medicare home health & hospice educational event …€020‐01 08/2011 medicare home health...

E‐026‐01 08/2011

Medicare Home Health & Hospice Educational Event Pre / Post Test

CGS Administrators, LLC

Event Title:

Medicare Billing Updates for Home Health Agencies – MAHC Annual Conference

Date:

April 25, 2012

Pre Test

1. Which of the following status/location codes denotes a Medicare claim submission error:

a. D B9997.

b. R B9997.

c. P B9997.

2. The top claim submission error received by home health agencies who bill to CGS from July 1, 2011 – January 31, 2012, was for:

a. Overlapping another home health agency’s episode.

b. Duplicate billing.

c. System unable to find a processed Request for Anticipated Payment for the final claim that was submitted.

3. What percentage of total inquries did the top five telephone inquiry reasons comprise between November 1, 2011 and January 31, 2012?

a. 40.98%.

b. 50.98%.

c. 60.98%.

Post Test

1. Which of the following status/location codes denotes a Medicare claim submission error:

a. D B9997.

b. R B9997.

c. P B9997.

2. The top claim submission error received by home health agencies who bill to CGS from November 1, 2011 – January 31, 2012, was for:

a. Overlapping another home health agency’s episode.

b. Duplicate billing.

c. System unable to find a processed Request for Anticipated Payment for the final claim that was submitted.

3. What percentage of total inquiries did the top five telephone inquiry reasons comprise between November 1, 2011 and January 31, 2012?

a. 40.98%.

b. 50.98%.

c. 60.98%.

E‐020‐01 08/2011

Medicare Home Health & Hospice Educational Event Evaluation

CGS Administrators, LLC

Event Title:

Medicare Billing Updates for Home Health Agencies – MAHC Annual Conference

Date:

April 25, 2012

1. Educational Event Evaluation Excellent Good Average Fair Poor

Program was well organized and used time effectively

Information was communicated in a clear and understandable manner

Audiovisuals/handouts were effective

Content was relevant to the session objectives

2. Presenter(s) Evaluation

Speaker Effectiveness Excellent Good Average Fair Poor

Name: Janna Arndt

3. Please provide us with any additional comments about your experience today.

4. What suggestions do you have to improve the quality of our current educational offerings or for new offerings?

CGS Administrators, LLC MAHC Annual Conference April 25, 2012 1

Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2012 AMA. ICD-9-CM codes, descriptors © 2012.

Medicare Billing Updates for

Home Health Agencies

MAHC 2012 Annual Conference

April 25, 2012

Changes Impacting Medicare Home

Health Claims Processing

2

Change Request 7338

• Updates to Chapter 10 Home Health Agency Billing » www.cms.gov/mlnmattersarticles/

downloads/MM7338.pdf » Transfer situations between HHAs

–HHAs should provide transfer notifications to beneficiary if episode start date is one day immediately following end of prior episode with other agency

Other agency’s RAP may not yet be submitted for continuous episode of care

»HHAs should check eligibility screens ELGH Page 03 and ELGH Page 04 prior to admitting/submitting billing transactions 3



• Updates to Chapter 10 (cont’d)

» Discharge and readmission

– Impact of hospitalization during episode does not create discharge/readmission for Medicare payment purposes

All services within 60 day episode billed on one claim if beneficiary returns to same HHA after hospitalization

»Services prior to and after hospitalization billed on one claim by HHA

4

Change Request 7338

5

Beneficiary Elected Transfer

• CGS process change for determining beneficiary’s primary home health agency when dispute between two HHAs

» Review beneficiary’s episode history on Common Working File (CWF)

–No longer reviewing each episode individually

» If episode by another HHA within 60 days of the 2nd HHA’s start date, will review status code submitted by 1st HHA

» If status code indicates beneficiary still 1st HHA’s patient, 2nd HHA must produce transfer documentation for episode to stand

6

• Administrative Simplification Compliance Act (ASCA) requires Medicare claims submitted electronically

» Exceptions for small providers, untimely claims, some MSP situations

» If provider able to submit claim electronically or FISS, paper claims returned

• See CGS “Submitting Paper Claims” Web page for more information

» www.cgsmedicare.com/hhh/claims/ Submitting_Paper_Claims.html

Submitting Paper Claims



7

Submitting Paper Claims

Data Analysis

8

Claim Submission Errors (CSEs)

• RAP or claim that can’t process as billed

» Return to provider (RTP) = T B9997

–Missing, incomplete or incorrect information

» Reject = R B9997

–Contains information inconsistent with Common Working File (CWF)

–Duplicate billing

9



Claim Submission Errors (CSEs)

• Costs your home health agency money

» Staff time

» Delayed Medicare payment

» No Medicare payment

• Costs your home health agency time

» To check for claim errors

» To research problem

» To resolve issue

» To correct claim or rebill 10

CSE Reduction Benefits

• Timely Medicare payments

» Consistent cash flow

» Avoiding no payment for services, interruptions in payment for services

• Increased productivity

» Decreased repetition of errors/staff hours needed for rework

• Avoiding negative consequences of appearing in Medicare Administrative Contractor (MAC) data analysis

» Inappropriate billing/payment

» Unnecessary Medicare program costs 11

CGS Home Health Claims Data

Number of Home Health

“Claims” Submitted 1,429,245

Total of Top 6 HH CSE

Reasons 119,551 (8.36%)

12

July 1, 2011 – January 31, 2012



13

0

10,000

20,000

30,000

40,000

50,000

60,000N

u

m

b

e

r

o

f

E

r

r

o

r

s

Reason Code

Top CGS Home Health CSE RTP Reasons July 1, 2011 - January 31, 2012

38107 - Matching RAP notfound (56,604)

38157/38200 - DuplicateRAP/claim (29,471)

U538I - Overlappinganother HH episode(14,496)31147 - HIPPScode/supply billingmismatch (6,694)31755 - DOS doesn'tmatch 0023 DOS (6,584)

31018 - "STAT" code/DOSmismatch (5,702)

No Processed Matching RAP – RC 38107

• What it says: “… A matching RAP cannot be found for the home health claim (TOB 3X9) currently processing…”

• What the edit does: Checks to ensure there is a processed RAP in FISS (if required) when the episode’s final claim is submitted

• What causes it: FISS can’t find a finalized RAP that matches the home health claim submitted

• How many: 56,604 (Jul ‘11 – Jan ‘12)

14

• Most common causes:

» HH PPS timely filing requirements not met

–Unless Low Utilization Payment Adjustment (LUPA), claim must be matched to RAP

Within the greater of 60 days from

»Date RAP paid, OR

»End of episode

– If not matched, FISS auto-cancels RAP

Payment recouped

Episode remains on Common Working File (CWF)

15




• Most common causes: (cont.) » Key fields do not match between RAP/claim:

– ‘NPI’ of billing provider – ‘STMT DATES FROM’ – ‘ADMIT DATE’

