Skip to main content
Corporate

Billing Osteoporosis Drugs for Home Health Beneficiaries

Home health consolidated billing rules require the primary home health agency (HHA) to bill osteoporosis drugs for beneficiaries meeting coverage requirements for these drugs and who are under their care for a 60-day episode or 30-day period of care under the Patient-Driven Groupings Model (PDGM). Osteoporosis drugs are excluded from reimbursement under the Home Health Prospective Payment System (HH PPS), and instead, are paid on a reasonable cost basis.

Reimbursement for administering the drug is included in the HH PPS episode payment. The primary HHA should submit these charges with other skilled nursing visits billed on HH PPS claims – TOB (type of bill) 329 – along with all other home health-related services provided by the HHA during the episode.

In order for the home health agency to bill Medicare, the beneficiary must be entitled to Medicare Part B. In addition, Medicare requires that the date of service on a claim for covered osteoporosis drugs falls within the start and end dates of an existing home health PPS episode. The provider number on the claim for osteoporosis drugs must also match the provider number that established the home health episode during which the drug was administered. HHAs should be aware that if Medicare denies the skilled nursing visit during which the osteoporosis drug was administered, the charges for the drug will not be paid by Medicare.

Osteoporosis drugs can be entered into the Fiscal Intermediary Standard System (FISS) Home Health Claims Entry option 26 (accessible from FISS Main Menu option 02). See Chapter 4 – Claims and Attachments MenuPDF of the Fiscal Intermediary Standard System (FISS) Guide for information on entering Medicare claims using FISS.

In addition to the usual information that is required on Medicare claims, the following identifies specific information required for HHAs to submit osteoporosis drugs to Medicare.

Field Name Description

TOB

34X —HHA visits provided on an outpatient basis. ('X' denotes the frequency of bill.)

Frequency indicators are accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual - http://www.nubc.org/External Website

STMT DATES FROM/TO

Enter the dates of service for the billing period. NOTE: these should fall within the "FROM" and "TO" dates for the HH PPS episode of care or HH PDGM for claims with a “From” date on or after January 1, 2020, provided by the primary HHA.

REV

Enter revenue code: 0636— Pharmacy - Extension of 025X – Drugs requiring detailed coding.

HCPC

Enter the appropriate HCPCS code:

J0630—Drugs containing calcitonin
J3110—Drugs containing teriparatide
J3490—Drugs that are FDA approved and awaiting a specific HCPCS code

TOT UNIT/COV UNIT

Enter units as defined by HCPCS code:

J0630—1 unit for every 100-400 units furnished during billing period
2 units for every 401-800 units furnished during billing period
3 units for every 801-1200 units furnished during billing period
4 units for every 1201-1600 units furnished during billing period
5 units for every 1601-2000 units furnished during billing period
6 units for every 2001-2400 units furnished during billing period
J3110—Report 1 unit for every 10 mcg furnished during billing period
J3490—Report units as defined by HCPCS code

TOT CHARGES

Enter the charge per revenue code for the osteoporosis drug.

SERV DATE

Enter the line item date of service the drug was provided.

DIAG CODES

Enter the ICD-10 code M810 for services on or after October 1, 2015.

Others as required to describe bone fracture sustained due to post-menopausal osteoporosis

Coverage requirements for osteoporosis drugs are found in the Medicare Benefit Policy Manual (Pub. 100-02, Chapter 7, §50.4.3External PDF). See the CGS Calcitonin and Forteo webpage for more coverage information on these osteoporosis drugs. Additional information may be accessed from the Medicare Claims Processing Manual (Pub. 100-04, Chapter 10, § 10, 20 and 90.1External PDF).

Updated: 12.18.19

Was this page helpful? YES NO


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved