CMS Pub. 100-04, ch. 10, § 40.2

The following data elements are required to submit a claim under home health PPS. For

billing of home health claims not under an HH plan of care (not under HH PPS), see §90.

Home health services under a plan of care are paid based on a 30-day period of care.

HHAs submit an NOA at the beginning of an admission and then submit one claim for

each 30-day period of care. Claims submitted before an NOA has been received for the

beneficiary will be returned to the provider.

Billing Provider Name, Address, and Telephone Number

Required – The HHA’s minimum entry is the agency’s name, city, state, and ZIP Code.

The post office box 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. A/B MACs (HHH) use this information in connection with the provider

identifier to verify provider identity.

Patient Control Number and Medical/Health Record Number

Required - The patient’s control number may be shown if the patient is assigned one and

the number is needed for association and reference purposes.

The HHA may enter the number assigned to the patient’s medical/health record. If this

number is entered, the A/B MAC (HHH) must carry it through their system and return it

on the remittance record.

Type of Bill

Required - This 4-digit alphanumeric code gives two pieces of information. The first

three digits indicate the base type of bill. The fourth digit indicates the sequence of this

bill in this particular period of care. The types of bill accepted for HH PPS claims are:

032x - Home Health Services under a Plan of Treatment

4th Digit - Definition

7 - Replacement of Prior Claim - HHAs use to correct a previously submitted bill.

Apply this code for the corrected or “new” bill. These adjustment claims must be

accepted at any point within the timely filing period after the payment of the

original claim.

8 - Void/Cancel of a Prior Claim - HHAs use this code to indicate this bill is an

exact duplicate of an incorrect bill previously submitted. A replacement claim

must be submitted for the period of care to be paid.

9 - Final Claim for an HH PPS Period – This code indicates an HH original bill to

be processed following the submission of an HH PPS Notice of Admission (TOB

032A)

HHAs must submit HH PPS claims with the 4th digit of “9.” These claims may be

adjusted with code “7” or cancelled with code “8.” A/B MACs (HHH) do not accept late

charge bills, submitted with code “5,” on HH PPS claims. To add services within the

period of a paid HH claim, the HHA must submit an adjustment.

Statement Covers Period

Required - The beginning and ending dates of the period covered by this claim. For

continuous care periods, the “through” date must be 29 days after the “From” date for a

30-day period of care

In cases where the beneficiary has been discharged or transferred within the period,

HHAs will report the date of discharge in accordance with internal discharge procedures

as the “through” date. If the beneficiary has died, the HHA reports the date of death in

the “through date.”

The HHA may submit claims for payment immediately after the claim “through” date. It

is not required to hold claims until the end of the period of care unless the beneficiary

continues under care.

Patient Name/Identifier

Required - The HHA enters the patient’s last name, first name, and middle initial.

Patient Address

Required - The HHA enters the patient’s full mailing address, including street number

and name, post office box number or RFD, City, State, and ZIP Code.

Patient Birth Date

Required - The HHA enters the month, day, and year of birth of patient. If the full

correct date is not known, leave blank.

Patient 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.

Admission/Start of Care Date

Required - The HHA enters a date of admission matching the From date on the first

period of care in an admission. On subsequent periods of care, the HHA continues to

submit the admission date reported on the first period of care.

Point of Origin for Admission or Visit

Required - The HHA enters the appropriate NUBC point of origin code.

Patient Discharge Status

Required - The HHA enters the code that most accurately describes the patient’s status as

of the “Through” date of the billing period. Any applicable NUBC approved code may

be used.

Patient status code 06 should be reported in all cases where the HHA is aware that the

period of care will be paid a partial period payment adjustment. These are cases in which

the agency is aware that the beneficiary has transferred to another HHA within the 30-day

period, or the agency is aware that the beneficiary was discharged with the goals of the

original plan of care met and has been readmitted within the period. Situations may

occur in which the HHA is unaware at the time of billing the discharge that these

circumstances exist. In these situations, Medicare claims processing systems will adjust

the discharge claim automatically to reflect the partial period payment adjustment,

changing the patient status code on the paid claims record to 06.

In cases where the ownership of an HHA is changing and the CMS certification number

(CCN) also changes, the service dates on the claims must fall within the effective dates of

the terminating CCN. To ensure this, all periods of care with “from” dates before the

termination date of the CCN that would extend beyond the termination date must be

resolved by the provider submitting claims with “through” dates on or before the

termination date. The provider must code the claim with patient status 06. Billing for the

beneficiary is being “transferred” to the new agency ownership. In changes of ownership

which do not affect the CCN, billing is unaffected.

