29.2.9 Revenue code for optional reporting of wound
care supplies:
62X - Medical/Surgical Supplies
- Extension of 27X. Code indicates charges for supply items required
for patient care. The category is an extension of 27X for reporting
additional breakdown where needed.
|
Subcategory
|
Standard
Abbreviation
|
|
3 - Surgical
Dressings
|
SURG DRESSING
|
• Required detail: Only
service units and a charge must be reported with this revenue code.
If also reporting revenue code 27X to identify non-routine supplies
other than those used for wound care, ensure that the change amounts
for the two revenue code lines are mutually exclusive.
• HHA may voluntarily
report a separate revenue code line for charges for nonroutine wound
care supplies, using revenue code 623. Notwithstanding the standard
abbreviation “surg dressing”, use this item to report charges for
ALL nonroutine wound care supplies, including but not limited to
surgical dressings.
• Information on patient
differences in supply costs can be used to make refinements in the
home health PPS case-mix adjuster. The case-mix system for home
health prospective payment was developed from information on the cost
of visit time for different types of patients. If supply costs also
vary significantly for different types of patients, the case-mix
adjuster may be modified to take both labor and supply cost differences
into account. Wound care supplies are a category with potentially
large variation. HHAs can assist the TRICARE’s Program future refinement
of payment rates if they consistently and accurately report their
charges for nonroutine wound care supplies under revenue center
code 623. HHAs should ensure that charges reported under revenue
code 27X for nonroutine supplies are also complete and accurate.
• You may continue to
report a “Total” line, with revenue code 0001, in FL 42. The adjacent
charges entry in FL 47 may be the sum of charges billed. The contractor’s
claims systems shall assure this amount reflects charges associated with
all revenue code lines, excluding any 023.
3.1.2.19.30 FL 44.
HCPCS/Rates Required. On the earliest dated 023 revenue code line,
report the HIPPS code which was reported on the RAP. On claims reflecting
a SCIC, report on each additional 023 line the HIPPS codes produced
by the Grouper based on each additional OASIS assessment.
• For
revenue code lines other than 023, which detail all services within
the episode period, report HCPCS codes as appropriate to that revenue
code.
• Coding
detail for each revenue code under HHA PPS is defined above under
FL 43.
3.1.2.19.31 FL 45.
Service Date Required. On each 023 revenue code line, report the
date of the first service provided under the HIPPS code reported
on that line. For other line items detailing all services within
the episode period, report services dates as appropriate to that
revenue code. Coding detail for each revenue code under HHA PPS
is defined above under FL 43.
3.1.2.19.32 FL 46.
Units of Service Required. Do not report units of service on 023
revenue code lines (the field may be zero or blank). For line items
detailing all services within the episode period, report units of
service as appropriate to that revenue code. Coding detail for each
revenue code under HHA PPS is defined above under FL 43. For the
revenue codes that represent home health visits (042X, 043X, 044X,
055X, 056X, and 057X), report as units of service the number of
15-minute increments that comprise the time spent treating the beneficiary.
Time spent completing the OASIS assessment in the home as part of
an otherwise covered and billable visit, and time spent updating
medical records in the home as part of such a visit, may also be
reported. Visits of any length are to be reported, rounding the time
to the nearest 15-minute increment.
3.1.2.19.33 FL 47.
Total Charges Required. Zero charges must be reported on the 023
revenue line. The contractor’s claims systems shall place the reimbursement
amount for the RAP in this field on the electronic claim record.
• For
other line items detailing all services within the episode period,
report charges as appropriate to that revenue code. Coding detail
for each revenue code under HHA PPS is defined above under FL 43.
• Charges may be reported
in dollars and cents (i.e., charges are not required to be rounded
to dollars and zero cents). The contractor’s claims system shall
not make any payment determinations based upon submitted charge
amounts.
3.1.2.19.34 FL 48.
Non-Covered Charges Required. The total non-covered charges pertaining
to the related revenue code in FL 42 are entered here. Report all
non-covered charges, including no-payment claims.
• Claims with Both Covered
and Non-Covered Charges - Report (along with covered charges) all
non-covered charges, related revenue codes, and HCPCS codes, where applicable.
