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 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.
3.1.2.19.3 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:
3.1.2.19.3.1 Code Structure (only codes used to bill the
TRICARE Program are shown).
3.1.2.19.3.2 First Digit: Type of Facility
3.1.2.19.3.3 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.
3.1.2.19.3.4 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.
3.1.2.19.4 FL 5. Federal
Tax Number Required.
3.1.2.19.5 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 17 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 17 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.
3.1.2.19.6 FL 8.
Patient’s Name/Identifier Required.
Enter the patient’s last name, first name, and middle initial.
3.1.2.19.7 FL 9.
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.
3.1.2.19.8 FL 10. 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.
3.1.2.19.9 FL 11.
Patient’s Sex Required. M for male or F for
female must be present. This item is used in conjunction with diagnoses
and surgical procedures to identify
inconsistencies.
3.1.2.19.10 FL 12.
Admission/Start of Care Date Required.
Enter the same date of admission that was submitted on the RAP for
the episode (MMDDYYYY).
3.1.2.19.11 FL 15. Point
of Origin for Admission or Visit Required.
Enter the same source of admission code that was submitted on the
RAP for the episode.
3.1.2.19.12 FL
17.
Patient
’s Discharge Status Required.
Enter the code that most accurately describes the patient’s status
as of the “Through” date of the bill period (FL 6)
.3.1.2.19.12.1 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.
3.1.2.19.12.2 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.
3.1.2.19.13 FLs
18-28
. Condition
Codes
Are Conditional. Enter any NUBC
approved code to describe conditions and apply to the claim.
3.1.2.19.13.1 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
|
3.1.2.19.13.2 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.
3.1.2.19.13.3 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
|
3.1.2.19.13.4 Enter “Remarks” in FL 84 indicating the reason
for cancellation of the claim.
3.1.2.19.14 FLs 3
1-34
. Occurrence
Codes and Dates
Are Conditional. 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)
.3.1.2.19.14.1 Fields
31A-34A
must be completed before fields 31B-34B.
3.1.2.19.14.2 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.
3.1.2.19.14.3 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.
3.1.2.19.15 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
(s):
3.1.2.19.15.1 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.
3.1.2.19.15.2 Code
85. Effective for services dates on or after January 1, 2019, value
code 85 and an associated FIPS state and county code where the beneficiary
resides are required on each claim. Code 61 and the CBSA code will
continue to be required on all claims.
3.1.2.19.15.3 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.
3.1.2.19.15.4 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). 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.
3.1.2.19.15.5 If more
than one value code is shown for a billing period, codes are shown
in ascending numeric sequence.
3.1.2.19.16 FL
s 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.
3.1.2.19.16.1 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.
3.1.2.19.16.2 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:
3.1.2.19.16.2.1 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.
3.1.2.19.16.2.2 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.
3.1.2.19.16.2.3 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.
3.1.2.19.16.2.4 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.
3.1.2.19.16.2.5 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.
3.1.2.19.16.2.6 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.
3.1.2.19.16.2.7 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.
3.1.2.19.16.2.8 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.
3.1.2.19.16.2.8.1 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.
3.1.2.19.16.2.8.2 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.
3.1.2.19.16.2.9 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.
3.1.2.19.17 FL 44.
HCPCS/
Accommodation Rates
/HIPPS
Rate Codes 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.
3.1.2.19.18 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.
3.1.2.19.19 FL 46. Service Units Required. Transaction
standards require the reporting of a number greater than zero as
the units on the 0023 revenue code line. 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.
3.1.2.19.20 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.
3.1.2.19.21 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.
3.1.2.19.22 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
|
|
3.1.2.19.23 FLs 50A, B, and
C. Payer Name 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.
3.1.2.19.24 FL 52. 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.
3.1.2.19.25 FL 56. National
Provider Identifier - Billing Provider Required. The
HHA enters their provider identifier.
3.1.2.19.26 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.
