CMS Pub. 100-04, ch. 10, § 10

Claims

(Rev. 2977, Issued; 06-20-14, Effective: 09-23-14; ICD-10: Upon Implementation of ICD-10, Implementation: 09-23-14; ICD-10: Upon Implementation of ICD-10)

This chapter, in general, describes billing and claims processing requirements that are

applicable only to home health agencies. For general bill processing requirements refer

to the appropriate other chapters in the Medicare Claims Processing Manual. For a

description of home health coverage policies see Pub. 100-02, Medicare Benefit Policy

Manual, chapter 7.

A. Where and How to Bill

Institutional providers, including home health agencies, use one of two institutional claim

formats to bill Original Medicare. In the great majority of cases, these providers are

required to use the electronic HIPAA standard institutional claim transaction, the 837

institutional claim. The minority of providers that are eligible for an exception to

electronic claim submission use the paper Form CMS-1450, also known as the UB-04.

Such claim forms are submitted to certain Medicare Administrative Contractors (A/B

MACs (HHH)) with jurisdiction over home health and hospice claims. Some home

health agencies may also become approved as Durable Medical Equipment (DME)

suppliers, in which case they would submit bills for DMEPOS services to the DME

MACs on a professional claim format (the 837professional or paper Form CMS-1500).

References to the claim form in this chapter refer to the paper Form CMS-1450 unless

otherwise noted. However, the instructions regarding specific data requirements apply

also to the electronic 837 institutional claim.

B. Services to Include on the Claim for Home Health Benefits

Effective for all services provided on or after October 1, 2000, all services under the

home health plan of care, except the following, are included in the home health PPS

payment amount. Services that may be included in the plan of care but excluded from the

HH prospective payment system (HH PPS) are:

• Osteoporosis drugs (although the cost of administration is within the PPS rate);

and

• Durable medical equipment, including prosthetics, orthotics, and oxygen

The DMEPOS services may be included on type of bill (TOB) 032x for the home health

benefits, and are paid in addition to the PPS payment. See §20 for additional instructions

regarding competitively bid DME. Osteoporosis drugs must be billed on type of bill

034x.

Other services not under an HH plan of care provided by an HHA are billed using type of

bill 034x. See §90 for guidance as to the payment methodologies used by Medicare to

reimburse these services, and see §40.4 in this chapter for information on deductible and

coinsurance.