CMS Pub. 100-04, ch. 10, § 90

034x

(Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21)

HHAs may submit claims for certain medical and other health services which are paid

from the Part B trust fund. The HHA may receive payment for these services outside of

the prospective payment system (see Pub. 100-02, Medicare Benefit Policy Manual,

chapter 7).

A. Patient Not Under A Home Health Plan Of Care

The HHA submits claims with TOB 034x to bill for certain “medical and other health

services” when there is no home health plan of care. Specifically the HHA may bill

using TOB 034x for the following services. (There must be a physician’s certification on

file.):

• Surgical dressings, splints, casts, and other devices used for reduction of fractures

and dislocations. (See chapter 20 for billing enteral and parenteral supplies and

equipment.)

• Rental or purchase of DME. (See chapter 20 for billing enteral and parenteral

supplies and equipment.)

• Prosthetic devices. (See chapter 20 for billing enteral and parenteral supplies and

equipment.)

• Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes.

• Outpatient physical therapy services. (See the Medicare Benefit Policy Manual,

chapter 15 and the Medicare Claims Processing Manual, chapter 5.)

• Outpatient speech-language pathology services. (See the Medicare Benefit Policy

Manual, chapter 15 and the Medicare Claims Processing Manual, chapter 5.)

• Outpatient occupational therapy services. (See the Medicare Benefit Policy

Manual, chapter 15 and the Medicare Claims Processing Manual, chapter 5.)

• Diabetes Outpatient Self-Management Training (DSMT). (See the Medicare

Benefit Policy Manual, chapter 15, section 300.5.1)

• Bone Mass Measurements. (See the Medicare Claims Processing Manual, chapter

13, section 140.)

• Smoking and Tobacco-Use Cessation Counseling Services. (See the Medicare

Claims Processing Manual, chapter 32, section 12.)

Bills for services not under a home health plan of care should be submitted only after

services are delivered. They should be submitted on a periodic basis, e.g., monthly,

without regard to a period of care. These items are not reimbursed under HH PPS.

B. The Patient is Under a Home Health Plan of Care

If a patient is receiving home health services under a plan of care, the agency may bill for

the following services on TOB 034x:

• A covered osteoporosis drug,

• Pneumococcal pneumonia, influenza virus, and hepatitis B vaccines, and

• Disposable negative pressure wound therapy services.

All other services are home health services and should be billed as an HH PPS period of

care with Type of Bill 032x.

DME, orthotic, and prosthetics can be billed as a home health service using type of bill

032x or as a medical and other health service using type of bill 034x as appropriate.

Alternately, these services may be provided to HH beneficiaries by a supplier. Refer to

instructions in chapter 20 of this manual for submitting claims under arrangement with

suppliers.

C Billing Spanning Two Calendar Years

The agency should not submit a medical and other health services bill paid from the Part

B trust fund (TOB 034x only) for an inclusive period beginning in 1 calendar year and

extending into the next. If the agency does not bill on a calendar month basis, it prepares

two bills. The first covers the period ending December 31 of the old year; the second, the

period beginning January 1 of the new year. This permits the A/B MAC (HHH) to apply

the appropriate deductible for both years. HH PPS claims (TOB 032x) may span the

calendar year since they represent 30-day periods of care.

D Billing For Laboratory Services

HHAs may provide laboratory services only if issued a CLIA number and/or having a

CLIA certificate of waiver. HHAs do not report laboratory services, even when on the

HH plan of care, to an A/B MAC (A) or (HHH) using an institutional claim format.

These services are always billed to A/B MACs (B) using a professional claim format. To

submit such claims, the HHA must have a CLIA number and a professional billing

number. HHAs should contact the State Survey Agency to obtain a CLIA number.

HHAs should contact the appropriate MAC to obtain a billing number. The survey

process is used to validate that laboratory services in an HHA facility are being provided

in accordance with the CLIA certificate.