3.1.2.19.27 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.
|
3.1.2.19.28 FLs 60A, B, and C. Certificate/SSN/HI Insured’s
Unique Identifier 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 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.
3.1.2.19.29 FLs 61A, B, and C. Insured’s 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.
3.1.2.19.30 FLs 62A, B, and C. Insured’s 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.
3.1.2.19.31 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.
3.1.2.19.32 FL 64.
DCN
Required. If submitting an adjustment (TOB 0327) to a previously
paid HH PPS claim, the HHA enters the control number assigned to
the original HH PPS claim here.3.1.2.19.32.1 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.
3.1.2.19.32.2 Providers
do not need to submit an ICN/DCN on all HHA PPS claims, only on adjustments
to paid claims. 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
|
3.1.2.19.33 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.
3.1.2.19.34 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.
3.1.2.19.35 FLs 6
7A-
Q.
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 67A-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 67A-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.
3.1.2.19.36 FL 76.
Attending Provider Name and Identifiers Required.
Enter the NPI and name of the attending
physician who signed the POC.
3.1.2.19.37 FL
s 7
8-79.
Other
Provider (Individual) Names and Identifiers Required.
Enter
the NPI and name of the physician who certified/re-certified the
patient’s eligibility for home health services.Note: Both
the attending physician and other provider fields should be completed
unless the attending physician is also the certifying/re-certifying
physician, then only the attending physician is required to be reported.
3.1.2.19.38 FL 80.
Remarks Are Conditional. Required
only in cases where the claim is canceled or adjusted.
3.1.2.21 Claims Adjustments and Cancellations
3.1.2.21.1 Both RAPs
and claims may be canceled by HHAs if a mistake is made in billing
(TOB 328); episodes will be canceled in the system, as well.
3.1.2.21.2 Adjustment
claims may also be used to change information on a previously submitted claim
(TOB 327), which may also change payment.
3.1.2.21.3 RAPs can
only be canceled, and then re-billed, not adjusted.
3.1.2.21.4 HHRGs can
be changed mid-episode if there is a significant change in the patient’s condition
(SCIC adjustment).
3.1.2.21.5 PEP Adjustments.
Episodes can be truncated and given PEP adjustment if the beneficiaries
choose to transfer among HHAs or if a patient is discharged and
subsequently readmitted during the same 60-day period.
3.1.2.21.5.1 In such
cases, payment will be pro-rated for the shortened episode. Such
adjustments to payment are called PEPs. When either the agency the
beneficiary is transferring from is preparing the claim for the
episode, or an agency that has discharged a patient knows when preparing
the claim that the same patient will be readmitted in the same 60
days, the claim should contain patient status code 06 in FL 17 (Patient
Status) of the CMS 1450 UB-04.
3.1.2.21.5.2 Based on
the presence of this code, Pricer calculates a PEP adjustment to
the claim. This is a proportional payment amount based on the number
of days of service provided, which is the total number of days counted
from and including the day of the first billable service, to and
including the day of the last billable service.
3.1.2.21.5.3 Transfers.
Transfer describes when a single beneficiary chooses to change HHAs
during the same 60-day period. By law under the HHA PPS system,
beneficiaries must be able to transfer among HHAs, and episode payments
must be pro-rated to reflect these changes.
• To accommodate this
requirement, HHAs will be allowed to submit a RAP with a transfer
indicator in FL 15 (Point of Origin for Admission
or Visit) of CMS 1450 UB-04 even when an episode
may already be open for the same beneficiary at another HHA.
• In such cases, the
previously open episode will be automatically closed in the TRICARE
Program systems as of the date services began at the HHA the beneficiary transferred
to, and the new episode for the “transfer to” agency will begin
on that same date.
• Payment
will be pro-rated for the shortened episode of the “transferred
from” agency, adjusted to a period less than 60 days, whether according
to the claim closing the episode from that agency or according to
the RAP from the “transfer to” agency. The HHAs may not submit RAPs
opening episodes when anticipating a transfer if actual services
have yet to be delivered.