In cases where an HHA is aware in advance that a beneficiary will become enrolled in a

Medicare Advantage (MA) Organization as of a certain date, the provider should submit

a claim for the shortened period prior to the MA Organization enrollment date. The

provider must code the claim with patient status 06. Payment responsibility for the

beneficiary is being “transferred” from Medicare fee-for-service to MA Organization,

since HH PPS applies only to Medicare fee-for-service.

In cases where an HHA provides care in a 30-day period of care and then discharges the

beneficiary in the next 30-day period of care, but does not provide any billable visits in

the next 30-day period, special handling of the patient status code may be needed.

Normally, the patient status code for 30-day period before the discharge would be 30,

since the beneficiary has not yet been discharged. However, since there will not be a

claim for the period in which the discharge occurred, this would result in the HH

admission period remaining open in Medicare systems and prevent billing for any later

HH services.

In order to close the HH admission period in these cases, the HHA should report patient

status 01 on the claim for the last 30-day period in which visits occurred. This will

trigger Medicare systems to close the HH admission period. If the claim has been

submitted with patient status 30 before the discharge occurred, the HHA should adjust the

claim to change the patient status to 01.

If the cause of the discharge in the next 30-day period is a transfer to another HHA before

any visits were provided, the HHA should take care not to report patient status 06 on the

claim. This would result in an incorrect partial period payment adjustment. If the cause

of the discharge in the next 30-day period is the beneficiary’s death, the HHA should take

care not to report patient status 20 on the claim. This would result in an incorrect date of

death being recorded in Medicare systems and potentially affect claims from other

providers.

Condition Codes

Conditional – The HHA enters any NUBC approved code to describe conditions that

apply to the claim.

If the claim is for a patient transferred from another HHA, the HHA enters condition code

47.

If the claim is for a period of care in which there are no skilled HH visits in the billing

period, but a policy exception that allows billing for covered services is documented at

the HHA, the HHA enters condition code 54.

As a result of disaster conditions (such as hurricane or wildfire) that render submission of

OASIS assessments impossible, Medicare may issue a waiver indicating OASIS

submission is waived. In this case, HHAs should report condition code DR on their

claim to indicate billing under the waiver. Since the OASIS assessment cannot be

submitted, the HHA cannot report occurrence code 50 to show the assessment completion

date. Claims without occurrence code 50 will be accepted if condition code DR is

present.

When a provider is unable to submit a start of care OASIS for an admission period of

care, they should submit the HIPPS code weighted closest to 1. For a period of

continuing care, when a provider is unable to submit a follow-up OASIS, they should

carry forward the last HIPPS code generated from the previous OASIS.

If as a result of disaster conditions, OASIS submission timeframes are relaxed, HHAs

should submit claims without condition code DR as soon as the OASIS was submitted.

In this case, matching OASIS assessment information and the occurrence code 50 date

are required to ensure Medicare pays the claim accurately.

HHAs that are adjusting previously paid claims enter one of the condition codes

representing Claim Change Reasons (code values D0 through E0). If adjusting the claim

to correct a HIPPS code, HHAs use condition code D2 and enter “Remarks” indicating

the reason for the HIPPS code change. HHAs use D9 if multiple changes are necessary.

When submitting an HH PPS claim as a demand bill, HHAs use condition code 20. See

§50 for more detailed instructions regarding demand billing.

When submitting an HH PPS claim for a denial notice, HHAs use condition code 21. See

§60 for more detailed instructions regarding no-payment billing.

Required - If canceling the claim (TOB 0328), HHAs report the condition codes D5 or

D6 and enter “Remarks” indicating the reason for cancellation of the claim.

Occurrence Codes and Dates

Required – The HHA enters occurrence code 50 and the date the OASIS assessment

corresponding to the period of care was completed (OASIS item M0090). If occurrence

code 50 is not reported on a claim or adjustment, the claim will be returned to the

provider for correction, unless condition code DR is present to indicate a waiver of

OASIS reporting is in effect.

On claims for initial periods of care (i.e. when the From and Admission dates match), the

HHA reports an inpatient admission that ended within 14 days of the “From” date by

using one of the following codes.

