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Home Health Billing Codes

The following codes represents that most frequently submitted on home health RAPs/claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

The Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 10)External PDF describes bill processing requirements that are applicable only to home health agencies.

Priority (Type) of Admission or Visit Codes

Code

Description

1

Emergency

2

Urgent

3

Elective

4

Newborn

5

Trauma

9

Information not available

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Point of Origin (formerly Source of Admission) Codes

Code

Description

1

Non-health care facility point of origin

2

Clinic or Physician's office

4

Transfer from hospital (different facility)

5

Transfer from skilled nursing facility (SNF) or intermediate care facility (ICF)

6

Transfer from another health care facility

8

Court/Law enforcement

9

Information not available

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Patient Status Codes

Patient Status Code

Description

01

Discharged to home or self-care (routine discharge)

02

Discharged/transferred to a short-term general hospital

03

Discharged/transferred to SNF (Skilled Nursing Facility)

04

Discharged/transferred to ICF (Intermediate Care Facility)

06

Discharged/transferred to home care of another organized home health service organization, OR discharged and readmitted to the same home health agency within a 60-day episode. This status should also be used if the beneficiary enrolls in a Medicare Advantage (MA) plan during an HH PPS episode. Note: Report this status code in all cases where your HHA is aware that the episode will be paid as a partial episode payment (PEP). Do not use for any other general discharge/transfer situation.

07

Left against medical advice or discontinued care

20

Expired (For claims submitted on/after 10/01/12, also enter occurrence code 55 and the beneficiary's date of death in FL 31-34.)

21

Discharge/transfer to court/law enforcement

30

Still a patient and services continue to be provided

43

Discharged/transferred to a federal hospital

50

Discharged/transferred for hospice services in the home

51

Discharged/transferred to hospice services in a medical facility

62

Transferred/Discharged to an inpatient rehabilitation facility (IRF) including distinct part units of a hospital.

63

Discharged/transferred to a long-term care hospital

65

Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

66

Discharged/transferred to a critical access hospital

70

Discharge/transfer to another type of health care institution not defined elsewhere in the code list

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Condition Codes

Code

Description

07

Treatment of Nonterminal Condition for Hospice Patient

Enter this code if the beneficiary is a hospice enrollee and the services provided are not related to the terminal illness and you are seeking reimbursement under traditional Medicare benefits.

20

Beneficiary Requested Billing (Demand Denials)

See the "Demand Denials (Condition Code 20)" Web page for more information regarding home health demand denials.

21

Billing for Denial Notice (No-Pay Bills)

See the "Home Health No-Payment Billing (Condition Code 21)" Web page for more information regarding submitting home health no-pay bills to Medicare.

47

Transfer from another Home Health Agency

Enter this code when a beneficiary has transferred from another HHA, and the "FROM" date on your RAP/claim is on/after July 1, 2010. See the Beneficiary Elected Home Health Transfer Web page for additional information.

54

No skilled HH visits in billing period. Policy exception documented at the HHA.

This code indicates that the HHA provided no skilled services during the billing period, but the HHA has documentation on file of an allowable circumstance. Refer to the MM9474 MLN Matters® article, New Condition Code for Reporting Home Health Episodes with No Skilled VisitsExternal PDF, for more information.

A6

PPV/Medicare Pneumococcal Pneumonia / Influenza 100% Payment

Enter this code if a pneumonia vaccine (PPV) or influenza virus vaccine was given that should be reimbursed under a special Medicare program provision. This is an appropriate code only when the bill type is 34X and the revenue code is 0636. Note: Providers who submit roster bills electronically in FISS don't need to use condition code A6.

DR

Disaster Related
This condition code identifies claims that are impacted, or may be impacted by specific payer policies related to a national or regional disaster.

M1

Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV)

Enter this code to indicate your claim is a roster billing for a mass influenza and pneumococcal vaccination or pneumococcal pneumonia (PPV) program for multiple beneficiaries.
Note: Providers who submit roster bills electronically in FISS don't need to use condition code M1.

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Expedited Review Condition Codes

The following condition codes are used in accordance with the Expedited Review process. For additional information on billing and claims processing requirements related to Expedited Determinations, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1, §150.3External PDF, and the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 30, §60.2.B and 260External PDF. Additional information is also available on the CGS Home Health Expedited Determination Process Web page.

Condition Code

Description

Used When The Claim Was Reviewed, And

Also Report:

C3

Partial approval of Medicare-covered services

  • Some days of the stay or services were denied.
  • Occurrence span code (OSC) M0 in FL 35-36 and the From and To dates of the approved stay.

C4

Services denied

  • All services beyond the intended discharge date were denied.
  • OSC 76 in FL 35-36 in cases where the beneficiary may be liable for payment and the dates of service, denoting the patient liability period.
  • An appropriate patient status code indicating the patient's status with your agency as of the claim's "TO" date.

C7

Extended authorization of Medicare-covered services

  • An authorization for extending Medicare coverage for the services being provided was granted.

 

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Claim Change Reason Codes and Corresponding Bill Type

When submitting adjustment (327)/cancellation (328) bill types, HHAs enter one of the following required reason codes in a condition code field locator. Use a code that represents why the adjustment/cancellation is being submitted and also corresponds with the type of bill in FL4.

NOTE: Use one claim change reason code per claim. If more than one code is necessary to reflect the reason for the change or if the following codes do not apply, use reason code D9. When reason code D9 is used, an explanation of the adjustment/cancellation must be recorded in the Remarks field (FISS Claim page 04)

Code

Description

D0

Changes to Service Dates (FL6) TOB 327
*do not use for adjusting line item DOS, use D9 instead

D1

Changes to Charges TOB 327
*adding or removing charges (do not use for adjusting units, use D9 for units)

D2

Change in Revenue Codes/HCPCS/HIPPS TOB 327
*to change revenue HIPPS or HCPCS codes. (Use D9 to add a revenue or HCPCS)

D5

Cancel to correct Medicare ID number or provider number TOB 328

D6

Cancel Duplicate or OIG Overpayment TOB 328

D9

Any Other Change or Multiple Changes TOB 327
Remarks (FL84) required

E0

Change in Patient Status TOB 327

RAPs (type of bill 322) can be cancelled, but not adjusted. Final claims and No-RAP-LUPA claims (329) can be adjusted or cancelled.

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Occurrence Codes and Dates

Use the following occurrence codes on home health outpatient therapy claims (type of bill 34X).

Code

Description

55

Date of Death – Occurrence code 55 and date of death is required when the Patient Discharge Status Code indicates death (20 expired).

Use the following occurrence codes on home health outpatient therapy claims (type of bill 34X).

11

Onset of symptoms/illness and the date of symptom onset.

17

Date occupational therapy (OT) plan established or last reviewed.

29

Date outpatient physical therapy (PT) plan established or last reviewed

30

Date outpatient speech-language pathology (SLP) plan established or last reviewed

35

Date treatment started for PT

44

Date treatment started for OT

45

Date treatment started for SLP

Note: Claim page 01 displays space for 10 occurrence codes/dates. However, FISS allows you to enter up to 30 occurrence codes/dates by pressing F6 to scroll forward.

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Value Codes and Amounts

  • When entering a value code that represents a number rather than a monetary amount (e.g., value code 61, 85), enter the number followed by two zeros. For example, value code 61 represents the Core Based Statistical Area (CBSA) or geographical area where the home health services were provided. To indicate a CBSA code 99916, the number would be keyed as 9991600 or 99916.00.
  • Claim Page 01 displays space for 9 values codes/amounts. However, FISS allows you to enter up to 36 value codes/amounts by pressing F6 to scroll forward.

When entering a dollar amount, you may type or omit the decimal point as you choose (i.e., $45.92 can be keyed as 45.92 or 4592; $1500.00 can be keyed as 1500.00 or 150000). However, it is important to ensure that the appropriate cents value is entered, regardless of whether the decimal point is used.

Value Code

Description

61

Location Where Service is Furnished (Core Based Statistical Area) (CBSA)

The CBSA code should be used on all 32X type of bills. Record value code 61 and the CBSA code that corresponds with the location where the service is provided.

Multiple occurrences of value code 61 are not allowed. In situations where the beneficiary's site of service changes from one CBSA to another within the episode period, submit the CBSA code corresponding to the site of service at the end of the episode.

Access the Home Health Payment Rates Web page for these calendar year codes.
Note: Final claims with "Through" dates on or after January 1, 2015, should use 2015 CBSA codes. The CBSA code submitted on the Request for Anticipated Payment (RAP) does not need to match the CBSA code submitted on the final claim; therefore, it is not necessary for providers to cancel the RAP when it is submitted with a different CBSA code.

85

County where service is rendered (Federal Information Processing Standards (FIPS) State and County Code.
The FIPS code should be used on all 32X type of bills with services provided on or after January 1, 2019. Record value code 85 and the associated Federal Information Processing Standards (FIPS) State and County Code in which the home health service was furnished. Refer to the CMS' SSA to FIPS State and County CrosswalkExternal Website information to access the FIPS State and County Code. As an example, looking at the Excel file, the FIPS State and County Code 19153 would be reported with value code 85 for Polk County in Iowa. Refer to MM10782External PDF for additional information.

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Home Health Revenue Codes

Code

Description

0001

Total Units and/or Charges

0023

HIPPS Code

027X

Medical/Surgical Supplies

0 – General Classification

1 – Nonsterile Supply

2 – Sterile Supply

3 – Take Home Supply

4 – Prosthetic/Orthotic Devises

9 – Other Supplies/Devises

When reporting 027X, include units, charges, and a service date. If revenue code 0274 is billed, a HCPCS code is also required.

029X

Durable Medical Equipment (DME) Other Than Rental (used when billing DME on HH PPS claims)

0 – General Classification

1 – Rental

2 – Purchase of New Equipment

3 – Purchase of Used Equipment

4 – Supplies/Drugs for Effectiveness*

9 – Other Equipment

* Revenue code 0294 is used exclusively when medical documentation shows that a drug can safely be administered only through a pump.

042X

Physical Therapy

0 – General Classification

1 – Visit Charge

On a 32X type of bill, report the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount. You will also need to report one of the following HCPCS that reflects the service for which the clinician spent most of his/her time during the visit. Multiple HCPCS codes should not be billed for a single physical therapy visit.

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.

043X

Occupational Therapy

0 – General Classification

1 – Visit Charge

On a 32X type of bill, report the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount. You will also need to report one of the following HCPCS that reflects the service for which the clinician spent most of his/her time during the visit. Multiple HCPCS codes should not be billed for a single occupational therapy visit.

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 therapy 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.

044X

Speech-Language Pathology

0 – General Classification

1 – Visit Charge

On a 32X type of bill, report the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount. You will also need to report one of the following HCPCS that reflects the service for which the clinician spent most of his/her time during the visit. Multiple HCPCS codes should not be billed for a single speech-language pathology visit.

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.

055X

Skilled Nursing

0 – General Classification

1 – Visit Charge

On a 32X type of bill, report the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount. You will also need to report one of the following HCPCS that reflects the service for which the clinician spent most of his/her time during the visit. Multiple HCPCS codes should not be billed for a single skilled nursing visit.

G0154: Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. NOTE: G0154 is not acceptable for visits on or after January 1, 2016.

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).

G0163: Not valid for services provided on or after January 1, 2017. Skilled services of a licensed nurse (LPN or 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).

G0164: Not valid for services provided on or after January 1, 2017. Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

G0493: Valid for services provided on or after January 1, 2017. 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: Valid for services provided on or after January 1, 2017. Skilled services of a licensed practical nurse (LPN) for the observation and assessment of a patient's condition, each 15 minutes (the change in a patient's condition requires skilled nursing personnel to identify and evaluate the patients need for possible modification of treatment in the home health or hospice setting).

G0495: Valid for services provided on or after January 1, 2017. 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: Valid for services provided on or after January 1, 2017. 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.

G0299: Direct skilled nursing services of a registered nurse (RN) in home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016.

G0300: Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016.

This revenue code is not valid on a 34X type of bill.

056X

Medical Social Services

0 – General Classification

1 – Visit Charge

On a 32X type of bill, report HCPCS code G0155, the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount.

This revenue code is not valid on a 34X type of bill.