3.1.2.21.5.4 Discharge
and Readmission Situation Under HHA PPS. HHAs may discharge beneficiaries
before the 60-day episode has closed if all treatment goals of the
POC have been met, or if the beneficiary ends care by transferring
to another HHA. Cases may occur in which an HHA has discharged a
beneficiary during a 60-day episode, but the beneficiary is readmitted
to the same agency in the same 60 days.
3.1.2.21.5.4.1 Since no
portion of the 60-day episode can be paid twice, the payment for
the first episode must be pro-rated to reflect the shortened period:
60 days less the number of days after the date of delivery of the
last billable service until what would have been the 60th day.
3.1.2.21.5.4.2 The next episode will begin the date the first
service is supplied under readmission (setting a new 60-day “clock”).
3.1.2.21.5.4.3 As with transfers, FL 15 (Point of Origin)
of CMS 1450 UB-04 can be used to send “a transfer to same HHA” indicator
on a RAP, so that the new episode can be opened by the HHA.
3.1.2.21.5.4.4 Beneficiaries do not have to be discharged
within the episode period because of admissions to other types of
health care providers (i.e., hospitals, SNFs), but HHAs may choose
to discharge in such cases.
• When discharging,
full episode payment would still be made unless the beneficiary
received more home care later in the same 60-day period.
• Discharge should be
made at the end of the 60-day episode period in all cases if the
beneficiary has not returned to the HHA.
3.1.2.21.5.5 Payment
When Death Occurs During an HHA PPS Episode. If a beneficiary’s
death occurs during an episode, the full payment due for the episode
will be made.
• This means that PEP
adjustments will not apply to the claim, but all other payment adjustments
apply.
• The
“Through” date on the claim (FL 6) of CMS 1450 UB-04, closing the
episode in which the beneficiary died, should be the date of death.
Such claims may be submitted earlier than the 60th day of the episode.
3.1.2.21.5.6 LUPA. If
an HHA provides four visits or less, it will be reimbursed on a
standardized per-visit payment instead of an episode payment for
a 60-day period. Such payment adjustments, and the episodes themselves,
are called LUPAs.
• On LUPA claims, non-routine
supplies will not be reimbursed in addition to the visit payments,
since total annual supply payments are factored into all payment
rates.
• Since
HHAs in such cases are likely to have received one split percentage
payment, which would likely be greater than the total LUPA payment,
the difference between these wage-index adjusted per visit payments
and the payment already received will be offset against future payments
when the claim for the episode is received. This offset will be
reflected on RAs and claims history.
• If the claim for the
LUPA is later adjusted such that the number of visits becomes five
or more, payments will be adjusted to an episode basis, rather than
a visit basis.
3.1.2.21.5.7 Special
Submission Case: “No-RAP” LUPAs. There are also reducing adjustments
in payments when the number of visits provided during the episode
fall below a certain threshold LUPAs.
• Normally, there will
be two percentage payments (initial and final) paid for an HHA PPS
episode - the first paid in response to a RAP, and the last in response
to a claim. However, there will be some cases in which an HHA knows
that an episode will be four visits or less even before the episode
begins, and therefore the episode will be paid a per-visit-based
LUPA payment instead of an episode payment.
• In such cases, the
HHA may choose not to submit a RAP, foregoing the initial percentage
that otherwise would likely have been largely recouped automatically against
other payments.
• However,
HHAs may submit both a RAP and claim in these instances if they
choose, but only the claim is required. HHAs should be aware that
submission of a RAP in these instances will result in recoupment
of funds when the claim is submitted. HHAs should also be aware
that receipt of the RAP or a “No-RAP LUPA” claim causes the creation
of an episode record in the system and establishes an agency as
the primary HHA which can bill for the episode. If submission of
a “No-RAP LUPA” delays submission of the claim significantly, the
agency is at risk for that period of not being established as the
primary HHA.