Code Short Descriptor Long Descriptor

61 Hospital Discharge

Date

The Through date of a hospital stay that ended

within 14 days prior to the From date this HHA

claim.

62 Other Institutional

Discharge Date

The Through date of skilled nursing facility (SNF),

inpatient rehabilitation facility (IRF), long term

care hospital (LTCH) or inpatient psychiatric facility

(IPF) stay that ended within 14 days prior to this

HHA admission.

On claims for continuing periods of care, the HHA reports an inpatient hospital

admission that ended within 14 days of the “From” date by using occurrence code 61.

To determine the 14 day period, include the “From” date, then count back using the day

before the “From” date as day 1. For example, if the “From” date is January 20th, then

January 19th is day 1. Counting back from January 19th, the 14 day period is January 6

through January 19. If an inpatient discharge date falls on any date in that period or on

the admission day itself (January 20), it is eligible to be reported on the claim.

If more than one inpatient discharge occurs during the 14 day period, the HHA reports

only the most recent applicable discharge date. Claims reporting more than one of any

combination of occurrence codes 61 and 62 will be returned to the provider for

correction.

Conditional - The HHA enters any other NUBC approved code to describe occurrences

that apply to the claim.

Occurrence Span Code and Dates

Conditional - The HHA enters any NUBC approved Occurrence Span code to describe

occurrences that apply to the claim. Reporting of occurrence span code 74 is not required

to show the dates of an inpatient admission.

Value Codes and Amounts

Required - Home health payments must be based upon the site at which the beneficiary

is served, as described by a CBSA code. For certain dates of service when required by

law, payments may be further adjusted if the site is in a rural CBSA or rural county.

Value codes reporting both the CBSA and the State and County code where the

beneficiary received home health services are required on all claims.

For periods of care in which the beneficiary’s site of service changes from one CBSA or

county to another within the period, HHAs should submit the CBSA code or State and

County code corresponding to the site of service at the end of the period.

Provider-submitted codes:

Code Title Definition

61 Location Where Service

is Furnished (HHA and

Hospice)

HHAs report the Core Based Statistical Area

(CBSA) number (or rural state code) of the location

where the home health or hospice service is

delivered. The HHA reports the number in dollar

portion of the form locator right justified to the left

of the dollar/cents delimiter, add two zeros to the

cents field if no cents.

85 County Where Service

is Rendered

Where required by law or regulation, report the

Federal Information Processing Standards (FIPS)

State and County Code of the place of residence

where the home health service is delivered.

Medicare-applied codes: The following codes are added during processing and may be

visible in the A/B MAC (HHH)’s online claim history. They are never submitted by the

HHA.

Code Title Definition

17 Outlier Amount The amount of any outlier payment returned by the

Pricer with this code. A/B MACs (HHH) always

place condition code 61 on the claim along with

this value code.

62 HH Visits - Part A The number of visits determined by Medicare to be

payable from the Part A trust fund to reflect the

shift of payments from the Part A to the Part B trust

fund as mandated by §1812 (a)(3) of the Social

Security Act.

63 HH Visits - Part B The number of visits determined by Medicare to be

payable from the Part B trust fund to reflect the

shift of payments from the Part A to the Part B trust

fund as mandated by §1812 (a)(3) of the Social

Security Act.

64 HH Reimbursement -

Part A

The dollar amounts determined to be associated

with the HH visits identified in a value code 62

amount. This Part A payment reflects the shift of

payments from the Part A to the Part B trust fund as

mandated by §1812 (a)(3) of the Social Security

Act.

65 HH Reimbursement -

Part B

The dollar amounts determined to be associated

with the HH visits identified in a value code 63

Code Title Definition

amount. This Part B payment reflects the shift of

payments from the Part A to the Part B trust fund as

mandated by §1812 (a)(3) of the Social Security

Act.

QF Late-filed NOA penalty

amount

The dollar amount that the claim payment was

reduced due to the NOA being filed more than 5

days after the HH From date.

QV Value-based purchasing

adjustment amount

The dollar amount of the difference between the

HHA’s value-based purchasing adjusted payment

and the payment amount that would have otherwise

been made. May be a positive or a negative

amount.

If information returned from the CWF indicates all visits on the claim are Part A, the

shared system must place value codes 62 and 64 on the claim record, showing the total

visits and total PPS payment amount as the values, and send the claim to CWF with RIC

code V.

If information returned from CWF indicates all visits on the claim are Part B, the shared

system must place value codes 63 and 65 on the claim record, showing the total visits and

total PPS payment amount as the values, and send the claim to CWF with RIC code W.

