Correction to Home Health (HH) Billing for Denial Notices
Correction to the Calculation of 60-Day Gaps in Home Health Services
- It is used to validate whether a home health period of care is correctly coded as an early or later period.
- It is also used to identify early periods that should pay a Low Utilization Payment Adjustment (LUPA) add-on amount.
- Medicare administrative contractors recently identified a minor variance between the way the 60-day gap is counted and used for these two purposes.
- The requirements below revise the counting method used for identifying LUPA add-ons, in order to create consistency.
Submission and ProcessingIn order to submit a no-payment bill to Medicare under HH PPS, providers must use TOB 0320, and condition code 21.
The claims with condition code 21 and any other TOB will be returned to the provider for correction. A Notice of Admission (TOB 032A) is not required before the submission of a claim with TOB 0320 and condition code 21.
The claims to process through the subsequent HH PPS edits in the system, providers are instructed to submit a 0023 revenue line on the claim. If no OASIS assessment was done or if the HHA chooses not to perform payment grouping before submitting the claim, report any valid HIPPS code.
The claim must meet other minimum Medicare requirements. If an OASIS assessment was done and the HHA chooses to perform payment grouping for their internal accounting purposes, the HHA may report the resulting HIPPS code.
Simultaneous Covered and Non-Covered ServicesIn some cases, the providers may need to obtain a Medicare denial notice for non-covered services delivered in the same period as covered services that are part of an HH PPS period of care.
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 NOA and claim for the HH PPS period of care.
The period billed under the HH PPS claim and the non-payment bill should be the same. Medicare standard systems and the CWF will allow such duplicate claims to process when all services on one claim are non-covered.
Custodial Care under HH PPS, or Termination of the Benefit during a Period
This does not apply to cases in which a determination is being requested as to the beneficiary’s homebound status at the beginning of a period of care; there an ABN must be used assuming a triggering event occurs (i.e., the initiation of completely non-covered care).
However, in cases where the HH plan of care prescribes only custodial care, or if the benefit has terminated during a previous period, and the physician, beneficiary, and provider are all in agreement the benefit has terminated or does not apply, home health agencies (HHAs) can use,
- The ABN for notification of the beneficiary,
- A condition code 21 no-payment claim to bill all subsequent services.