Home Health (HH) Billing Updates'2022

Correction to Home Health (HH) Billing for Denial Notices

The implementation of the one-time home health Notice of Admission (NOA) in calendar year 2022, every claim for a home health period of care first required the submission of a Request for Anticipated Payment (RAP).

Correction to the Calculation of 60-Day Gaps in Home Health Services

A sequence of related home health periods of care is defined beginning with an admission to home health services and ending when there is a 60-day gap in home health services.

This 60-day gap is used by Medicare systems for two purposes.

• 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 Processing

In 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 Services

In 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

In certain cases, Medicare allows the use of no payment claims in association with an ABN involving custodial care and termination of a benefit during a period of care.

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.

Diagnostic Angiography and Revascularization of Lower Extremity

The Catheterization is divided into two types and there are, 

• Non Selective Catheter Placement

• Selective Catheter Placement

Non Selective Catheter Placement

• The non selective catheter placement is not to be coded with selective catheter placement together. 

• And the following to be considered as non selective catheter placement, puncture of catheter, Insertion, and placement of catheter into the aorta. 

• Also, if the catheter does not have any further movement it should be considered as non selective catheter placement.

E.g.,

When the documentation shows that the catheter placement was only in the aorta, the non-selective catheter placement CPT code 36200 is to be coded.

Selective Catheter Placement

• The selective catheter placement is advanced from the original vessel of puncture sites to another vessels and it should be considered as selective catheter placement.

• When the catheter is advanced and/or crossed from the aorta and it should be considered as selective catheter placement.

E.g., 

Insertion of a catheter into the aorta is considered non-selective. The catheter can “enter” the aorta, but it is considered a non-selective vessel. When the documentation shows that the catheter placement was only in the aorta, the non-selective catheter placement CPT code 36200 is coded. Once the catheter is placed into a selective artery, the non-selective code is removed and bundled in with the highest of level selective catheter placement. (First order, Second order, Third order).

Tips

The documentation states the catheter placed into a 3rd order vascular family (CPT 36247), any non-selective codes (36200), first order (36245), and second order (36246) are considered as bundled with CPT 36247 on the ipsilateral side (same side as catheter placement).Only highest level of catheter placement can be coded for each insertion point. 

Guidelines

The lower extremity endovascular revascularization codes describing services performed for occlusive disease (37220-37235) include catheterization (36200, 36140, 36245-36248) in the work described by the codes. 

Catheterization codes are not additionally reported for diagnostic lower extremity angiography when performed through the same access site as the interventional procedures (37220-37235) performed in the same session. 

However, catheterization for the diagnostic lower extremity angiogram may be reported separately if a different arterial puncture site is necessary.

Diagnostic angiography and radiological supervision and interpretation codes should NOT be used with interventional procedures,

• Contrast injections, angiography, roadmapping, and/or fluoroscopic guidance for the intervention,

• Vessel measurement, and

• Post-angioplasty/stent/atherectomy angiography, as this work is captured in the radiological supervision and interpretation code(s). In those therapeutic codes that include radiological supervision and interpretation, this work is captured in the therapeutic code.

Diagnostic angiography performed at the time of an interventional procedure is separately reportable if,

• No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR

• A prior study is available, but as documented in the medical record:

• The patient's condition with respect to the clinical indication has changed since the prior study, OR

• There is inadequate visualization of the anatomy and/or pathology, OR

• There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.

Diagnostic angiography performed at a separate sessions from an interventional procedure is separately reported.

Lower Extremity Vascular Family 

There are three vascular territories categorized for coding purposes in the lower extremities. There are,

• Iliac territory - Which included of Common Iliac, Internal Iliac, and External Iliac arteries.

• Femoral/Popliteal territory - Which has the common femoral, profunda femoral, superficial femoral, and popliteal arteries

• Tibial/Peroneal territory -  Which includes the Anterior Tibial, Posterior Tibial, and Peroneal arteries.

There is a hierarchy that must be followed when reporting these interventions which is a stent with atherectomy supersedes atherectomy, which supersedes stent, which supersedes angioplasty when performed in the same vessel territory.

Note: Diagnostic angiography performed at the time of an interventional procedure is NOT separately reportable if it is specifically included in the interventional code descriptor.

Tips for Selecting the codes,

Pneumococcal Vaccine Claims Processing Updates April 2022

The Pneumococcal Vaccine CPT codes will be payable by Medicare. The new codes will be in the 2021 Medicare Physician Fee Schedule Database file update and the annual HCPCS update. 

90677-  Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.

• Which is effective for Dates of Service (DOS) on or after July 1, 2021

90671 - Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

• Which is effective for DOS on or after July 16, 2021 
• The CPT 90677 does not apply for Coinsurance and deductible.
  

A Medicare Administrative Contractor (MAC) will pay institutional providers for these codes based on the Type of Bill (TOB) used. The two payment methods are,

      1. The Medicare Administrative Contractor (MAC) will pay these institutional providers using reasonable cost if you use the following,

• Hospitals (TOBs 12X and 13X)
• Skilled Nursing Facilities (TOBs 22X and 23X)
• Home Health Agencies (TOB 34X)
• Hospital-based Renal Dialysis Facilities (RDFS) (TOB 72X)
• Critical Access Hospitals (CAHs) (TOB 85X)

      2. A MACs will pay these institutional providers based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP) if you use,

• Comprehensive Outpatient Rehabilitation Facilities (TOB 75X)
• Independent RDFs (TOB 72X)
• Indian Health Services (IHS),

• Hospitals (TOBs 12X and 13X)
• Hospices (TOBs 81X and 82X)
• IHS CAHs (TOB 85X)

A MAC will hold  the claims they get before April 1, 2022, for mentioned below CPT codes,

• HCPCS code 90677 with DOS on and after July 1, 2021
• HCPCS code 90671 with DOS on or after July 16, 2021

A MAC will process the claims when Medicare systems are ready on April 4, 2022. Also, your MAC will initiate a mass adjustment for any claims that rejected with HCPCS 90677 with a DOS from July 1, 2021 to September 30, 2021. 

They will also adjust rejected claims with HCPCS code 90671 with dates of service from July 16, 2021 to March 31, 2022. These adjustments will occur after April 4, 2022.