If information returned from CWF indicates certain visits on the claim are payable from

both Part A and Part B, the shared system must place value codes 62, 63, 64, and 65 on

the claim record. The shared system also must populate the values for code 62 and 63

based on the numbers of visits returned from CWF and prorate the total PPS

reimbursement amount based on the numbers of visits to determine the dollars amounts

to be associated with value codes 64 and 65. The shared system will return the claim to

CWF with RIC code U.

Revenue Code and Revenue Description

Required

HH PPS claims must report a 0023 revenue code line which contains a HIPPS code.

HHAs enter only one 0023 revenue code per claim in all cases.

Claims must also report all services provided to the beneficiary within the period of care.

All services must be billed on one claim for the entire period. The A/B MAC (HHH) will

return to the provider TOB 0329 when submitted without any visit charges.

Each service must be reported in line item detail. Each service visit (revenue codes 042x,

043x, 044x, 055x, 056x and 057x) must be reported as a separate line. Any of the

following revenue codes may be used:

027x Medical/Surgical Supplies (Also see 062x, an extension of 027x)

Required detail: With the exception of revenue code 0274 (prosthetic

and orthotic devices), only service units and a charge must be reported

with this revenue code. If also reporting revenue code 0623 to

separately identify specific wound care supplies, not just supplies for

wound care patients, ensure that the charge amounts for revenue code

0623 lines are mutually exclusive from other lines for supply revenue

codes reported on the claim. Report only nonroutine supply items in

this revenue code or in 0623.

Revenue code 0274 requires an HCPCS code, the date of service units

and a charge amount.

NOTE: Revenue Codes 0275 through 0278 are not used for Medicare

billing on HH PPS claims.

042x Physical Therapy

Required detail: One of the physical therapy HCPCS codes defined

below in the instructions for the HCPCS code field, the date of service,

service units which represent the number of 15 minute increments that

comprised the visit, and a charge amount.

043x Occupational Therapy

Required detail: One of the occupational therapy HCPCS codes defined

below in the instructions for the HCPCS code field, the date of service,

service units which represent the number of 15 minute increments that

comprised the visit, and a charge amount.

044x Speech-Language Pathology

Required detail: One of the speech-language pathology HCPCS codes

defined below in the instructions for the HCPCS code field, the date of

service, service units which represent the number of 15 minute

increments that comprised the visit, and a charge amount.

055x Skilled Nursing

Required detail: One of the skilled nursing HCPCS codes defined

below in the instructions for the HCPCS code field, the date of service,

service units which represent the number of 15 minute increments that

comprised the visit, and a charge amount.

056x Medical Social Services

Required detail: The medical social services HCPCS code defined

below in the instructions for the HCPCS code field, the date of service,

service units which represent the number of 15 minute increments that

comprised the visit, and a charge amount.

057x Home Health Aide (Home Health)

Required detail: The home health aide HCPCS code defined below in

the instructions for the HCPCS code field, the date of service, service

units which represent the number of 15 minute increments that

comprised the visit, and a charge amount.

NOTE: A/B MACs (HHH) will return claims to the provider if revenue codes 058x or

059x are submitted with covered charges on Medicare home health claims. They also

return to the provider if revenue code 0624, investigational devices is reported on HH

claims

Revenue Codes for Optional Billing of DME

Billing of DME provided in the period of care is not required on the HH PPS claim.

Home health agencies retain the option to bill these services to their A/B MAC (HHH)

processing home health claims or to have the services provided under arrangement with a

supplier that bills these services to the DME MAC. Agencies that choose to bill DME

services on their HH PPS claims must use the revenue codes below. These services will

be paid separately in addition to the HH PPS amount, based on the applicable Medicare

fee schedule. For additional instructions for billing DME services see chapter 20 of this

manual.

0274 Prosthetic/Orthotic Devices

Required detail: The applicable HCPCS code for the item, a date of service, a

number of service units, and a charge amount.

029x Durable Medical Equipment (DME) (Other Than Renal)

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, a

number of service units, and a charge amount. Monthly rental items should be

reported with a separate line for each month’s rental and service units of one.

Revenue code 0294 is used to bill drugs/supplies for the effective use of DME.

060x Oxygen (Home Health)

Required detail: The applicable HCPCS code for the item, a date of service, a

number of service units, and a charge amount.

Revenue Code for Optional Reporting of Wound Care Supplies

0623 Medical/Surgical Supplies - Extension of 027x

Required detail: Only service units and a charge must be reported with this

revenue code. If also reporting revenue code 027x to identify nonroutine

supplies other than those used for wound care, the HHA must ensure that the

charge amounts for the two revenue code lines are mutually exclusive.

HHAs may voluntarily report a separate revenue code line for charges for nonroutine

wound care supplies, using revenue code 0623. Notwithstanding the standard

abbreviation “surg dressings,” HHAs use this code to report charges for ALL nonroutine

wound care supplies, including but not limited to surgical dressings.

Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, defines routine vs. nonroutine

supplies. HHAs use that definition to determine whether any wound care supply item

should be reported in this line because it is nonroutine.

HHAs can assist Medicare’s future refinement of payment rates if they consistently and

accurately report their charges for nonroutine wound care supplies under revenue center

code 0623. HHAs should ensure that charges reported under revenue code 027x for

nonroutine supplies are also complete and accurate.

HCPCS/Accommodation Rates/HIPPS Rate Codes

Required - On the 0023 revenue code line, the HHA may submit the HIPPS code they

expect will be used for payment if they choose to run grouping software at their site for

internal accounting purposes. If not, they may submit any valid HIPPS code in order to meet

this requirement.

HHAs enter only one HIPPS code per claim in all cases. Claims submitted with

additional HIPPS codes will be returned to the provider.

Medicare will determine the appropriate HIPPS code for payment based on claims and

OASIS data and will replace the provider-submitted HIPPS code as necessary. If the

HIPPS code further changes based on medical review or other processes, the code used

for payment is recorded in the APC-HIPPS field of the electronic claim record.

For revenue code lines other than 0023, the HHA reports HCPCS codes as appropriate to

that revenue code. The G- and Q- HCPCS codes listed below are for use by HHAs on

Type of Bill 032x only. Claims with these HCPCS codes will be returned to the provider

if submitted with Type of Bill 034x.

To report HH visits, the HHA reports one of the following HCPCS codes to represent a

visit by each HH care discipline:

Physical Therapy (revenue code 042x)

G0151 Services performed by a qualified physical therapist in the home health or hospice

setting, each 15 minutes.

G0157 Services performed by a qualified physical therapist assistant in the home health

or hospice setting, each 15 minutes.

G0159 Services performed by a qualified physical therapist, in the home health setting, in

the establishment or delivery of a safe and effective physical therapy maintenance

program, each 15 minutes.

G2168 Services performed by a physical therapist assistant in the home health setting in

the delivery of a safe and effective physical therapy maintenance program, each 15

minutes.

Occupational Therapy (revenue code 043x)

G0152 Services performed by a qualified occupational therapist in the home health or

hospice setting, each 15 minutes.

G0158 Services performed by a qualified occupational therapist assistant in the home

health or hospice setting, each 15 minutes.

G0160 Services performed by a qualified occupational therapist, in the home health

setting, in the establishment or delivery of a safe and effective occupational therapy

maintenance program, each 15 minutes.

G2169 Services performed by an occupational therapist assistant in the home health

setting in the delivery of a safe and effective occupational therapy maintenance program,

each 15 minutes.

Speech-Language Pathology (revenue code 044x)

G0153 Services performed by a qualified speech-language pathologist in the home health

or hospice setting, each 15 minutes.

G0161 Services performed by a qualified speech-language pathologist, in the home

health setting, in the establishment or delivery of a safe and effective speech-language

pathology maintenance program, each 15 minutes.

Note that modifiers indicating services delivered under a therapy plan of care (modifiers

GN, GO or GP) are not required on HH PPS claims.

Skilled Nursing (revenue code 055x)

General skilled nursing:

G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or

hospice setting

G0300 Direct skilled nursing of a licensed practical nurse (LPN) in the home health or

hospice setting.

Care plan oversight:

G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of

the plan of care, each 15 minutes (the patient’s underlying condition or complication

requires an RN to ensure that essential non-skilled care achieves its purpose in the home

health or hospice setting).

G0493 Skilled services of a registered nurse (RN) for the observation and assessment of

the patient’s condition, each 15 minutes (the change in the patient’s condition requires

skilled nursing personnel to identify and evaluate the patient’s need for possible

modification of treatment in the home health or hospice setting).

G0494 Skilled services of a licensed practical nurse (LPN) for the observation and

assessment of the patient’s condition, each 15 minutes (the change in the patient’s

condition requires skilled nursing personnel to identify and evaluate the patient’s need for

possible modification of treatment in the home health or hospice setting).

Training:

G0495 Skilled services of a registered nurse (RN), in the training and/or education of a

patient or family member, in the home health or hospice setting, each 15 minutes.

G0496 Skilled services of a licensed practical nurse (LPN), in the training and/or

education of a patient or family member, in the home health or hospice setting, each 15

minutes.

Medical Social Services (revenue code 056x)

G0155 Services of a clinical social worker under a home health plan of care, each 15

minutes.

Home Health Aide (revenue code 057x)

G0156 Services of a home health aide under a home health plan of care, each 15 minutes.

Regarding all skilled nursing and skilled therapy visits

In the course of a single visit, a nurse or qualified therapist may provide more than one of

the nursing or therapy services reflected in the codes above. HHAs must not report more

than one G-code for each visit regardless of the variety of services provided during the

visit. In cases where more than one nursing or therapy service is provided in a visit, the

HHA must report the G-code which reflects the service for which the clinician spent most

of his/her time.

For instance, if direct skilled nursing services are provided, and the nurse also provides

training/education of a patient or family member during that same visit, Medicare would

expect the HHA to report the G-code which reflects the service for which most of the

time was spent during that visit. Similarly, if a qualified therapist is performing a therapy

service and also establishes a maintenance program during the same visit, the HHA

should report the G-code that reflects the service for which most of the time was spent

during that visit. In all cases, however, the number of 15-minute increments reported for

the visit should reflect the total time of the visit.

Telehealth Service Reporting

Beginning on or after January 1, 2023, HHAs may voluntarily report the use of

telecommunications technology in the provision of home health services on claims. This

information is required on home health claims beginning on July 1, 2023. HHAs shall

submit the use of telecommunications technology when furnishing home health services,

on the home health claim via three G-codes.

G0320: home health services furnished using synchronous telemedicine rendered via a

real-time two-way audio and video telecommunications system

G0321: home health services furnished using synchronous telemedicine rendered via

telephone or other real-time interactive audio-only telecommunications system

G0322: the collection of physiologic data digitally stored and/or transmitted by the

patient to the home health agency (i.e., remote patient monitoring).

HHAs shall submit services furnished via telecommunications technology in line item

detail and with covered charges. Each service must be reported as a separately dated line

under the appropriate revenue code for each discipline furnishing the service. Two

occurrences of G0320 or G0321 on the same day for the same revenue code shall be

reported as separate line items with the same date of service and with service units

reporting 1. Services furnished via telecommunications technology are not considered by

Medicare systems when enforcing requirements for matching visit dates on home health

claims.

The use of remote patient monitoring that spans a number of days shall be reported as a

single G0322 line item reporting the beginning date of monitoring and the number of

days of monitoring in the service units field. If more than one discipline is using the

remote monitoring information during the billing period, the HHA may choose which

revenue code to report on the remote monitoring line item.

Claims with no billable visits are not submitted to Mediare, including claims for billing

periods where only telehealth services are provided.

Site of Service Reporting

HHAs must report where home health services were provided. The following codes are

used for this reporting:

Q5001: Hospice or home health care provided in patient’s home/residence

Q5002: Hospice or home health care provided in assisted living facility

Q5009: Hospice or home health care provided in place not otherwise specified

The location where services were provided must always be reported along with the first

visit reported on the claim. In addition to reporting a visit line using the G codes as

described above, HHAs must report an additional line item with the same revenue code

and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), one

unit and a nominal covered charge (e.g., a penny). If the location where services were

provided changes during the period of care, the new location should be reported with an

additional line corresponding to the first visit provided in the new location.

Disposable Negative Pressure Wound Therapy Services

Effective for claims with statement covers Through dates on or after January 1, 2024,

Medicare makes a separate payment amount for a disposable negative pressure wound

therapy (NPWT) device for a patient under a home health plan of care. Payment is equal

to the supply price used to determine the relative value for the service under the Medicare

Physician Fee Schedule (as of January 1, 2022) for the applicable disposable device and

updated by the consumer price index for all urban consumers minus the productivity

adjustment for each future year.

Disposable NPWT services are billed using the following HCPCS code:

• A9272 - wound suction, disposable, includes dressing, all accessories and

components, any type, each.

