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. Refer to the Centers for Medicare & Medicaid Services (CMS) Pub. 100-04, Ch. 10, Section 90.1
for additional information.
Reimbursement for administering the drug is included in the charge for the skilled nursing visit. The primary HHA submits these charges with other skilled nursing visits billed on the claim – TOB (type of bill) 329 – along with all other home health-related services provided by the HHA during the period of care. The Osteoporosis drug is billed with the TOB 034X, using revenue code 0636.
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 submitted via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) using the Home Health Claims Entry option 26 (accessible from FISS Main Menu option 02). See Chapter 4 – Claims and Attachments Menu
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/ |
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 Effective with dates of service on or after January 1, 2021: J0897 – Drugs containing denosumab J3111 – Drugs containing romosozumab-aqqg (effective with dates of service on or after January 1, 2020) J3590 – Drugs containing abaloparatide |
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, §50.4.3). 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 90.1).
Resources:
Updated: 02.xx.2021
heir 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. Refer to the Centers for Medicare & Medicaid Services (CMS) Pub. 100-04, Ch. 10, Section 90.1 for additional information.
Reimbursement for administering the drug is included in the charge for the skilled nursing visit. The primary HHA submits these charges with other skilled nursing visits billed on the claim – TOB (type of bill) 329 – along with all other home health-related services provided by the HHA during the period of care. The Osteoporosis drug is billed with the TOB 034X, using revenue code 0636.
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 submitted via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) using the Home Health Claims Entry option 26 (accessible from FISS Main Menu option 02). See Chapter 4 – Claims and Attachments Menu 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/ |
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 Effective with dates of service on or after January 1, 2021: J0897 – Drugs containing denosumab J3111 – Drugs containing romosozumab-aqqg (effective with dates of service on or after January 1, 2020) J3590 – Drugs containing abaloparatide |
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, §50.4.3). 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 90.1).
Resources:
Updated: 02.03.2021
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