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 31-34. 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 FLs 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
ensure 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 non-routine
wound care supplies, using revenue code 623. Notwithstanding the
standard abbreviation “surg dressing”, use this item to report charges
for ALL non-routine 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 non-routine
wound care supplies under revenue center code 623. HHAs should ensure
that charges reported under revenue code 27X for non-routine
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 ensure 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
upon 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
upon 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 Medicare Secondary
Payer (MSP) situations will be made based upon 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 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 67A-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 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 FLs 78-79. 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 shall 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 upon the
presence of this code, Pricer calculates a PEP adjustment to the
claim. This is a proportional payment amount based upon 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 upon 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 upon 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 upon the
original HIPPS.
• A HIPPS code may also be changed
based upon medical review of claims.
3.1.2.21.5.9 SCIC. While HHA PPS payment
is based
upon 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 upon 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 upon 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 upon 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 upon the cost per unit
per discipline. The discipline of care with the lowest associated
cost per unit will be discounted in the calculation of episode cost 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 Non
-visit
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.
• Non-visit
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 non-payment
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. 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.