16

MAP1711 PAGE 01 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY

XXXXXX SC INST CLAIM ENTRY C2012100 HH:MM:SS

HIC 555333111A TOB XXX S/LOC S B0100 OSCAR SV: UB-FORM

NPI XXXXXXXXXX TRANS HOSP PROV PROCESS NEW HIC

PAT.CNTL#: TAX#/SUB: TAXO.CD:

STMT DATES FROM 0701YY TO 0829YY DAYS COV N-C CO LTR

LAST HASKELL FIRST EDDIE MI DOB 02141941

ADDR 1 1945 THEODORE CLEAVER RD 2 BALTIMORE MD

3 4 CARR:

5 6 LOC:

ZIP 21236 SEX M MS ADMIT DATE 0701YY HR 14 TYPE 9 SRC 1 D HM STAT 01


17

MAP1712 PAGE 02 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXX SC INST CLAIM ENTRY C2012100 HH:MM:SS

REV CD PAGE 01 HIC 555333111A TOB XXX S/LOC S B0100 PROVIDER TOT COV SERV T/R CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND 0023 5AHNW 0701YY

• Most common causes: (cont.) » Key fields do not match (cont.)

–First four positions of HIPPS code – ‘HCPC’ – ‘SERV DT’ on 0023 rev code line

Must reflect date of first Medicare billable service in episode


• Most common causes: (cont.)

» RAP not submitted/processed prior to final claim submission

– RAP in FISS status/location (S/LOC) P B9997 and CAN DT is blank

18

NPI 1357913579

HIC 111222333A PROVIDER S/LOC P B9997 TOB 322

OPERATOR ID XXXXXX FROM DATE 0327YY TO DDE SORT

MEDICAL REVIEW SELECT

HIC PROV/MRN S/LOC TOB ADM DT FRM DT THRU DT REC DT

SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC #DAYS

111222333A XXXXXX T B9997 329 0601YY 0327YY 0525YY 0601YY

TAYLOR T 2984.93 0602YY 38107

111222333A XXXXXX P B9997 322 0601YY 0327YY 0327YY 0602YY

TAYLOR T 1364.33 0609YY 37185

3/27 RAP submitted after final claim submitted




• Best ways to prevent the error:

» Review RA OR access FISS Option 12 to ensure RAP is in S/LOC P B9997

–Never submit RAP and claim for same episode on the same day

» Ensure key fields match between RAP and claim (See slides 16, 17)

» Avoid RAP auto-cancel by submitting claim timely (See slide 15)

» Check for auto-canceled RAPs prior to billing claims

19


20

Check for Auto-Cancels - ELGH Page 3

• CWF Part A Eligibility System Screen, enter episode “FROM” date in “APP DATE” field » Enter other information as required to access

eligibility information • Page 3 displays 2 most recent episodes based on

“APP DATE” • Review “CAN IND” field

» If “1”, RAP auto-canceled

ELGH CWF PART A ELIGIBILITY SYSTEM ELGHCRO

MM/DD/CCYY HH:MM:SS HOME HEALTH PPS EPISODES PAGE 03 OF 12

HH-REC CN XXXXXXXXXA NM XXXXX IT X DB MMDDCCYY SX X

START END INTER PROV PATSTAT CAN-IND

DATE DATE NUM NUM

12/12/20YY 02/09/20YY 15004 XX7X02 30 1

09/09/20YY 11/07/20YY 15004 XX7X01 30 0

21

Check for Auto-Cancels - FISS Option 12

• Enter information in NPI and HIC fields

» May also complete S/LOC, TOB, FROM DATE and TO DATE fields

–S/LOC = P B9997

–TOB = 328

MAP1741 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY

XXXXXX SC CLAIM SUMMARY INQUIRY C2012100 HH:MM:SS

NPI 1357913579

HIC 111222333A PROVIDER S/LOC P B9997 TOB 328

OPERATOR ID XXXXXX FROM DATE 0327YY TO DATE DDE SORT

MEDICAL REVIEW SELECT

HIC PROV/MRN S/LOC TOB ADM DT FRM DT THRU DT REC DT

SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC #DAYS

S 111222333A XXXXXX P B9997 328 0601YY 0327YY 0327YY 1229YY

TAYLOR T 1364.33 0105YY 0105YY 37185



22

• Auto-cancel information found on FISS Page 03

» Look at ADJUSTMENT REASON CODE field

» “NF” indicates RAP auto-canceled by FISS

ESRD HOURS 00 ADJUSTMENT REASON CODE NF REJECT CODE NONPAY CODE

ATT PHYS NPI XXXXXXXXXX LN MOUSE FN MICKEY MI

OPR PHYS NPI 0000000000 LN FN MI

OTH PHYS NPI 0000000000 LN FN MI

37185 <== REASON CODES

PRESS PF3-EXIT PF7-PREV PAGE PF8-NEXT PAGE

Check for Auto-Cancels - FISS Option 12

Resolving Auto-Canceled RAPs

• If RAP auto-canceled, resubmit as originally billed

» Changed information may create overlapping episode errors

–Sent to RTP for correction

• Once resubmitted RAP finalizes, bill claim

• If information on original RAP incorrect, must still resubmit RAP as originally billed

» When resubmitted RAP finalizes, submit cancel RAP

» When cancel RAP finalizes, submit corrected RAP

» When corrected RAP finalizes, submit claim

23

Reason Codes 38157 & 38200

24

• What it says: “RAP/claim is exact duplicate of previously submitted RAP/claim with the same provider number…”

• What the edit does: Checks to ensure only one RAP/claim processes for each episode of care

• What causes it: 2nd RAP/claim submitted with same HICN, dates of service, billing provider number, and original RAP/claim not cancelled

• How many: 29,471 (Jul ‘11 – Jan ‘12)



25


• Best way to prevent the error:

» If batch file software, delete batches once submitted to Medicare

» Use RA or FISS Option 12 to monitor/track Medicare RAPs/claims and stay timely in posting Medicare payments

» Don’t correct and resubmit RAPs/claims in RTP file for same HICN and DOS

–Recommend: If resubmitting, suppress view (SV) of RTP RAP/claim

» Claims appear in RTP file for 36 months

26

Suppress View of Claim from RTP File

• From FISS Main Menu, enter “03”

• Access claim from Home Health Claim Correction Menu (Option 27)

• On FISS Claim Page 01, access SV field

• Enter “Y” in SV field and press “F9” key


XXXXXX SC INST CLAIM ENTRY C201136E HH:MM:SS

HIC 987654321A TOB 329 S/LOC S B0100 OSCAR SV: Y UB-FORM

NPI 1234567890 TRANS HOSP PROV PROCESS NEW HIC

PAT.CNTL#: TAX#/SUB: TAXO.CD:


LAST DUCK FIRST DAFFY MI DOB 12241930

ADDR 1 777 LAKESIDE DRIVE 2 ACME IA

27

• Best way to prevent the error (cont.) » Adjust processed or rejected final claims instead

of resubmitting, when appropriate –Examples: add visits omitted on original claim,

remove dates of service overlapping inpatient stay

» Cancel processed RAPs/final claims to remove incorrect episode information –Example: incorrect date of service billed on

RAP’s 0023 revenue line » Ensure “original” TOB is finalized prior to

submitting adjustment/cancel –RAPs –Final claims




28

Adjust or Resubmit Home Health Claims?

• If finalized claim (P B9997, R B9997) posts to the CWF, submit adjustment

» Review TPE-TO-TPE field on MAP171D

–Blank = Information posted to CWF

Examples: Overlap Medicare Secondary Payer (MSP) record, inpatient date of service

»No need to re-submit RAP

–X = Information not posted, resubmit claim

Examples: Overlap hospice election, Medicare Advantage (MA) Plan enrollment

29

MAP171D PAGE 02 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY

XXXXXX SC INST CLAIM INQUIRY C201136E HH:MM:SS

DCN 21014000XXXXXXIAR HIC 111222333B RECEIPT DATE 0520YY TOB 329

STATUS P LOCATION B9997 TRAN DT 0602YY STMT COV DT 0126YY TO 0310YY

PROVIDER ID XXXXXXXXXX BENE NAME MUNSTER, HERMAN

NONPAY CD GENER HARDCPY MR INCLD IN COMP CL MR IND

TPE-TO-TPE USER ACT CODE WAIV IND MR REV URC DEMAND

REJ CD MR HOSP RED RCN IND MR HOSP-RO ORIG UAC

MED REV RSNS


• Access FISS Inquiry Option 12

» Enter NPI, HICN, S/LOC

–May need to enter TOB and FROM/TO date

» Press Enter

» Select claim Press F8 Press F10

30


• Resource: www.cgsmedicare.com/hhh/education/materials/ resolving_rejected_claims.html



31

• If finalized RAP/claim posts episode to CWF, submit cancel

» Examples:

–Repay duplicate payment received

–Remove episode established under incorrect provider number

–Remove shortened episodes caused by inappropriately billing multiple RAPs

–Remove incorrect episode when “FROM” date overlaps inpatient date of service (RAP rejects – R B9997)

Cancel Home Health RAPs/Claims?

Additional Resources

• Adjustments/Cancels

» www.cgsmedicare.com/hhh/education/ materials/pdf/Chapter%205-Claims%20Correction%20Menu_06-2011.pdf

» www.cgsmedicare.com/hhh/education/ materials/Adjustments_Cancels.html

• Correcting Home Health Episodes

» www.cgsmedicare.com/hhh/education/ materials/correcting_cwf.html

» www.cgsmedicare.com/hhh/education/ materials/U538F.html

32


• Home Health Visits Overlap Inpatient Stay

» www.cgsmedicare.com/hhh/education/ materials/C7080.html

» September 1, 2010, Newsline (pgs. 22-23) www.cgsmedicare.com/hhh/pubs/newsline/ 201009_rhhi.pdf

» January 1, 2011, Newsline (pgs. 27-28) www.cgsmedicare.com/hhh/pubs/newsline/ 201101_rhhi.pdf

• Medicare Secondary Payer

» www.cgsmedicare.com/hhh/education/ materials/pdf/MSP_Billing.pdf

33




• Medicare Advantage Plans and Home Health Services

» www.cgsmedicare.com/hhh/education/ materials/Medicare_Advantage_Plans.html

• Overlapping Home Health Services Unrelated to Hospice Election

» www.cgsmedicare.com/hhh/education/ materials/C7010.html

» www.cgsmedicare.com/hhh/education/ materials/Election_Med_Hospice_Benefit.html

34

Overlapping Episode – RC U538I

• What it says: “A RAP or home health claim overlaps an existing episode with a different provider number…”

• What the edit does: checks CWF (ELGH/ELGA) for HH PPS episodes posted to beneficiary eligibility file

• What causes it: “FROM” date submitted on RAP/claim falls within posted episode, and condition code doesn’t indicate a transfer between HHAs during an episode

• How many: 14,496 (Jul ‘11 – Jan '12) 35

• Most common cause:

» Not checking ELGH/ELGA for episodes prior to admission or billing RAPs/claims

–Use APP DATE field if “FROM” date isn’t current

36

ELGH CWF PART A ELIGIBILITY SYSTEM ELGHCRO

MM/DD/CCYY HH:MM:SS HOME HEALTH PPS EPISODES PAGE 03 OF 12

HH-REC CN XXXXXXXXXA NM XXXXX IT X DB MMDDCCYY SX X

START END INTER PROV PATSTAT CAN-IND

DATE DATE NUM NUM

12/12/20YY 02/09/20YY 15004 XX7X02 30 1

09/09/20YY 11/07/20YY 15004 XX7X01 30 0

Two most recent episodes based on APP date

Does your “FROM” date fall within the episode dates??




37


» To report transfer to your HHA during episode, submit

–COND CODE “47” (FL 18-28) when “FROM” date on/after 07/01/2010

Must still use valid SRC code (required on all HH PPS billing transactions)

ZIP SEX MS ADMIT DATE HR TYPE 9 SRC 2 D HM STAT

COND CODES 01 47 02 03 04 05 06 07 08 09 10

FISS Page 01


HIPPS Code/Supply Billing Mismatch –

RC 31147

• What it says: “5th position of HIPPS code on final claim contains a letter; supply rev codes 027X or 0623 are not present on claim.”

• What the edit does: Verifies non-routine supplies (NRS) are billed on final claims whenever the 5th position of the HIPPS code is a letter

• What causes it: Omission of revenue codes 027X or 0623 on final claim when HIPPS code 5th position equal letters S, T, U, V, W, or X

• How many: 6,694 (Jul ‘11 – Jan '12) 38

• Best way to prevent the error: » If 5th position of HIPPS code = letter, rev code 027X

or 0623 must appear on claim » Use revenue code 027X to report NRS » Report wound care supplies separately using revenue

code 0623 (optional) – Also key service units, charges, and service date

» Match SERV DT to 0023 revenue line SERV DT

39

MAP1712 PAGE 02 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXX SC INST CLAIM ENTRY C2012100 HH:MM:SS REV CD PAGE 01 HIC XXXXXXXXXA TOB 329 S/LOC S B0100 PROVIDER TOT COV SERV T/R CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND 0023 1CHMT 0103YY 0270 1 1 34.56 0103YY 0623 1 1 67.89 0103YY


RC 31147



• Best way to prevent the error (cont.) » If 5th position of HIPPS code is a number, rev code

027X or 0623 not required on claim » Reminder: Changes to NRS provision from RAP to

final claim should not change NRS severity level

40

NRS Severity Level

HIPPS Position #5 If Supplies Provided

HIPPS Position #5 If Supplies Not Provided

1 S 1

2 T 2

3 U 3

4 V 4

5 W 5

6 X 6


RC 31147

No Match Between Visit DOS and 0023 DOS –

RC 31755

• What it says: “Date on 0023 revenue line does not match the ADMIT date and FROM date on start of care episodes OR final claim does not contain visit equal to service date on 0023 revenue line…”

• What the edit does: Verifies date billed with HIPPS code = visit provided to beneficiary; Ensures 1st Medicare billable visit in episode used as FROM/ADMIT date for initial episodes

• What causes it: 0023 date doesn’t match line item date of service OR when FROM date = ADMIT date, do not match 0023 service date

• How many: 6,584 (Jul ‘11 – Jan '12) 41


XXXXXX SC INST CLAIM UPDATE C2012100 HH:MM:SS

REV CD PAGE 01

HIC 123456789A TOB 329 S/LOC S B0100 PROVIDER 1234567890

TOT COV SERV T/R

CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND

1 0023 1CHM2 00060 00060 0401YY

2 0420 G0151 00003 00003 165.00 0401YY

3 0420 G0151 00002 00002 165.00 0404YY

4 0420 G0151 00002 00002 165.00 0406YY

5 0420 G0151 00002 00002 165.00 0408YY

6 0430 G0152 00002 00002 170.00 0401YY

7 0430 G0152 00002 00002 170.00 0405YY

8 0550 G0154 00008 00008 145.00 0401YY

9 0550 G0154 00003 00003 145.00 0404YY

10 0001 1290.00


» Final claims

–Verify one visit date = 0023 SERV DATE

42


RC 31755




» Start of care RAPs/claims

–FROM/ADMIT date (FISS Page 01) must equal 0023 SERV DATE (FISS Page 02)

43


RC 31755


LAST FUDD FIRST ELMER MI A DOB 11111911

ADDR 1 1234 WABBIT LANE 2 WARNER BROS IA

3 4 CARR:

5 6 LOC:


TOT COV SERV T/R CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND

1 0023 1BFL2 00060 00060 0326YY

“STAT” Code/DOS Mismatch –

RC Code 31018

• What it says: “Statement through date must be 59 days after the from date if patient status is equal to 30.”

• What the edit does: Verifies that 60 day episodes are billed on home health claims

• What causes it: Reporting less than 60 days on a home health claim and submitting patient status code “30” OR billing more than 60 days on a home health claim

• How many: 5,702 (Jul ‘11 – Jan '12) 44

• Most common causes:

45

MAP1711 PAGE 01 CGS J15 MAC - HHH REGION

XXXXXX SC INST CLAIM ENTRY

HIC XXXXXXXXXA TOB 329 S/LOC S B0100 OSCAR

NPI XXXXXXXXXX TRANS HOSP PROV

PAT.CNTL#: TAX#

STMT DATES FROM 0620YY TO 0819YY

LAST BROWN FIRST CHARLIE DOB 01011927

ADDR 1 4321 LINUS AND LUCY STREET 2 DES MOINES IA

MAP1711 PAGE 01 CGS J15 MAC - HHH REGIO

XXXXXX SC INST CLAIM ENTRY

HIC XXXXXXXXXA TOB 329 S/LOC S B0100 OSCAR

NPI XXXXXXXXXX TRANS HOSP PROV

PAT.CNTL#: TAX#

STMT DATES FROM 0620YY TO 0720YY

LAST BROWN FIRST

ADDR 1 4321 LINUS AND LUCY STREET 2 DES MOINES

3 4 CARR:

5 6 LOC:



RC Code 31018




» Don’t bill more than 60 days on a home health final claim – type of bill (TOB) 3X9

» One final claim per episode per agency

–Unless beneficiary discharged (met POC goals) and re-admitted during same 60 day episode

» If billing less than 60 days, ensure patient status code is other than “30”

46


RC Code 31018

47

• Error 38107 Web page www.cgsmedicare.com/hhh/education/materials/ 38107.html

• Errors 38031, 38157 and 38200 CSE Web page www.cgsmedicare.com/hhh/education/materials/ 38031_38157_38200.html

• Error U538I Web page www.cgsmedicare.com/hhh/education/materials/ U538I.html

Resolving Top Home Health Billing Errors

48




Resolving Top Home Health Billing Errors



• ‘Top Claim Submission Errors (Reason Codes) and How to Resolve’ web page, www.cgsmedicare.com/hhh/education/materials/CSEs.html » Lists most common errors by RC » Explains reason for error » Provides suggestions for how to prevent/resolve

49

Top Home Health Billing Errors

50

Provider Inquiries

• CMS requirements for provider questions handled by claims processing contractors

» Top provider inquiry data drives education/resources

–All provider questions start in Provider Contact Center (PCC)

» Inquiry triage process

–Questions elevated through tiers depending on complexity/research required for response

51

Inquiry Triage Process

Source of Information: CMS Pub. 100-09, Ch. 6, § 30.1



52

Provider Inquiries

• CMS requirements for provider questions handled by claims processing contractors (cont.)

» Develop/enhance self-service technology

» Require providers to use self-service tools to handle inquiry volume

–CSRs answer questions that cannot be addressed using self-service means

Top HH+H Provider Inquiries

Number of Home

Health/Hospice Provider

Telephone Questions

Handled

11,230

Sum of Top 5 Home

Health/Hospice Inquiry

Reasons

4,602

Percent of Total Inquiries 40.98% 53

November 1, 2011 – January 31, 2012

54

Reason for

Call

Type of Issues # of

Calls

Billing

Instructions

Instructions for submitting MSP

claims, special billing

situations, new billers

1,460

Claim

Correction

Understanding reason code

narrative; instructions for

correcting RAPs/claims

1,098

Provider

Enrollment

Requirements

Provider enrollment revalidation 867

Top HH+H Provider Inquiries



55

Reason for

Call

Type of Issues # of

Calls

Address,

Phone, Fax,

Web Address

CGS mailing addresses, links

to information on CMS or CGS

Web sites

620

Claim Overlap Beneficiary inpatient stay,

overlapping HH PPS episodes 557

Top HH+H Provider Inquiries (cont.)

56

Provider Inquiry ‘Resources’

www.cgsmedicare.com/hhh/education/materials/ Resources_Most_Common_HHH_Questions.html

List of links, information

Review prior to contacting

Updated quarterly

Based on inquiry data

57

CGS Website Navigation &

Resources



58

CGS Website

• www.cgsmedicare.com

• Primary links on left

59

CGS Website

• Quick links on right

60

CGS Website • Primary links

Primary Link Information Available

News & Publication

Recent news, join/update listserv, CGS Bulletins, Cahaba’s Newslines

Claims Processing

Rates/fee schedules, checking claim status, FISS Claims Processing Issues, common FISS status/locations, RA/ERA, submitting paper claims

EDI PC Print, GPNet, PC-ACE Pro32, FAQs

Customer Service

Phone numbers, Mailing addresses, IVR User Guide, Website feedback, Duplicate remit form

Education Calendar of events, educational materials, FAQs, Advisory Group, new provider resources



• Primary links (cont.)