057X

Home Health Aide

0 – General Classification

1 – Visit Charge

9 – Other home health aide

On a 32X type of bill, report HCPCS code G0156, the date of service, the service units representing the number of 15-minute increments that comprised the visit, and a charge amount.

This revenue code is not valid on a 34X type of bill.

060X

Oxygen (when including DME on HH PPS claims)

0 – General Classification

1 – Oxygen – State or Portable Equip/Supply or Cont Over 1 LPM, but under 4 LPM

2 – Oxygen – Stat/Equip Under 1 LPM, Monthly payment reduced by 50%

3 – Oxygen – Stat/Equip Over 4 LPM, Monthly payment increased by 50%

4 – Oxygen – Stat/Equip/Portable Exceeds 4 LPM and portable oxygen prescribed

062X

Medical/Surgical Supplies – Extension of 027X

This code indicates charges for supply items required for patient care. The category is an extension of 027X for reporting additional breakdown where needed.

3 – Surgical Dressings SURG DRESSING

Also required with this revenue code: service units, a service date, and a charge amount.

HHAs may voluntarily report a separate revenue code line for charges for non-routine wound care supplies using revenue code 0623. We encourage HHAs to report this information so that it can be used to make refinements in the HH PPS case mix adjuster. If also reporting 027X to identify non-routine supplies other than those used for wound care, ensure that the charge amounts for the two revenue codes are mutually exclusive.

063X

Drugs Requiring Specific Identification (for use on 34X type of bills only)

Record drugs as line item date of service. Report the applicable HCPCS code

6 – Drugs Requiring Detailed Coding*

* Charges for drugs and biologicals (with the exception of radiopharmaceuticals, which are reported under revenue codes 0343 and 0344) requiring specific identifications as required by the payer.

077X

Preventive Care Services (for use on 34X type of bills only)

0 – General classification

1 – Vaccine Administration

094X

Other Therapeutic Services (for use on 34X type of bills only)

2 – Education/Training (includes Diabetes-Related Dietary Therapy)

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Home Health HCPCS Codes

Code

Description

Used with Revenue Code

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.

042X (Physical Therapy)

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.

043X (Occupational Therapy)

G0153

Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.

044X (Speech-Language Pathology)

G0154

Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. Not acceptable for visits on or after January 1, 2016.

055X (Skilled Nursing)

G0155

Services of clinical social worker in home health or hospice setting, each 15 minutes

056X (Medical Social Services)

G0156

Services of home health/hospice aide in home health or hospice settings, each 15 minutes

057X (Home Health Aide)

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.

042X (Physical Therapy)

G0158

Services performed by a qualified occupational therapy assistant in the home health or hospice setting, each 15 minutes.

043X (Occupational Therapy)

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.

042X (Physical Therapy)

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

043X (Occupational Therapy)

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.

044X (Speech-Language Pathology)

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).

055X (Skilled Nursing)

G0163

Skilled services of a licensed nurse (LPN or 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). Not valid for services provided on or after January 1, 2017.

G0164

Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. Not valid for services provided on or after January 1, 2017.

G0299:

Direct skilled nursing services of a registered nurse (RN) in home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016.

G0300:

Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016.

G0493

Valid for services provided on or after January 1, 2017. 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

Valid for services provided on or after January 1, 2017. Skilled services of a licensed practical nurse (LPN) for the observation and assessment of a patient's condition, each 15 minutes (the change in a patient's condition requires skilled nursing personnel to identify and evaluate the patients need for possible modification of treatment in the home health or hospice setting).

G0495

Valid for services provided on or after January 1, 2017. 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

Valid for services provided on or after January 1, 2017. 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.

Q5001*

Hospice or home health care provided in patient's home/residence. See Medicare Learning Network (MLN) Matters® article, MM8136External PDF for additional information.

Any home health discipline line (therapy, nursing, aide, social worker)

Q5002*

Hospice or home health care provided in assisted living facility. See Medicare Learning Network (MLN) Matters® article, MM8136External PDF for additional information.

Q5009*

Hospice or home health care provided in place not otherwise specified (NO). See Medicare Learning Network (MLN) Matters® article, MM8136External PDF for additional information.

* Required on home health claims for episodes beginning on/after July 1, 2013.

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Posted: 02.09.21

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