On the CMS 1450 UB-04 flat file, use record type 61, Field No. 10
(total charges) and Field No. 11 (non-covered charges).
• Claims with ALL Non-Covered
Charges - Submit claims when all of the charges on the claim are
non-covered (no-payment claim). Complete all items on a no-payment
claim in accordance with instructions for completing payment claims, with
the exception that all charges are reported as non-covered.
3.1.2.19.35 Examples
of Completed FLs 42 through 48. The following provides examples
of revenue code lines as HHAs should complete them, based on the
reporting requirements above.
|
FL 42
|
FL 44
|
FL 45
|
FL 46
|
FL 47
|
FL 48
|
|
Report the multiple 023 lines in a
SCIC situation as follows:
|
|
023
|
HAEJ1
|
100101
|
|
0.00
|
|
|
023
|
HAFM1
|
100101
|
|
0.00
|
|
|
Report additional revenue code lines
as follows:
|
|
270
|
|
|
8
|
84.73
|
|
|
291
|
K0006
|
100101
|
1
|
120.00
|
|
|
420
|
G0151
|
100501
|
3
|
155.00
|
|
|
430
|
G0152
|
100701
|
4
|
160.00
|
|
|
440
|
G0153
|
100901
|
4
|
175.00
|
|
|
550
|
G0154
|
100201
|
1
|
140.00
|
|
|
560
|
G0155
|
101401
|
8
|
200.00
|
|
|
570
|
G0156
|
101601
|
3
|
65.00
|
|
|
580
|
|
101801
|
3
|
0.00
|
75.00
|
|
623
|
|
|
5
|
47.75
|
|
3.1.2.19.36 FL 49.
(Untitled) Not Required.
3.1.2.19.37 FLs 50A,
B, and C. Payer Identification Required. If the TRICARE Program
is the primary payer, the HHA enters “TRICARE” on line A. When TRICARE
is entered on line 50A, this indicates that the HHA has developed
for other insurance coverage and has determined that the TRICARE
Program is the primary payer. All additional entries across the
line (FLs 51-55) supply information needed by the payer named in
FL 50A. If the TRICARE Program is the secondary or tertiary payer,
HHAs identify the primary payer on line A and enter the TRICARE
information on line B or C as appropriate. Conditional and other payments
for the TRICARE Program in Secondary Payer (MSP) situations will
be made based on the HHA PPS claim.
3.1.2.19.38 FL 51.
Provider Number Required. Enter the 9-18 position TIN assigned by
TRICARE. It must be entered on the same line as “TRICARE” in FL
50.
• If
the provider number changes within a 60-day episode, reflect this
by closing out the original episode with a PEP claim under the original
provider number and opening a new episode under the new provider
number.
• In
this case, report the original provider number in this field.
3.1.2.19.39 FLs 52A,
B, and C. Release of Information Certification Indicator Required.
A Y code indicates the provider has on file a signed
statement permitting the provider to release data to other organizations
in order to adjudicate the claim. An R code indicates
the release is limited or restricted. An N code indicates
no release on file.
3.1.2.19.40 FLs 53A,
B, and C. Assignment of Benefits Certification Indicator Not Required.
3.1.2.19.41 FLs 54A,
B, and C. Prior Payments Not Required.
3.1.2.19.42 FLs 55A,
B, and C. Estimated Amount Due Not Required.
3.1.2.19.43 FL 56.
(Untitled) Not Required.
3.1.2.19.44 FL 57.
(Untitled) Not Required.