The HHA reports the HCPCS code with revenue code 027x (other than 0274), units

representing the number of disposable devices provided during the billing period and a

charge amount. Since Medicare payment no longer includes the services of the

practitioner applying the device, revenue codes 042x, 043x or 0559 are not used for

dNPWT HCPCS codes on Type of Bill 032x.

Modifiers

If the NOA that corresponds to a claim was filed late and the HHA is requesting an

exception to the late-filing penalty (see section 10.1.10.3), append modifier KX to the

HIPPS code reported on the revenue code 0023 line.

Service Date

Required - For initial periods of care, the HHA reports on the 0023 revenue code line the

date of the first covered visit provided during the period. Claims and provider-submitted

adjustments where the Admission Date and From Date match but the 0023 revenue code

line date does not also match are returned to the provider. Contractor-submitted

adjustments are excluded from this edit.

For subsequent periods, the HHA reports on the 0023 revenue code the date of the first

visit provided during the period, regardless of whether the visit was covered or non-covered.

For other line items detailing all services within the period, the HHA reports service dates

as appropriate to that revenue code. For service visits that begin in 1 calendar day and

span into the next calendar day, report one visit using the date the visit ended as the

service date.

When the claim Admission Date matches the Statement Covers “From” Date, Medicare

systems ensure that the Service Date on the 0023 revenue code line also matches these

dates.

Service Units

Required - Transaction standards require the reporting of a number greater than zero as

the units on the 0023 revenue code line. However, Medicare systems will disregard the

submitted units in processing the claim. For line items detailing all services within the

period, the HHA reports units of service as appropriate to that revenue code. Coding

detail for each revenue code under HH PPS is defined above under Revenue Codes.

For the revenue codes that represent home health visits (042x, 043x, 044x, 055x, 056x,

and 057x), the HHA reports as service units a 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. If any visits report over 96 units (over 24 hours) on a single line item,

Medicare systems return the claim returned to the provider.

Covered and noncovered increments of the same visit must be reported on separate lines.

This is to ensure that only covered increments are included in the per-unit based

calculation of outlier payments.

Telehealth services with HCPCS codes G0320 or G0321 are reported with units of 1.

Total Charges

Required - The HHA must report zero charges on the 0023 revenue code line (the field

must contain zero).

For line items detailing all services within the period of care, the HHA reports charges as

appropriate to that revenue code. Coding detail for each revenue code under HH PPS is

defined above under Revenue Codes. Charges may be reported in dollars and cents (i.e.,

charges are not required to be rounded to dollars and zero cents). Medicare claims

processing systems will not make any payments based upon submitted charge amounts.

Non-covered Charges

Required – The HHA reports the total non-covered charges pertaining to the related

revenue code here. Examples of non-covered charges on HH PPS claims may include:

• Visits provided exclusively to perform OASIS assessments

• Visits provided exclusively for supervisory or administrative purposes

• Therapy visits provided prior to the required re-assessments

Payer Name

Required - See chapter 25.

Release of Information Certification Indicator

Required - See chapter 25.

National Provider Identifier – Billing Provider

Required - The HHA enters their provider identifier.

Insured’s Name

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Patient’s Relationship To Insured

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Insured’s Unique Identifier

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Insured’s Group Name

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Insured’s Group Number

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Treatment Authorization Code

Conditional - Treatment authorization codes are not required on all claims. The HHA

submits a code in this field only if the period is subject to Pre-Claim Review. In that

case, the required tracking number is submitted in the first position of the field in all

submission formats.

Document Control Number (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.

Employer Name

Required only if MSP involved. See Pub. 100-05, Medicare Secondary Payer Manual.

Principal Diagnosis Code

Required - The HHA enters the ICD code for the principal diagnosis. The code must be

reported according to Official ICD Guidelines for Coding and Reporting, as required by

the HIPAA. The code must be the full diagnosis code, including all five digits for ICD-9-

CM or all seven digits for ICD-10 CM where applicable. Where the proper code has

fewer than the maximum number of digits, the HHA does not fill it with zeros.

Medicare systems may return claims to the provider when the principal diagnosis code is

not sufficient to determine the HHRG assignment under the PDGM.

Other Diagnosis Codes

Required - The HHA enters the full diagnosis codes for additional conditions if they

coexisted at the time of the establishment of the plan of care. These codes may not

duplicate the principal diagnosis as an additional or secondary diagnosis.