61

CGS Website

Primary Link Information Available

Enrollment Electronic funds transfer (EFT), Enrollment packets, revalidation

Financial Audits, cost reports, PS&R, credit balance form, rates/fee schedule

Appeals Levels of appeal, redetermination address, reopenings, resources

LCDs & Coverage

Active LCDs, home health and hospice coverage guidelines, OASIS

Medical Review

ADRs, Overview of MR (edits, reason codes), signature guidelines

62

‘News & Publications’ Page

Current/recent ListServ messages

CGS monthly newsletter

Cahaba Newslines

‘Claims Processing’ Page

63



‘FISS Claims Processing Issues’ Page

64

65

Telephone numbers

Mailing addresses

IVR Guide

Duplicate Remit form

‘Customer Service’ Page

66

‘Events & Education’ Page

Coming Soon!

CGS Resources

Upcoming Events



67

‘Educational Materials & Resources’ Page

Scroll down for provider-specific

resources

FISS Guide

MSP Resources

• www.cgsmedicare.com/hhh/education/materials/index.html

68

Home Health Education Resources

‘Educational Materials & Resources’ Page

69

‘HH Claims Filing’ Page



70

‘HH Claims Filing’ Page

71

‘HH Coverage Guidelines’ Page www.cgsmedicare.com/hhh/coverage/Home_ Health_Coverage_Guidelines.html

• www.cgsmedicare.com/hhh/education/materials/HH_QRT.html

72

‘HH Quick Resource Tools’ Page



73

‘FAQs’ Page

MSP FAQs

HH FAQs

Provider Enrollment FAQs

‘LCDs & Coverage’ Page

74

HH PT LCD

HH Coverage

‘Medical Review’ Page

75

ADR information

Signature requirements



CGS Website Search Engine

76

Enter search term and click “Go”

• Accessible from top of each web page

CMS Website • Effective 03/09/12, URLs on CMS Website

(www.cms.gov) changed • Affects Web pages saved as “favorites” or

“bookmarks” • Also affects links included on CGS Web pages,

written materials » Links on CGS information to be updated

• Will not receive “Page Not Found” message » Redirected to new link for 1 year

77

78

Questions

Home Health Provider Contact Center (877) 299-4500

Avoiding Reason Code 38107

Check for Processed RAP Prior to submitting the final home health claim for an episode, check for a processed RAP by following the steps below:

1. Log on to FISS 2. At the Main Menu, enter “01” and press <Enter> 3. Enter “12” and press <Enter> 4. MAP 1741 will appear 5. Enter your National Provider Identifier (NPI) 6. Enter Patient’s HIC Number 7. Enter “322” in TOB 8. Enter “FROM DATE” and “TO DATE” of RAP and press <Enter>

*REMINDER: Under HH PPS, HHAs are not required to submit RAPs when 4 or fewer visits have been provided during the episode. If a RAP is required, it must be in S/LOC P B9997 prior to the claim’s submission to Medicare to avoid receiving reason code 38107. Please also ensure when reviewing the RAPs listed for the episode in question on MAP 1741, you are looking at the RAP with the most recent date in the PD DT (paid date) field.

MAP1741 CGS J15 MAC ACPFA052 MM/DD/YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH:MM:SS NPI HIC PROVIDER S/LOC TOB OPERATOR ID XXXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV/MRN S/LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC #DAYS

Note: Fields where information can be keyed in MAP 1741 are bolded.

Is RAP listed?*

Yes

No

Is a date shown in “CAN DT”

field?

Yes

No Review step 9 and submit final claim to Medicare.

Press F3 to “refresh” the

screen. Repeat steps 3 – 8.

If RAP is not listed, verify information

entered in steps 5-8.

Correct information: Submit RAP to Medicare. When RAP processes (S/LOC P B9997), review

step 9 and submit final claim to Medicare.

Note the date. Press F3 & follow

steps 10 - 18

Yes Is RAP in

S/LOC P B9997?

Incorrect information

Disclaimer: This resource is not a legal document. Reproduction of this material for profit is prohibited.

C G S A d m i n i s t r a t o r s L L C H - 0 1 4 - 0 1 June 2011

Avoiding Reason Code 38107

Matching RAP & Claim Information

9. Prior to submitting the final claim to Medicare, ensure the information in each of the following fields matches between the RAP and final claim: • National Provider Identifier (NPI) of billing provider (FL 56) • “FROM” date (FL 6) • “ADMIT” date (FL 12) • First four positions of the HIPPS code (FL 44)

o Note: FISS edits the fifth position of the HIPPS code to ensure the letter or number submitted does not change the supply severity level.

• Service date on 0023 revenue line (FL 45) o This must be the date of the first Medicare billable

service.

Checking for Auto-Canceled RAPs 10. Follow steps 1-6 11. Enter “P B9997” in S/LOC field 12. Enter “328” in TOB 13. Enter “FROM DATE” and “TO DATE” of RAP and press <Enter> 14. Review list of billing transactions. If no “328” appears, RAP not auto-

canceled. 15. Select “328” TOB with “CAN DT” matching “CAN DT” on “322” TOB 16. View Claim Page 3 for “ADJUSTMENT REASON CODE” field 17. If “NF” in “ADJUSTMENT REASON CODE” field, RAP auto-canceled 18. Re-bill RAP. When processed (S/LOC P B9997), review step 9 and

submit final claim to Medicare.


C G S A d m i n i s t r a t o r s L L C H - 0 1 4 - 0 1 June 2011

Avoiding Billing Errors Caused by Overlapping Home Health Episodes

HHAs are strongly encouraged to check eligibility prior to admitting the patient to your HHA AND before submitting the RAP/claim to Medicare for each episode:

• Log on to ELGH.• Enter the information required to access the beneficiary’s eligibility information. In addition, enter the start of care date or first calendar day of the episode in the APP DATE field found on the CWF Part A Eligibility System screen.• Review the information found on ELGH page 3, noting especially the information in the START DATE, END DATE, and PROV NUM fields.• Print this page and file with the patient’s record. Apply time/date stamp if not shown on screen print.

Appropriate Billing Action Based on Review of ELGH Page 3:

1. If your dates of service fall between the dates listed in the START DATE and END DATE fields on ELGH page 3 AND the provider number listed IS NOT your provider number, complete the following steps:

• Log on to http://www.cms.gov/CostReports/ Click on “Home Health Agency” link. Scroll down to list of downloads. Click on “HHA ProviderID Information” to download a spreadsheet containing the contact information for HHAs.

