- Q. Will the Medicare claim extend back earlier than May 1, 2021 or later than October 31, 2021? It is possible that the first episode will begin prior to May 1, 2021, or that the final episode will extend beyond October 31, 2021. How the agency established the episode beginning and ending dates will determine this. There are some specific rules for establishing episode dates, but the agency may also have some flexibility in this and may find it easier to align episode dates with already established plans of care. In any event, all services within the episode dates that were billed to Medicaid must be included on the Medicare claim, even if they occurred before May 1, 2021, or after October 31, 2021.
- Q. What if some or all of the period listed on Form A falls within periods covered by a Medicare HMO plan? As soon as you receive your TPL Project Packet, please review the list of cases included in the packet (Form A) and confirm each beneficiary’s eligibility or Managed Care Plan enrollment through the Medicare Common Working File right away. If a beneficiary was enrolled in a Medicare Advantage Plan Medicare Advantage Plan at any time during the period March 1 – December 31, 2021, please fill out Form B (included in your Phase 10 packet) and return it to the Center to the attention of Corinna Beebe ASAP. Please also notify Corinna Beebe (860-336-4818) of any beneficiaries who have Medicare eligibility issues at any time during the period of the Project. MA enrollment periods and eligibility issues may affect episode dates. Corinna will review the information submitted and will provide further instructions as soon as possible. It is imperative that claims are billed appropriately in these cases, especially if the MA period begins or ends within an episode. If a claim is not submitted correctly, Medicare will dismiss the entire episode, and your agency may be held financially liable.
- Q. What about a patient who has private insurance as primary. How do we proceed? Such situations will be handled on a case-by-case basis. Please refer particular cases to Corinna Beebe at 860-336-4818 or Lisa Fogg at 860-336-4815.
- Q. Do we use a default HHRG code or do we actually calculate the HHRG code? Valid HHRG/HIPPS codes must appear on the RAP and final claim. Under some circumstances, the Medicare Claims Processing system will automatically adjust “therapy” and “early/later” portions of the HIPPS code. Please see the following information in the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 10, §10.1.8 et. seq. for more specifics on this. Also see: Instructions regarding “therapy threshold” coding and Instructions regarding “early/later” coding, below.
- Q. What condition code do we put on the RAP? Do not put a condition code on the RAP! If condition codes are put on the RAP, it will not be accepted by Medicare, and further processing will be required. Put a condition code ‘’20’’ on the final claim if you want Medicare to make an independent coverage determination. However, if upon your review of the record, you believe the episode should be covered by Medicare, then a condition code 20 should not appear either on the RAP or on the final claim. Final claims filed with condition code 20 are known by Medicare as “beneficiary driven claims.” See further instructions from CMS regarding beneficiary driven claims.
- Q. Should we submit claims with a condition code ‘’21’’ asking for a denial? Absolutely not.
- Q. Will providers be compensated for each case that is copied and mailed? No.
- Q. Do all cases billed to Medicare require RAPs as well as Final Claims? RAPs are not required if the case is to be billed as No-RAP LUPA, or if the claim is an adjustment to a previously established Medicare episode and claim. In all other instances, both a RAP and a Final Claim are required.
- Q. When must a claim be submitted as an “adjusted” bill? If services affected by the Project fall within the dates of claims that were previously established in Medicare’s Common Working File, a RAP cannot be submitted. Rather, the existing claim needs to be adjusted to include the additional services. If these additional services can be billed as covered, please do so. If it is still your opinion that the additional services do not meet Medicare coverage criteria, they may be billed as non-covered using Condition Code 20 and the claim should include a dollar amount in the “non covered” column. However it is very important that you do not include the previously paid services in the “non-covered” column or they will very likely be denied and the prior payment will be recouped by Medicare. In all cases, please be sure to properly bill and send to the Center documentation for all visits rendered during the affected episodes, even if they have already been paid by Medicare. If services are included on the bill but not included in the documentation, Medicare will deny the visits, even if they were submitted as “covered” and even if they were previously paid.
- Q. Are Medbox prefill cases billed to Medicare as SN visits? Yes, if this service was performed by a nurse.
- Q. Do we need to bill Medicare for services that were previously billed to Medicaid during the period chosen for the Project? All home health services paid by Medicaid during the episode being submitted should be included on the final claim, even if they were provided before May 1, 2021, or after October 31, 2021. See also the first question, regarding dates earlier than May 1, 2021, and later than October 31, 2021 (above).