• Physician
orders must be signed when these claims are submitted.
• If an HHA later needs
to add visits to the claim, so that the claim will have more than four
visits and no longer be a LUPA, the HHA should submit an adjustment
claim so the intermediary may issue full payment based on the HIPPS
code.
3.1.2.21.5.8 Therapy
Threshold Adjustment. There are downward adjustments in HHRs if
the number of therapy services delivered during an episode does
not meet anticipated thresholds - therapy threshold.
3.1.2.21.5.8.1 The total
case-mix adjusted episode payment is based on the OASIS assessment and
the therapy hours provided over the course of the episode.
3.1.2.21.5.8.2 The number of therapy hours projected on the
OASIS assessment at the start of the episode, will be confirmed
by the visit information submitted in line item detail on the claim
for the episode.
3.1.2.21.5.8.3 Because
the advent of 15-minute increment reporting on home health claims
only recently preceded HHA PPS, therapy hours will be proxied from
visits at the start of HHA PPS episodes, rather than constructed
from increments. Ten visits will be proxied to represent eight hours
of therapy.
3.1.2.21.5.8.4 Each HIPPS
code is formulated with anticipation of a projected range of hours
of therapy service (physical, occupational or speech therapy combined).
3.1.2.21.5.8.5 Logic is inherent in HIPPS coding so that there
are essentially two HIPPS representing the same payment group:
• One
if a beneficiary does not receive the therapy hours projected, and
• Another if he or she
does meet the “therapy threshold”.
• Therefore, when the
therapy threshold is not met, there is an automatic “fall back”
HIPPS code, and the TRICARE Program systems will correct payment without
access to the full OASIS data set.
• If therapy use is
below the utilization threshold appropriate to the HIPPS code submitted
on the RAP and unchanged on the claim for the episode, Pricer software
in the claims system will regroup the case-mix for the episode with
a new HIPPS code and pay the episode on the basis of the new code.
• HHAs will receive
the difference between the full payment of the resulting new HIPPS
amount and the initial payment already received by the provider
in response to the RAP with the previous HIPPS code.
• The electronic RA
will show both the HIPPS code submitted on the claim and the HIPPS
that was used for payment, so such cases can be clearly identified.
• If the HHA later submits
an adjustment claim on the episode that brings the therapy visit
total above the utilization threshold, such as may happen in the case
of services provided under arrangements which were not billed timely
to the primary agency, the TRICARE Program systems will re-price
the claim and pay the full episode payment based on the original
HIPPS.
• A
HIPPS code may also be changed based on medical review of claims.
3.1.2.21.5.9 SCIC. While
HHA PPS payment is based on a patient assessment done at the beginning or
in advance of the episode period itself, sometimes a change in patient
condition will occur that is significant enough to require the patient
to be re-assessed during the 60-day episode period and to require
new physician’s orders.
3.1.2.21.5.9.1 In such
cases, the HIPPS code output from Grouper for each assessment should
be placed on a separate line of the claim for the completed episode,
even in the rare case of two different HIPPS codes applying to services
on the same day.
3.1.2.21.5.9.2 Since a
line item date is required in every case, Pricer will then be able
to calculate the number of days of service provided under each HIPPS
code, and pay proportional amounts under each HIPPS based on the
number of days of service provided under each payment group (count
of days under each HIPPS from and including the first billable service,
to and including the last billable service).
3.1.2.21.5.9.3 The total of these amounts will be the full
payment for the episode, and such adjustments are referred to as
SCIC adjustments.
3.1.2.21.5.9.4 The electronic
RA, including a claim for a SCIC-adjusted episode, will show the
total claim reimbursement and separate segments showing the reimbursement
for each HIPPS code.
3.1.2.21.5.9.5 There is
no limit on the number of SCIC adjustments that can occur in a single episode.