• Follow the steps given for appropriately completing beneficiary elected transfers as outlined on the “Beneficiary Elected Home Health Transfer” Web page (http://www.cgs medicare.com/hhh/education/materials/hh_transfer.html). Please note the documentation requirements found in this reference.

• If this is a transfer situation, and your agency is the receiving home health agency in a beneficiary elected transfer, your RAP and final claim for this episode will need to contain a point of origin code “B” in FL 15 on the UB-04 claim form when the “FROM” date is prior to July 1, 2010. Enter a valid point of origin code (but not “B”) in FL 15 and condition code 47 in FL 18-28 if the “FROM” date is on/after July 1, 2010. See Medicare Learning Network (MLN) Matters article, MM7338 (https://www.cms.gov/MLNMattersArticles/ downloads/MM7338.pdf), for additional information on home health transfers.

2. If your dates of service fall between the dates listed in the START DATE and END DATE fields on ELGH page 3 AND the provider number listed IS your provider number, ensure that you have billed the discharge claim for the beneficiary if the discharge is due to the patient meeting the goals of the plan of care. When discharging and readmitting a patient to your home health agency during the same 60-day period, a point of origin code “C” in FL 15 should be used on the first RAP and final claim that is submitted for the second admission date if the “FROM” date is prior to July 1, 2010. Enter a valid point of origin code (but not “C”) in FL 15 if the “FROM” date is on/after July 1, 2010. No additional coding to indicate a second admission to the same HHA during the same 60 day episode is required when the “FROM” date is on/after July 1, 2010. This situation will automatically result in a Partial Episode Payment (PEP). See the “Discharge and Readmit for Home Health Services” Web page (http://www.cgsmedicare.com/hhh/education/materials/discharge_and_remit.html) for additional information.

3. If your dates of service DO NOT fall between the dates listed in the START DATE and END DATE fields on ELGH Page 3, bill the RAP and final claim as usual.

PLEASE NOTE: IF YOU HAVE COMPLETED THE ABOVE STEPS AND OVERLAPPING ISSUES PERSIST, PLEASE CALL THE CGS PROVIDER CONTACT CENTER AT 1.877.299.4500.

Revised December 30, 2011.H-029-02 © 2011 Copyright, CGS Administrators, LLC. Disclaimer:Thisresourceisnotalegaldocument.Reproductionofthismaterialforprofitisprohibited.

http://www.cms.gov/CostReports/

http://www.cgsmedicare.com/hhh/education/materials/hh_transfer.html

http://www.cgsmedicare.com/hhh/education/materials/hh_transfer.html

https://www.cms.gov/MLNMattersArticles/downloads/MM7338.pdf

https://www.cms.gov/MLNMattersArticles/downloads/MM7338.pdf

http://www.cgsmedicare.com/hhh/education/materials/discharge_and_remit.html

CGS Administrators, LLC Disclaimer: This resource is not a legal document. Reproduction of this material for profit is prohibited.

June 2011 H-010-01

Page 1 of 3

Special Billing Situations Under HH PPS

Low Utilization Payment Adjustment (LUPA)

• A LUPA occurs when 4 or fewer visits

are provided in a 60-day episode. Instead of payment being based on the HIPPS code, payment is made based on a national average per-visit payment by discipline (skilled nursing, therapy, aide, etc.) for the visits provided during the episode.

• If the HHA determines at the beginning of the episode that 4 or fewer visits will be provided to a patient during that 60-day episode, the HHA has the choice to submit a No-RAP-LUPA claim. This means that the HHA may submit the final claim for the episode to Medicare without first submitting a RAP.

• Like all final claims under HH PPS, physician’s orders must be signed and dated prior to submitting No-RAP-LUPA claims to Medicare for payment.

• When billing No-RAP-LUPA claims, all required claim data should be entered as usual for a home health final claim, including the “Statement Covers Through” date (FL 6) which should reflect the 60th day of the episode or the date the patient transfers to another HHA, is discharged or dies. The claim data requirements are not different for LUPAs. The payment is different due to the 4 or fewer visits billed on the claim.

• An “add-on” payment is made to the first billable visit on LUPA claims when it is the first or only episode in a series of adjacent episodes.


June 2011 H-010-01

Page 2 of 3

Beneficiary Discharge/Readmission

• Cases may occur where an HHA discharges a beneficiary prior to the end of a 60-day episode because they have met the goals of the plan of care, and the beneficiary is later readmitted to the same HHA during the same

• The second admission prior to the end of the episode will generate a new OASIS, plan of care (POC), Request for Anticipated Payment (RAP), final claim (or No-RAP-LUPA instead of a RAP and claim) and a new 60-day episode.

60-day episode.

• The HHA receives a Partial Episode Payment (PEP)

• When billing the discharge final claim to Medicare in this situation, the “Patient Discharge Status” code (FL 17) should be recorded as “06” if the HHA knows that it is a discharge/readmission situation. Otherwise, the HHA should record the appropriate discharge status code. This field is the “STAT” field found on FISS Page 01. Complete all other fields as usual.

for the home health services provided prior to the patient’s second admission to the agency. PEPs are a proportion of the episode payment and are based on the span of days (first billable visit to last billable visit) care was provided prior to the second admission within the 60-day episode.

• When billing the readmission RAP/claim, the first Medicare billable service date after the readmission is recorded as the “Statement Covers From” date (FL 6), “Admission Date” (FL 12), and the earliest “Service Date” (FL 45) billed with revenue code 0023.

• If the date in FL 6 is prior to July 1, 2010, enter a “Point of Origin” code “C” in FL 15. For dates of service on/after July 1, 2010, “C” should not be entered in this field. Complete all other fields as usual.

• The “Point of Origin for Admission or Visit” (FL 15) code is a required field for home health billing transactions. See the CGS “Home Health Medicare Billing Codes Sheet” for a listing of the most common point of origin codes used in home health billing.

• HHAs should be aware that a PEP will be generated automatically for dates of service on/after July 1, 2010, that fall within the HH PPS episodes established for the beneficiary by their HHA. Therefore, it is very important for HHAs to ensure they are verifying the beneficiary’s episode history on ELGH/ELGA prior to admission or readmission AND

• More information and a listing of resources regarding discharging and readmitting a beneficiary during the same HH PPS episode to the same HHA is available at

submitting their RAPs/claims to Medicare.

www.cgsmedicare.com/hhh/education/materials/discharge_and_remit.html

Additional information on home health discharge and readmission is accessible in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10).

http://www.cgsmedicare.com/hhh/education/materials/discharge_and_remit.html�

http://www.cms.gov/manuals/downloads/clm104c10.pdf�


June 2011 H-010-01

Page 3 of 3

Beneficiary Elected Transfers

• A patient may decide to transfer from one HHA to another at any time and as many times as they wish. When this occurs within an established HH PPS episode, the HHA the patient is transferring from

• The

(first HHA) should discharge the patient from their care.