3.1.2.19.45 FLs 58A,
B, and C. Insured’s Name Required. On the same lettered line (A,
B, or C) that corresponds to the line on which the TRICARE Program
payer information is shown in FLs 50-54, enter the patient’s name
as shown on his HI card or other TRICARE Program notice. Enter the
name of the individual in whose name the insurance is carried if
there are payer(s) of higher priority than the TRICARE Program and
you are requesting payment because:
3.1.2.19.45.1 Another
payer paid some of the charges and the TRICARE Program is secondarily
liable for the remainder;
3.1.2.19.45.2 Another
payer denied the claim; or
3.1.2.19.45.3 You are
requesting conditional payment. If that person is the patient, enter
“Patient.” Payers of higher priority than the TRICARE Program include:
• Employer
Group Health Plans (EGHPs) for employed beneficiaries and their spouses;
• EGHPs for beneficiaries
entitled to benefits solely on the basis of End Stage Renal Disease
(ESRD) during a TRICARE Program Coordination Period;
• An auto-medical, no-fault,
or liability insurer;
• Lisps for disabled
beneficiaries; or
• Worker’s
Compensation (WC) including Black Lung (BL).
3.1.2.19.46 FLs 59A,
B, and C. Patient’s Relationship to Insured Required. If claiming
payment under any of the circumstances described under FLs 58A,
B, or C, enter the code indicating the relationship of the patient
to the identified insured.
|
Code
Structure
|
|
Code
|
Title
|
Definition
|
|
01
|
Patient
is the Insured
|
Self-explanatory
|
|
02
|
Spouse
|
Self-explanatory
|
|
03
|
Natural
Child/Insured Financial Responsibility
|
Self-explanatory
|
|
04
|
Natural
Child/Insured Does Not Have Financial Responsibility
|
Self-explanatory
|
|
05
|
Step
Child
|
Self-explanatory
|
|
06
|
Foster
Child
|
Self-explanatory
|
|
08
|
Employee
|
Patient
is employed by the insured.
|
|
09
|
Unknown
|
Patient’s
relationship to the insured is unknown.
|
|
15
|
Injured
Plaintiff
|
Patient
is claiming insurance as a result of injury covered by insured.
|
3.1.2.19.47 FLs 60A,
B, and C. Certificate/SSN/HI Claim/Identification Number Required.
On the same lettered line (A, B, or C) that corresponds to the line
on which the TRICARE Program payer information was shown on FLs
39-41, and 50-54, enter the patient’s TRICARE Program HICN; i.e.,
if the TRICARE Program is the primary payer, enter this information
in FL 60A. Show the number as it appears on the patient’s HI Card,
Certificate of Award, Utilization Notice, Explanation of Benefits,
Temporary Eligibility Notice, or as reported by the Social Security
Office. If claiming a conditional payment under any of the circumstances
described under FLs 58A, B, or C, enter the involved claim number
for that coverage on the appropriate line.
3.1.2.19.48 FLs 61A,
B, and C. Group Name Required. Where you are claiming a payment
under the circumstances described in FLs 58A, B, or C, and there
is involvement of WC or an EGHP, enter the name of the group or
plan through which that insurance is provided.
3.1.2.19.49 FLs 62A,
B, and C. Insurance Group Number Required. Where you are claiming
a payment under the circumstance described under FLs 58A, B, or
C and there is involvement of WC or an EGHP, enter identification
number, control number or code assigned by such HI carrier to identify
the group under which the insured individual is covered.
3.1.2.19.50 FL 63.
Treatment Authorization Code Required. Enter the claims-OASIS matching
key output by the Grouper software. This data element links the
claim record to the specific OASIS assessment used to produce the
HIPPS code reported in FL 44. This is an 18-position code, containing the
start of care date (eight positions, from OASIS Item M0030), the
date the assessment was completed (eight positions, from OASIS Item
M0090), and the reason for assessment (two positions, from OASIS Item
M0100). Copy these OASIS items exactly as they appear on the OASIS
assessment, matching the date formats used on the assessment.
• In
most cases, the claims-OASIS matching key on the claim will match
that submitted on the RAP. In SCIC cases, however, the matching
key reported must correspond to the OASIS assessment that produced
the HIPPS code on the latest dated 023 revenue code line on the
claim.
• The
IDE revenue code, 624, is not allowed on HHA PPS RAPs. Therefore,
treatment authorization codes associated with IDE items must never
be submitted in this field.