All HIPPS codes related to a single SCIC-adjusted episode should
appear on the same claim at the end of that episode, with two exceptions:
• One
- If the patient is re-assessed and there is no change in the HIPPS
code, the same HIPPS does not have to be submitted twice, and no
SCIC adjustment will apply.
• Two - If the HIPPS
code weight increased but the proration of days in the SCIC adjustment
would result in a financial disadvantage to the HHA, the SCIC is
not required to be reported.
3.1.2.21.5.9.6 Exceptions are not expected to occur frequently,
nor is the case of multiple SCIC adjustments (i.e., three or more
HIPPS for an episode).
3.1.2.21.5.9.7 Payment
will be made based on six HIPPS, and will be determined by contractor medical
review staff, if more than six HIPPS are billed.
3.1.2.21.6 Outlier
Payments. There are cost outliers, in addition to episode payments.
3.1.2.21.6.1 HHA PPS
payment groups are based on averages of home care experience. When
cases “lie outside” expected experience by involving an unusually
high level of services in a 60-day period, the TRICARE Program systems
will provide extra, or “outlier,” payments in addition to the case-mix adjusted
episode payment. Outlier payments can result from medically necessary
high utilization in any or all of the service disciplines.
3.1.2.21.6.2 Outlier
determinations will be made comparing the summed wage-adjusted imputed costs
for each discipline (i.e., the summed products of each wage-adjusted
per-visit rate for each discipline multiplied by the number of visits
of each discipline on the claim) with the sum of: the case-mix adjusted
episode payment plus a wage-adjusted fixed loss threshold amount.
3.1.2.21.6.3 If the
total product of the number of the visits and the national standardized
visit rates is greater than the case-mix specific HRG payment amount
plus the fixed loss threshold amount, a set percentage (the loss
sharing ratio) of the amount by which the product exceeds the sum
will be paid to the HHA as an outlier payment, in addition to the
episode payment.
3.1.2.21.6.4 Effective January 1, 2017, the methodology
to calculate the outlier payment will utilize a cost-per-unit approach
rather than a cost-per-visit approach. The national per-visit rates
are converted into per 15 minute unit rates. The per-unit rate by
discipline will be used along with the visit length data reported
on the home health claim to calculate the estimated cost of an episode
to determine whether the claim will receive an outlier payment and
the amount of payment for an EOC. The amount of time per day used
to estimate the cost of an episode for the outlier calculation is
limited to eight hours or 32 units per day (care is not limited,
only the number of hours/units eligible for inclusion in the outlier
calculation). For rare instances when more than one discipline of
care is provided and there is more than eight hours of care provided
in one day, the episode cost associated with the care provided during
that day will be calculated using a hierarchical method based on
the cost per unit per discipline shown in
Addendum K (CY 2017), Figure 12.K.2017-5.
The discipline of care with the lowest associated cost per unit
will be discounted in the calculation of episode cost in order to
cap the estimation of an episode’s cost at eight hours of care per
day.
3.1.2.21.6.5 Outlier
payment amounts are wage index adjusted to reflect the MSA or CBSA
in which the beneficiary was served.
3.1.2.21.6.6 Outlier payment is a payment for an entire
episode, and therefore only carried at the claim level in paid claim
history, not allocated to specific lines of the claim.
3.1.2.21.6.7 Separate
outliers will not be calculated for different HIPPS codes in a SCIC
situation, but rather the outlier calculation will be done for the
entire claim.
3.1.2.21.6.8 Outlier
payments will be made on remittances for specific episode claims.
HHAs do not submit anything on their claims to be eligible for outlier
consideration. The outlier payment will be included in the total
reimbursement for the episode claim on a remittance, but it will
be identified separately on the claim in history with a value code
17 in CMS 1450 UB-04 FLs 39-41, with an attached amount, and in
condition code 61 in CMS 1450 UB-04 FLs 18-28. Outlier
payments will also appear on the electronic RA in a separate segment.
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.