HHA that the patient is transferring to (receiving HHA) will need to establish a new start of care date and plan of care (POC). The original start of care date and POC established by the first HHA may not

• In addition, the receiving HHA

be used by the receiving HHA.

must document that the patient has been informed they will no longer receive home health services from the first HHA after the transfer date and the first HHA will no longer receive Medicare payment on their behalf. CGS also advises HHAs to review the beneficiary’s HH PPS episode history on ELGH/ELGA and print a copy showing this information before accepting the patient for care. The receiving HHA must also document their contact with the first HHA informing them of the transfer. Additional information and a listing of resources regarding beneficiary elected transfers is available at http://www.cgsmedicare.com/hhh/education/materials/hh_transfer.html

• When a patient transfer situation occurs between HHAs within an HH PPS episode, the first HHA will receive a Partial Episode Payment (PEP), in which payment for HH PPS services is based on a proportion of the episode (first billable visit through last billable visit).

• If the first HHA is aware of the transfer prior to submitting their final claim, the “Statement Covers Through” date (FL 6) should be recorded as the date of transfer. The “Patient Discharge Status” code (FL 17) should be recorded as “06”. These fields are found on Page 01 of FISS. Complete all other fields as usual.

• The receiving HHA should record the first Medicare billable service as the “Statement Covers From” date (FL 6), “Admission Date” (FL 12), and earliest “Service Date” (FL 45) billed with revenue code 0023 when billing a beneficiary elected transfer OR if the patient was discharged from another HHA and readmitted to their HHA within the same 60 day episode.

• If the “Statement Covers From” date is prior to July 1, 2010, the “Point of Origin” code (FL 15) should be recorded as “B” on the CMS-1450 claim form. If the “Statement Covers From” date is on/after July 1, 2010, “B” should not be entered in FL 15. Instead, HHAs must enter a valid code in FL 15 and also enter condition code “47” in FL 18-28. See the CGS “Home Health Medicare Billing Codes Sheet” for a listing of the most common point of origin codes used in home health billing. Complete all other fields as usual.

Additional information on home health beneficiary elected transfers is accessible in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10).

http://www.cgsmedicare.com/hhh/education/materials/hh_transfer.html�


Home Health Medicare Billing Codes Sheet

Type of Bill (TOB)* (FL 4) 322 Request for Anticipated Payment

(RAP) 329 Final Claim for Episode

327 Adjustment Claim 320 Nonpayment Claim 328 Void/Cancel Prior RAP/Claim 34X Outpatient Services

3XG or 3XI Contractor adjustment CMS Pub. 100-04, Chapter 10

* FISS will automatically change the 2nd digit of HH PPS TOBs from 2 to 3, if required. Example: 329 to 339

Priority (Type) of Admission or Visit Codes (FL 14) 1 Emergency 4 Newborn 2 Urgent 5 Trauma 3 Elective 9 Information not available

C G S A d m i n i s t r a t o r s L L C

J u n e 2 0 1 1 • H - 0 0 8 - 0 1

Claim Change Reason Codes (CCRC) (FL 18-28) & Adjustment Reason Codes (ARC) (FISS only)

Description CCRC ARC TOB Changes in Service Dates D0 RF 3X7 Changes to Charges D1 RG 3X7 Changes in revenue/HCPC/HIPPS codes D2 RH 3X7 Cancel to correct provider/HIC # D5 RI 3X8 Cancel duplicate or OIG payment D6 RJ 3X8 Change to make Medicare secondary D7 RK 3X7 Change to make Medicare primary D8 RL 3X7 Any other/multiple change (s) D9 RM 3X7 Change in patient status E0 RN 3X7 NOTE: RAPs cannot be adjusted. If information must be changed on a processed RAP, it must be cancelled and resubmitted to Medicare.

Core Based Statistical Area (CBSA) Value Code (FL 39-41) 61

CBSA code for where HH services were provided. CBSA codes are required on all 32X and 33X TOB. Place “61” in the first value code field locator and the CBSA code in the dollar amount column followed by two zeros.

Other value codes may be required when Medicare is the secondary payer. CMS Pub. 100-04, Chapter 10


Medicare Secondary Payer (MSP) Value Codes (VC) (FL 39-41) & Payer Codes (PC) (FISS only)

Description VC PC Description VC PC Working Aged 12 N/A Black Lung 41 N/A ESRD 13 N/A Disabled 43 N/A No Fault (no attorney involved) 14 N/A Veteran’s Administration 42 N/A

Worker’s Compensation 15 N/A Conditional Payment Any of the above

C

Public Health Svc/Other Federal 16 N/A Medicare Z NOTE: Medicare does not make secondary payer payments on RAPs. Submit RAPs with Medicare as primary. CMS Pub. 100-05, Chapter 3

Point of Origin (formerly Source of Admission Codes) (FL 15) 1 Non-Health Care Facility Point of Origin 7 Emergency Room (ER) (discontinued

effective 07/01/2010) 2 Clinic or Physician’s Office 8 Court/Law Enforcement 4 Transfer from Hospital (Different Facility) 9 Information not available

5 Transfer from Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) B

Transfer from Another HHA (cannot be submitted on home health RAPs/claims when “FROM” date is on/after 07/01/2010)

6 Transfer from Another Health Care Facility C Readmission to Same HHA (cannot be submitted on home health RAPs/claims when “FROM” date is on/after 07/01/2010)

Note: The codes listed on this billing codes sheet represent those most frequently submitted on home health RAPs/claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual - www.nubc.org


http://www.cms.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912&intNumPerPage=10�

http://www.cms.gov/manuals/downloads/msp105c03.pdf�

http://www.nubc.org/�

http://www.nubc.org/�

Home Health Medicare Billing Codes Sheet

Common Revenue Codes (FL 42) and HCPCS/Rates/HIPPS Rate Codes (FL 44) Rev Code Definition HCPCS Comments

0001 Total units/charges N/A No HCPCS required with revenue code

0023 HIPPS code As assigned by

Grouper software

See CMS Coding and Billing Information Web page for more information

027X Medical/Surgical Supplies N/A unless 0274 HCPCS required when submitting revenue code 0274 (Prosthetic/Orthotic devices) – See CPT coding book for appropriate HCPCs code.

042X Physical Therapy Varied See Medicare Learning Network (MLN) article, MM7182 for more information.

043X Occupational Therapy Varied See Medicare Learning Network (MLN) article, MM7182 for more information.

044X Speech Language Pathology Varied See Medicare Learning Network (MLN)

article, MM7182 for more information.

055X Skilled Nursing Varied See Medicare Learning Network (MLN) article, MM7182 for more information.

056X Medical Social Services G0155 057X Home Health Aide G0156

062X Medical/Surgical Supplies N/A Optional Use: When HHAs choose to report additional breakdown for surgical/wound care dressings.