- Q. If the beneficiary has only Part B, are Home Health Services covered under Medicare Part B? Yes, beneficiaries are eligible for Home Health Care under both Part A and Part B. Refer to https://www.medicare.gov/coverage/home-health-services for more information.
- Q. Can claims for this project be submitted to Medicare on paper?
It is our understanding that Medicare claims must be submitted electronically. If you feel your agency may be exempt from this requirement, please contact Medicare Customer Service as noted below.
- Q. Are there any contacts at Medicare for specific billing issues?
Providers may contact Medicare’s Customer Service Line for answers to specific billing questions at the following numbers:For the Interactive Voice Response System: 866-275-3033
For a Menu prompt to speak with a Representative: 866-289-0423
- Q. How do we deal with claims with rejection code 37253? For questions regarding RTP’d claims for reason code 37253, see: https://www.cms.gov/files/document/se20010.pdf and Correcting Reason Code 37253.
Questions about the state’s operation of the project:
- John F. McCormick, CPA
Director, Office of Quality Assurance
Connecticut Department of Social Services
Questions about the Center’s operation of the project:
- Lisa Moore, Appeals Administrator
Questions about billing and documentation:
- Corinna Beebe, Appeals Manager
- Lisa Moore, Appeals Administrator
Questions about Medicare coverage and appeals:
- Mary A. Ashkar, Attorney at Law
- Eric Krupa, Attorney at Law
CMA Main office: (860) 456-7790
CMA Fax: (860) 456-1704
Mail: P.O. Box 350, Willimantic, CT 06226
The number of therapy visits projected on the OASIS assessment at the start of the episode, entered in OASIS, will be confirmed by the visit information submitted in line item detail on the claim for the episode.
The HH PPS adjusts Medicare payment based on whether one of three therapy thresholds (6, 14 or 20 visits) is met. As a result of these multiple thresholds, meeting a threshold can change the payment equation that applies to a particular episode. Also, additional therapy visits may change the score in the service domain of the HIPPS code.
Due to the complexity of the payment system regarding therapies, the Pricer software in Medicare’s claims processing system will recode all claims based on the actual number of therapy services provided. This recoding will be performed without regard to whether the number of therapies delivered increased or decreased compared to the number of expected therapies reported on the OASIS assessment and used to base RAP payment.
Since the number of therapy visits provided can change the payment equation used under the refined four-equation case mix model, in some cases this recoding may change several positions of the HIPPS code. In these cases, values in the treatment authorization code submitted on the claim will be used to determine the new code. Tables demonstrating how values in the treatment authorization code are converted into new HIPPS code values are included in section 70.4 below.
The electronic remittance advice will show both the HIPPS code submitted on the claim and the HIPPS code that was used for payment, so adjustments can be clearly identified.
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10.1.19.2 – Adjustments of Episode Payment – Early or Later Episodes
(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)
The HH PPS uses a 4-equation case-mix model that recognizes and differentiates payment for episodes of care based on whether a patient is in what is considered to be an early episode of care (1st or 2nd episode in a sequence of adjacent covered episodes) or a later episode of care (the 3rd episode and beyond in a sequence of adjacent covered episodes).
Early episodes include not only the initial episode in a sequence of adjacent covered episodes, but also the next adjacent covered episode, if any, that followed the initial episode. Later episodes are defined as all adjacent episodes beyond the second episode. Episodes are considered to be adjacent if they are separated by no more than a 60-day period between claims.
The 60-day period to determine a gap that will begin a new sequence of episodes is generally counted from the calculated 60-day end date of the episode. That is, in most cases Medicare systems will count from ‘‘day 60’’ of an episode without regard to an earlier discharge date in the episode. The exception is episodes subject to PEP adjustment. In PEP cases, Medicare systems will count 60 days from the date of the last billable home health visit provided in the PEP episode.
Any Original Medicare covered episode for a beneficiary is considered in determining adjacent covered episodes. A sequence of adjacent covered episodes is not interrupted if a beneficiary transfers between HHAs. Episodes covered by Medicare Advantage plans are not considered in determining adjacent episodes.
Example: A patient is admitted to Agency A on July 5th into a payment episode that ends on the date of Sept 2nd. The patient is then recertified on Sept 3rd, with an end of episode date of November 1st. Agency B admits on Jan 1.