In listing the diagnoses, the HHA places them in order to best reflect the seriousness of

the patient’s condition and to justify the disciplines and services provided in accordance

with the Official ICD Guidelines for Coding and Reporting. The sequence of codes

should follow ICD guidelines for reporting manifestation codes. Medicare does not have

any additional requirements regarding the reporting or sequence of the codes beyond

those contained in ICD guidelines.

The following instructions apply to both Principal and Other Diagnosis Code reporting.

Diagnosis coding and claim dates:

Diagnosis codes that reflect the patient’s condition as of the start of a period of care (the

claim From date) are reflected on the claim for the current period of care. Diagnosis

codes that reflect a change in the patient’s condition during a period of care should be

reflected on the claim for the next period.

ICD diagnosis codes are updated each year on October 1 and April 1. While the claim

describes the patient’s condition as of the From date, if the claim Through date spans

across an ICD update, the codes that are valid after the update are reported on the claim.

For example, the HHA submits a claim spanning September 15, 2023 to October 14,

2023, for a patient that has Parkinson's Disease as a secondary diagnosis, The code in

effect on September 15, 2023 is G20 (Parkinson's Disease) but effective October 1, the

code that applies to the patient's condition changed to G20.C (Parkinsonism,

unspecified). The G20.C code is reported on the claim.

The version of the HH Grouper logic applied to each claim is determined is based on the

claim From date. In the case of a claim with a From date of September 15, 2023 and

Through date of October 14, 2023, the Grouper applies the logic and codes in effect for

dates of service before September 30, 2023 and not the logic and codes effective October

1. When a diagnosis code changes as describe above, the HH Grouper maps the new

code back to its predecessor code to correctly determine the case-mix scoring and the

HIPPS code for the claim (e.g. maps G20.C back to G20 and uses the G20 code to assign

the HIPPS code).

Claim and assessment diagnosis codes:

The diagnosis codes used for payment grouping are determined from claim coding rather

than the OASIS assessment. As a result, the claim and OASIS diagnosis codes are not

expected to match in all cases.

Typically, the codes will match between the first claim in an admission and the start of

care (Reason for Assessment –RFA 01) assessment and claims corresponding to

recertification (RFA 04) assessments. Second 30-day claims in any 60-day period will

not necessarily match the OASIS assessment. When diagnosis codes change between

one 30-day claim and the next, there is no absolute requirement for the HHA to complete

an ‘other follow-up’ (RFA 05) assessment to ensure that diagnosis coding on the claim

matches to the assessment. However, the HHA would be required to complete an ‘other

follow-up’ (RFA 05) assessment when such a change would be considered a major

decline or improvement in the patient’s health status.

Attending Provider Name and Identifiers

Required - The HHA enters the name and national provider identifier (NPI) of the attending

physician who signed the plan of care.

Other Provider (Individual) Names and Identifiers

Required - The HHA enters the name and NPI 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 patient’s designated attending physician is the same as the physician who

certified/re-certified the patient’s eligibility. When the attending physician is also the

certifying/re-certifying physician, only the attending physician is required to be reported.

Remarks

Conditional – If the NOA that corresponds to a claim was filed late and the HHA is

requesting an exception to the late-filing penalty (see section 10.1.10.3), enter

information supporting the exception category that applied to the NOA.

The HHA shall provide sufficient information in the Remarks section of its claim to

allow the contractor to research the case. If the remarks are not sufficient, Medicare

contractors shall request documentation. Documentation should consist of printouts or

screen images of any Medicare systems screens that contain the information shown

above.

Medicare contractors shall not grant exceptions if:

• the HHA can correct the NOA without waiting for Medicare systems actions

• the HHA submits a partial NOA to fulfill the timely-filing requirement, or

• HHA with multiple provider identifiers submit the identifier of a location that

did not actually provide the service

In the great majority of cases, the five day timely filing period allows enough time to

submit NOAs on a day when Medicare systems are available (i.e. the period allows for

("dark days"). Additionally, the receipt date is typically applied to the NOA immediately

upon submission to Medicare systems, so subsequent dark days would not affect the

determination of timeliness. However, if the HHA can provide documentation showing

an NOA is submitted on the day before a dark day period and the NOA does not receive a

receipt date until the day following the dark days, the contractor shall grant an exception

to the timely filing requirement. CMS expects these cases to be very rare.

Remarks are otherwise required only in cases where the claim is cancelled or adjusted.

adjusted.