CMS Pub. 100-04, Chapter 10 * For revenue codes ending in an “X”, sub-classifications exist. Use a “0” to indicate general classification when the sub-classifications are not appropriate.

Patient Status Codes (FL 17) 01 Discharge to home or self-care

(routine discharge) 43 Discharge/transfer to federal hospital

02 Discharge/transfer to short-term general hospital 50 Discharge/transfer for hospice

services in the home

03 Discharge/transfer to SNF 51 Discharge/transfer to hospice services in a medical facility

04 Discharge/transfer to ICF 61 Discharge/transfer to hospital-based Medicare approved swing bed

05 Discharge to designated cancer center or children’s hospital 62 Discharge/transfer to IRF

(inpatient rehabilitation facility)

06 Discharge/transfer to home care of another HHA OR discharge and readmit to the same HHA within a 60-day episode

63 Discharge/transfer to long-term care hospital

07 Left against medical advice or discontinued care 64

Discharge/transfer to Medicaid certified, but non-Medicare certified nursing facility

20 Expired 65 Discharge/transfer to psychiatric hospital or psychiatric part unit of a hospital

21 Discharge/transfer to court/law enforcement 66 Discharge/transfer to Critical

Access Hospital (CAH)

30* Still a beneficiary. Services continue to be provided 70

Discharge/transfer to another type of health care institution not defined elsewhere in code list

* Required on RAPs

Common Home Health Billing Errors by Reason Code (RC) (When RAP/claim is in FISS status/location (S/LOC) T B9997 or R B9997)

RC Resolution RC Resolution

31018 If billing > 60 days, status code must be other than 30 31147 If 5th position of HIPPS code is a letter, non-routine supplies must be submitted on the claim

31755 The service date of a visit must match the service date billed with revenue code 0023

38157, 38200 Duplicate billing transaction; adjust or cancel claim or RAP instead of resubmitting

38107 Re-bill RAP if auto-cancel AND ensure RAP is in P B9997 AND ensure “FROM” date, “ADMIT” date, first 4 position of HIPPS code, and 0023 date matches between RAP and claim for same episode

U538I Enter condition code 47 to indicate transfer between HHAs

Disclaimer: This resource is not a legal

document. Reproduction of this material for profit is prohibited.


J u n e 2 0 1 1 • H - 0 0 8 - 0 1

http://www.cms.gov/HomeHealthPPS/03_coding_billing.asp�

http://www.cms.gov/MLNMattersArticles/Downloads/MM7182.pdf�




http://www.cms.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912&intNumPerPage=10�

Home Health Medicare Billing Codes Sheet FISS Fields and UB-04 Field Locators (FL) for Home Health Billing

R = required C = conditional N = not required O = optional

FISS Pg FISS Field Name UB FL Data Entered RAP Claims 1 HIC 60 Medicare (HIC) number R R 1 TOB 4 Type of Bill R R 1 NPI 56 NPI number R1 R1 1 PAT. CNTL # 3a Patient Control Number O O 1 STMT DATE FROM 6 From date of service R R 1 TO 6 To date of service R R 1 LAST 8 Patient’s last name R R 1 FIRST 8 Patient’s first name R R 1 DOB 10 Patient’s date of birth R R 1 ADDR1 9 Patient’s address R R 1 ADDR 2 9 City State R R 1 ZIP 9 Zip code R R 1 SEX 11 Gender (M or F) R R 1 ADMIT DATE 12 Date of admission R R 1 HR 13 Admission hour R2 R2 1 TYPE 14 Admission type or visit R R 1 SRC 15 Source of admission R R 1 STAT 17 Patient status R R 1 COND CODES 18-28 Condition codes C C 1 OCC DCS/DATE 31-34 Occurrence code(s)/date(s) N C

1 SPAN CODES/DATES 35-36 Occurrence span code(s)/date(s) N C

1 FAC ZIP 1 Zip code for provider or subpart R1 R1 1 DCN 64 Document control number N C3 1 VALUE CODES 39-41 Value codes R4 R4 2 REV 42 Revenue codes R5 R 2 HCPC 44 HCPCS R R 2 MODIFS 44 Modifiers N C 2 TOT UNIT 46 Total Units N R 2 COV UNIT 46 Covered Units N R 2 TOT CHARGES 47 Total charges N R 2 NCOV CHARGES 48 Noncovered charges N C 2 SERV DATE 45 Service Date R6 R

1 NPI & FAC ZIP required effective 1/1/2008. 2 Required for DDE 3 Adjustments & cancels only 4 Value code 61 and CBSA code required 5 Rev codes 0023 and 0001 required on RAPs & final claim 6 RAPs require the 1st covered, Medicare billable service date along with revenue code 0023 & the HIPPS

code

FISS Pg FISS Field Name UB FL Data Entered RAP Claims 3 CD 50 Payer code R R 3 PAYER 50 Payer name R R 3 RI 52 Release of information R R 3 MEDICAL RECORD NBR 3b Medical Record Number O O 3 DIAG CODES 67 Diagnosis codes R R 3 ATT PHYS NPI 76 Primary care physician’s NPI R R 3 LN 76 Primary physician’s last name R R 3 FN 76 Primary physician’s first name R R 3 MI 76 Primary physician’s middle initial O O 3 OPR PHYS NPI 77 Operating physician’s NPI C C 3 LN 77 Operating physician’s last name C C 3 FN 77 Operating physician’s first name C C 3 MI 77 Operating physician’s middle initial O O 3 OTH PHYS NPI 77 Other physician’s NPI C C 3 LN 77 Other physician’s last name C C 3 FN 77 Other physician’s first name C C 3 MI 77 Other physician’s middle initial O O

4 REMARKS 80 Remarks (adjustments, cancels, demand/no-pay bills, MSP) C C

5 INSURED NAME 58 Insured’s last name, first name N C7 5 SEX N/A Insured’s sex code N C7 5 DOB N/A Insured’s date of birth N C7 5 REL 59 Patient’s relationship N C7 5 CERT-SSN-HIC 60 Insured’s ID/HIC# N C7 5 GROUP NAME 61 Insurance group name N C7 5 GROUP NUMBER 62 Insurance group number N C7 5 TREAT AUTH CODE 63 Claim-OASIS Matching Key code R R8

7 Required when Medicare is not the primary payer 8 Enter the Claims-OASIS Matching Key code on the TREAT AUTH CODE line that reflects Medicare’s payer

status (primary, secondary or tertiary). W e b S i t e R e f e r e n c e s

Internet Only Manuals – Pub. 100-02, Chapter 7 & Pub. 100-04, Chapter 10 www.cms.gov/Manuals/

Home Health Agency (HHA) Center

www.cms.gov/center/hha.asp



J u n e 2 0 1 1 • H - 0 0 8 - 0 1

medicare home health & hospice educational event …€020‐01 08/2011 medicare home health...

Documents