When determining if two eligible episodes are adjacent, the HHA should count the number of days from the last day of one episode until the first day of the next episode. Adjacent episodes are defined as those where the number of days from the last day of one episode until the first day of the next episode is not greater than 60. The first day after last day of an episode is counted as day 1. Continue counting to, and including, the first day of the next episode.
In this example, November 1st was the last day of the episode and January 1 is the first day of the next episode. When counting the number of days from the last day of one episode (Nov 1st), November 2nd would be day 1, and Jan 1 would be day 61. Since the number of days from the end of one episode to the start of the next is more than 60 days, these two episodes are not adjacent. The episode starting January 1st would be reported by Agency B as “early”. December 31 represents day 60 in this example. If the next episode started December 31 instead of January 1, that episode would be considered adjacent since the number of days counted is not greater than 60. The episode starting December 31 would be reported by Agency B as “later.” All other episodes beginning between November 2 and December 31 in this example would also be reported as “later.”
HHAs report whether an episode is “early” or “later” using OASIS item M0110. This OASIS information is then used to determine the HIPPS code used for billing. The first position of the HIPPS code shows whether an episode is “early” or “later.” Since HHAs may not always have complete information about previous episodes, the HIPPS code is validated by Medicare systems. The Common Working File reads the episode history described in section 30.5 to determine whether an episode has been coded correctly based on the most current information available to Medicare. If the HIPPS code disagrees with Medicare’s episode history, the claim will be recoded.
The receipt of any episode may change the sequence of previously paid claims. For instance, a claim may be paid as “early” because the HHA was not aware of prior episodes and the previous HHA had not billed for the prior episodes. When the earlier dated episodes are received, Medicare systems will initiate an automatic adjustment to recode the previously paid claim and correct its payment. When claims are recoded, values in the treatment authorization code submitted on the claim will be used to determine the new code. Tables demonstrating how values in the treatment authorization code are converted into new HIPPS code values are included in section 70.4 below.
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50 – Beneficiary-Driven Demand Billing Under HH PPS
(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)
Demand billing is a procedure through which beneficiaries can request Medicare payment for services that: (1) their HHAs advised them were not medically reasonable and necessary, or that (2) they failed to meet the homebound, intermittent or noncustodial care requirements, and therefore would not be reimbursed if billed. The HHA must inform the beneficiary of this assessment in an Advance Beneficiary Notice of Noncoverage (ABN), which also must be signed by the beneficiary or appropriate representative. Instructions for the ABN are found in chapter 30 of this manual. Beneficiaries pay out of pocket or third party payers cover the services in question, but HHAs in return, upon request of the beneficiary, are required to bill Medicare for the disputed services. If, after its review, Medicare decides some or all the disputed services received on the “demand bill” are covered and pays for them, the HHA would refund the previously collected funds for these services. If the Medicare determination upholds the HHA’s judgment that the services were not medically reasonable and necessary, or that the beneficiary failed to meet the homebound or intermittent care requirements, the HHA keeps the funds collected, unless the Medicare contractor determines the ABN notification was not properly executed, or some other factor changed liability for payment of the disputed services back to the HHA.
The Medicare payment unit for home care under the home health prospective payment system (HH PPS) is an episode of care, usually 60 days in length. In order to be eligible for episode payment, Medicare beneficiaries must be: (1) under a physician plan of care and (2) at least one service must have been provided to the beneficiary, so that a RAP can be sent to Medicare and create a record of an episode in Medicare claims processing systems. Therefore, demand billing under HH PPS must conform to ALL of the following criteria:
- Situations in which disputed services are called for under a plan of care, but the HHA believes the services do not meet Medicare criteria for coverage;
- Claims sent to Medicare with TOB 032x; and
- Episodes on record in Medicare claims processing systems (at least one service in episode).
A – Interval of Billing
Under HH PPS, the interval of billing is standard. At most, a RAP and a claim are billed for each episode. Providers may submit a RAP after the delivery of the first service in the 60-day episode, and they must submit a claim either after discharge or after the end of the 60-day episode. This does not change in demand bill situations, so that only the claim at the end of the episode is the demand bill.