3.1.2.19.51 FL 64.
Employment Status Code Required. Where you are claiming payment
under the circumstances described in the second paragraphs of FLs
58A, B, or C, and there is involvement of WC or an EGHP, enter the
code which defines the employment status of the individual identified,
if the information is readily available.
|
Code
Structure
|
|
Code
|
Title
|
Definition
|
|
1
|
Employed
Full Time
|
Individual claimed
full time employment.
|
|
2
|
Employed
Part Time
|
Individual claimed
part time employment.
|
|
3
|
Not
Employed
|
Individual states
that he or she is not employed full time or part time.
|
|
4
|
Self-employed
|
Self-explanatory
|
|
5
|
Retired
|
Self-explanatory
|
|
6
|
On
Active Military Duty
|
Self-explanatory
|
|
7-8
|
|
Reserved for
national assignment.
|
|
9
|
Unknown
|
Individual’s
employment status is unknown
|
3.1.2.19.52 FL 65.
Employer Name Required. Where you are claiming a payment under the circumstance
described under FLs 58A, B, or C, and there is involvement of WC
or EGHP, enter the name of the employer that provides health care
coverage for the individual.
3.1.2.19.53 FL 66.
Employer Location Required. Where you are claiming a payment under
the circumstances described under FLs 58A, B, or C, and there is
involvement of WC or an EGHP, enter the specific location of the
employer of the individual. A specific location is the city, plant,
etc., in which the employer is located.
3.1.2.19.54 FL 67.
Principal Diagnosis Code Required. Enter the ICD-9-CM code for the
principal diagnosis. The code may be the full ICD-9-CM diagnosis
code, including all five digits where applicable. When the proper
code has fewer than five digits, do not fill with zeros.
Note: For services provided before the mandated date,
as directed by HHS, for ICD-10 implementation, use diagnosis codes
as contained in the ICD-9-CM. For services provided on or after the
mandated date, as directed by HHS, for ICD-10 implementation, use
diagnosis codes as contained in the ICD-10-CM.
• The ICD-9-CM codes
and principal diagnosis reported in FL 67 must match the primary
diagnosis code reported on the OASIS from Item M0230 (Primary Diagnosis),
and on the CMS Form 485, from Item 11 (ICD-9-CM/Principle Diagnosis).
• In most cases the
principal diagnosis code on the claim will match that submitted on
the RAP. In SCIC cases, however, the principle diagnosis code reported
must correspond to the OASIS assessment that produced the HIPPS
code on the latest dated 023 revenue code line on the claim.
3.1.2.19.55 FLs 68-75.
Other Diagnoses Codes Required. Enter the full ICD-9-CM codes for
up to eight additional conditions if they co-existed at the time
of the establishment of the POC. Do not duplicate the principal
diagnosis listed in FL 67 as an additional or secondary diagnosis.
Note: For services provided before the mandated date,
as directed by HHS, for ICD-10 implementation, use diagnosis codes
as contained in the ICD-9-CM. For services provided on or after the
mandated date, as directed by HHS, for ICD-10 implementation, use
diagnosis codes as contained in the ICD-10-CM.
• For other diagnoses,
the diagnoses and ICD-9-CM codes reported in FLs 67 A-Q must match
the additional diagnoses reported on the OASIS, from Item M0240 (Other
Diagnoses), and on the CMS Form 485, from Item 13 (ICD-9-CM/Other Pertinent
Diagnoses). Other pertinent diagnoses are all conditions that co-existed at
the time the POC was established. In listing the diagnoses, place
them in order to best reflect the seriousness of the patient’s condition
and to justify the disciplines and services provided. Surgical and V codes
which are not acceptable in the other diagnosis fields from M0240
on the OASIS, or on the CMS Form 485, from Item 13, may be reported
in FLs 67 A-Q on the claim if they are reported in the narrative from
Item 21 of the CMS Form 485.
• In most cases, the
other diagnoses codes on the claim will match those submitted on
the RAP. In SCIC cases, however, the other diagnoses codes reported
must correspond to the OASIS assessment that produced the HIPPS
code on the latest dated 023 revenue code line on the
claim.
3.1.2.19.56 FL 69.
Admitting Diagnosis Not Required.
3.1.2.19.57 FL 72.
E-Code Not Required.