B – Timeliness of Billing
Medicare requests that HHAs submit demand bills promptly. Timely filing requirements were not changed by HH PPS (see chapter 1 for information on timely filing). Medicare has defined “promptly” for HH PPS to mean submission at the end of the episode in question. The beneficiary must also be given either a copy of the claim or a written statement of the date the claim was submitted. HH PPS provides a new incentive to be prompt in filing claims, since RAP payments are automatically recouped against other payments if the claim for a given episode does not follow the RAP in the later of: (1) 120 days from the start of the episode; or (2) 60 days from the payment date of the RAP. The RAP must be re-billed once payment has been recouped if the claim is to be billed unless the claim is a no-RAP LUPA as described in §40.3.
C – Claim Requirements
Original HH PPS claims are submitted with TOB 0329, and provide all other information required on that claim for the HH PPS episode, including all visit-specific detail for the entire episode (the HHA must NOT use TOB 0320). When such claims also serve as demand bills, the following information must also be provided: condition code “20” and the services in dispute shown as noncovered line items. Demand bills may be submitted with all noncovered charges. Provision of this additional information assures medical review of the demand bill. HH PPS adjustment bills, TOB 0327, may also be submitted but must have been preceded by the submission of a TOB 0329 claim for the same episode. RAPs are not submitted as demand bills, but must be submitted for any episode for which a demand bill will be submitted. Such RAPs should not use condition code 20, only the claim of the episode uses this code.
Cases may arise in which the services in dispute are visits for which an HHA has physician’s orders, but the duration of the visits exceeds Medicare coverage limits. However, the portion of these visits that is not covered by Medicare may be covered by another payer (e.g., an 8 hour home health aide visit in which the first 2 hours may be covered by Medicare and the remaining 6 hours may be covered by other insurance). In such cases, HHAs must submit these visits on demand bills as a single line item, representing the portion potentially covered by Medicare with a covered charge amount and the portion to be submitted for consideration by other insurance with a noncovered charge amount on the same line. Units reported on this line item should represent the entire elapsed time of the visit (the sum of the covered and noncovered portions), represented in 15 minute increments.
Cases may also arise in which a State Medicaid program requests the demand bill on the beneficiary’s behalf regarding services which have been billed to Medicaid. In these cases, the dates of service for which the State requests the demand bill may not correspond exactly to the episode periods billed to Medicare. These cases require special instructions:
Request begins during non-Medicare episode:
A Medicare-Medicaid dually-eligible patient may be admitted to home care with the expectation that no services will be billed to Medicare. Later, the State may request demand bills beginning during the course of that episode. This may occur when requests correspond to a calendar year. For example, the patient may be admitted in December and the request for demand bills is effective January 1. In this case, the HHA should submit a demand bill to Medicare with episode dates corresponding to the OASIS assessment that began in December. All services in the episode should be submitted as non-covered line items. As with any demand bill, condition code 20 should be reported on this claim.
Request applies to services immediately following Medicare discharge:
A dually-eligible patient may be discharged from Medicare home health services before the end of a 60-day episode due to the patient meeting their treatment goals. The patient may remain under the care of the HHA receiving services billed to Medicaid. States may vary in their requirements for a new Start of Care OASIS assessment in these cases. If the State requesting a demand bill for the services within the original Medicare 60-day episode does not require a new OASIS assessment, the HHA should submit an adjustment to their previously paid Medicare claim, using TOB 0327. The HHA should add condition code 20 to the adjustment claim, change the statement “Through” date to reflect the full 60-day period and add the services provided during the demand bill request period as non-covered line items. The HHA should then submit claims with condition code 20 and all non-covered line items for any episodes of continuous care within the demand bill request period.
If the State requesting a demand bill for the services within the original Medicare 60-day episode requires a new OASIS assessment, the HHA should submit RAPs and submit claims with condition code 20 as they would for any other demand bill situation. When Medicare receives the RAP for the demand billed episode it will cause a PEP adjustment to apply to the prior episode. Medicare cannot presume that the demand billed episode will or will not be covered based on the RAP. If the final claim for the demand billed episode is later reviewed and found to be entirely non-covered, Medicare systems will automatically adjust the prior episode to restore the appropriate full episode payment.
D – Favorable Determinations and Medicare Payment
Results of Medicare determinations favorable to the party requesting the demand bill will not necessarily result in increased Medicare payment. In such cases, and even if a favorable determination is made but payment does not change, HHAs will still refund any monies collected from beneficiaries or other payers for services previously thought not medically necessary under Medicare. Medicare payment will change only with the addition of covered visits if one or more of the following conditions apply:
- An increase in the number of therapy visits results in a change in the payment group for the episode – in such cases, the payment group of the episode would be changed by the contractor in medical review;
- An increase in the number of overall visits that either:
- Changes payment from a low-utilization payment adjustment to a full episode; or
- Results in the episode meeting the threshold for outlier payment (it is highly unlikely both things occur for the same episode).
- A favorable ruling on a demand bill adds days to an episode that received a PEP adjustment.
If a favorable determination is made, contractors will assure pricing of the claim occurs after medical review so that claims also serving as demand bills receive appropriate payment.
E – Appeals
Appeal of Medicare determinations made on HH PPS claims also serving as demand bills is accomplished by appealing the HH PPS claim. Such appeals are done in accordance with regulations stipulating appeals rights for Medicare home health claims. HH PPS RAPs do not have appeal rights; rather, appeals rights are tied to the claims that represent all services delivered for the entire episode unit of payment.
F – Specific Demand Billing Scenarios
- Independent Assessment.Billing questions relative to the ABN and home health assessments have persisted. With regard to payment liability for the assessment itself, the assessment is a non-covered service that is not a Medicare benefit and is never separately payable by Medicare. In all such cases, a choice remains: The provider may or may not decide to hold the beneficiary liable, and Medicare cannot specify which is appropriate because the service at issue is outside Medicare’s scope.
If a decision is made to hold a beneficiary liable for just the assessment, Medicare providers must be in compliance with the home health Conditions of Participation(COPs), as follows:
42 CFR 484.10.e (1) The patient has the right to be advised, before care is initiated, of the extent to which payment for the HHA services may be expected from Medicare or other sources, and the extent to which payment may be required from the patient. Before care is initiated, the HHA must inform the patient, orally and in writing, of: (i) The extent to which payment may be expected from Medicare, Medicaid or any other Federally funded or aided program known to the HHA; (ii) The charges for services that will not be covered by Medicare; and (iii) The charges that the individual has to pay.
Therefore, while no notice may be required if the provider chooses to be liable, the conditions state a notice is required if the beneficiary is to be held liable, and must be delivered prior to the service in question. ABNs can be used for this purpose.
- Billing in Excess of the Benefit.In some states, the Medicaid program will cover more hours of care in a week than the Medicare benefit. Therefore, an HHA may be billing hours/visits in excess of the benefit during a Medicare home health episode for a dually eligible beneficiary. Since the care delivered in excess of the benefit is not part of the benefit, and does not affect the amount of Medicare’s prospectively set payment, there is no dispute as to liability, and an ABN is not required unless a triggering event occurs; that is, care in excess of the benefit is not a triggering event in and of itself requiring an ABN. Billing services in excess of the benefit is discussed in C in this section.
- One-Visit Episodes.Since intermittent skilled nursing care is a requirement of the Medicare home health benefit, questions often arise as to the billing of one-visit episodes. Medicare claims systems will process such billings, but these billings should only be done when some factor potentially justifies the medical necessity of the service relative to the benefit.
Many of these cases do not even need to be demand billed, because coverage is not in doubt, since physician orders called for delivery of the benefit. When the beneficiary dies after only one visit is a clear-cut example. When physician orders called for additional services, but the beneficiary died before more services could be delivered, the delivery of only one visit is covered. The death is clearly indicated on the claim with use of patient status code 20. Other cases in which orders clearly called for additional services, but circumstances prevented delivery of more than one service by the HHA, are also appropriately billed to Medicare in the same fashion.
There may be rare cases where, even though orders do not clearly indicate the need for additional services, the HHA feels delivery of the service is medically justified by Medicare’s standard, and should be covered. In such situations, when doubt exists, an HHA should still give the beneficiary an ABN if a triggering event has occurred, explaining Medicare may not cover the service, and then demand bill the service in question.
No billing is required when there is no dispute that the one service called for on the order does not meet the requirements for the Medicare home health benefit, or is not medically necessary. However, there are options for billing these non-covered services as discussed in chapter 1, section 60 of this manual. Note the COPs may require notification in this situation if the beneficiary is to be held liable, as discussed in number 1, immediately above.
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