3.1.2.19.58 FL 73.
(Untitled) Not Required.
3.1.2.19.59 FL 74.
Principal Procedure Code and Date Not Required.
3.1.2.19.60 FL 74 a-e.
Other Procedure Codes and Dates Not Required.
3.1.2.19.61 FL 76.
Attending/Requesting Physician ID Required. Enter the UPIN and name
of the attending physician who has signed the POC.
Note: Medicare requires HHAs to enter the UPIN and name
of the attending physician who has established the POC in FL 76
of the CMS 1450 UB-04. The UPIN information will be allowed on the
RAP and claims but not stored until required.
3.1.2.19.62 FL 77.
Other Physician ID Not Required.
3.1.2.19.63 FL 80.
Remarks Not Required.
3.1.2.19.64 FL 86.
Date Not Required. See FL 45, line 23.
3.1.2.24 Other Billing
Considerations.
3.1.2.24.1 Billing for Nonvisit Charges. Under HHA PPS,
all services under a POC must be billed as a HHA PPS episode. All
services within an EOC must be billed on one claim for the entire
episode.
• TOB
329 and 339 are not accepted without any visit charges. Per CMS
transmittal 2694, effective October 1, 2013, the TOB 033X will no
longer be used.
• Nonvisit
charges incurred after termination of the POC are payable under
medical and other health services on TOB 34X.
3.1.2.24.2 Billing
for Use of Multiple Providers. When a physician deems it necessary
to use two participating HHAs, the physician designates the agency
which furnishes the major services and assumes the major responsibility
for the patient’s care.
• The primary agency
bills for all services furnished by both agencies and keeps all records
pertaining to the care. The primary agency’s status as primary is
established through the submission of a RAP.
• The secondary agency
is paid through the primary agency under mutually agreed upon arrangements
between the two agencies.
• Two agencies must
never bill as primary for the same beneficiary for the same EOC. When
the system indicates an EOC is open for a beneficiary, deny the
RAP on any other agency billing within the episode unless the RAP
indicates a transfer or discharge and readmission situation exists.
3.1.2.24.3 Home Health
Services Are Suspended or Terminated and Then Reinstated. A physician may
suspend visits for a time to determine whether the patient has recovered
sufficiently to do without further home health service. When the
suspension is temporary (does not extend beyond the end of the 60-day
episode) and the physician later determines that the services must
be resumed, the resumed services are paid as part of the same episode
and under the same POC as before. The episode from date and the
admission date remain the same as on the RAP. No special indication
need be made on the episode claim for the period of suspended services.
Explanation of the suspension need only be indicated in the medical
record.
• If,
when services are resumed after a temporary suspension (one that
does not extend beyond the end date of the 60-day episode), the
HHA believes the beneficiary’s condition is changed sufficiently
to merit a SCIC adjustment, a new OASIS assessment may be performed,
and change orders acquired from the physician. The episode may then
be billed as a SCIC adjustment, with an additional 023 revenue code
line reflecting the HIPPS code generated by the new OASIS assessment.
• If the suspension
extends beyond the end of the current 60-day episode, HHAs must
submit a discharge claim for the episode. Full payment will be due
for the episode. If the beneficiary resumes care, the HHA must establish
a new POC and submit a RAP for a new episode. The admission date
would match the episode from date, as the admission is under a new
POC and care was not continuous.
3.1.2.24.4 Preparation
of a Home Health Billing Form in No-Payment Situations. HHAs must
report all non-covered charges on the CMS 1450 UB-04, including
no-payment claims as described below. HHAs must report these non-covered
charges for all home health services, including both Part A (TOB 0339)
and Part B (TOB 0329 or 034X) service. Non-covered charges must
be reported only on HHA PPS claims. RAPs do not require the reporting
of non-covered charges. HHA no-payment bills submitted with types
of bill 0329 or 0339 will update any current home health benefit
period on the system. Per CMS transmittal 2694, effective October
1, 2013, the TOB 033X will no longer be used.
3.1.2.24.5 HHA Claims
With Both Covered and Non-Covered Charges. HHAs must report (along with
covered charges) all non-covered charges, related revenue codes,
and HCPCS codes, where applicable. (Provider should not report the
non-payment codes outlined below). On the CMS 1450 UB-04 flat file,
HHAs must use record type 61, Field No. 10 (outpatient total charges)
and Field No. 11 (outpatient non-covered charges) to report these
charges. Providers utilizing the hard copy CMS 1450 UB-04 report
these charges in FL 47. “Total Charges,” and in FL 48 “Non-Covered
Charges.” You must be able to accept these charges in your system
and pass them on to other payers.
3.1.2.24.6 HHA Claims
With All Non-Covered Charges. HHAs must submit claims when all of
the charges on the claim are non-covered (no-payment claim). HHAs
must complete all items on a no-payment claim in accordance with
instructions for completing payment bills, with the exception that
all charges are reported as non-covered. You must provide a complete
system record for these claims. Total the charges on the system
under revenue code 0001 (total and non-covered). Non-payment codes
are required in the system records where no payment is made for
the entire claim. Utilize non-payment codes in §3624. These codes
alert the TRICARE Program to bypass edits in the systems processing
that are not appropriate in non-payment cases. Enter the appropriate
code in the “Non-Payment Code” field of the system record if the
nonpayment situation applies to all services covered by the bill.
When payment is made in full by an insurer primary to the TRICARE
Program, enter the appropriate “Cost Avoidance” codes for MSP cost
avoided claims. When you identify such situations in your development
or processing of the claim, adjust the claim data the provider submitted,
and prepare an appropriate system record.
3.1.2.24.7 No-Payment
Billing and Receipt of Denial Notices Under HHA PPS. HHAs may seek denials
for entire claims from the TRICARE Program in cases where a provider
knows all services will not be covered by the TRICARE Program. Such
denials are usually sought because of the requirements of other
payers (e.g., Medicaid) for providers to obtain TRICARE Program
denial notices before they will consider providing additional payment.
Such claims are often referred to as no-payment or no-pay bills, or
denial notices.
3.1.2.24.7.1 Submission and Processing. In order to submit
a no-payment bill to the TRICARE Program under HHA PPS, providers
must:
3.1.2.24.7.2 Use TOB 03x0 in FL 4 and condition code 21
in FL 18-28 of the CMS 1450 UB-04 claim form.
3.1.2.24.7.3 The statement
dates on the claim, FL 6, should conform to the billing period they
plan to submit to the other payer, insuring that no future date
is reported.
3.1.2.24.7.4 Providers
must also key in the charge for each line item on the claim as a
non-covered charge in FL 48 of each line.
3.1.2.24.7.5 In order
for these claims to process through the subsequent HHA PPS edits
in the system, providers are instructed to submit a 023 revenue
line and OASIS Matching Key on the claim. If no OASIS assessment
was done, report the lowest weighted HIPPS code (HAEJ1) as a proxy,
an 18-digit string of the number 1, 111111111111111111,
for the OASIS Claim-Matching Key in FL 63, and meet other minimum
TRICARE Program requirements for processing RAPs. If an OASIS assessment
was done, the actual HIPPS code and Matching Key output should be
used.
3.1.2.24.7.6 The TRICARE Program standard systems will bypass
the edit that required a matching RAP on history for these claims,
then continue to process them as no-pay bills. Standard systems
must also ensure that a matching RAP has not been paid for that
billing period.
3.1.2.24.7.7 FL 15, point
of origin, and treatment authorization code, FL 63,
should be unprotected for no-pay bills.
3.1.2.24.8 Simultaneous
Covered and Non-Covered Services. In some cases, providers may need to
obtain a TRICARE Program denial notice for non-covered services
delivered in the same period as covered services that are a part
of an HHA PPS episode. In such cases, the provider should submit
a non-payment bill according to the instructions above for the non-covered
services alone, and submit the appropriate HHA PPS RAP and claim
for the episode. If the episode billed through the RAP and claim
is 60 days in length, the period billed under the non-payment bill
should be the same. TRICARE contractor’s claims processing systems
and automated authorization files will allow such duplicate claims
to process when all services on the claim are non-covered.