Submitting a Final Claim under the Home Health Patient-Driven Groupings Model
Effective for home health periods of care beginning January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient-Driven Groupings Model (PDGM) as described in the Calendar Year (CY) 2019 home health (HH) final rule (CMS-1689-FC). The PDGM changed the unit of payment from 60-day episodes of care to 30-day periods of care and eliminates the therapy thresholds used in determining home health payment.
The following information provides details about submitting a final claim, including data elements needed when entering a final claim using the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). The corresponding UB-04 Form Locator (FL) is also identified. Select the topic below to access.
- When to Submit a Final Claim
- Low Utilization Payment Adjustments (LUPA)
- Periods of Care with No Visits Expected
- Inpatient Stays Spanning the End of a 30-day Period
- Claim Submission Data Elements
When to Submit a Final Claim
As of January 1, 2022, Home Health Agencies (HHAs) no longer submit Requests for Anticipated Payment (RAPs). Instead, for each admission to home health, the HHA notifies Medicare systems via submission of an NOA. The NOA is a one-time submission to establish that the beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA covers contiguous 30-day periods of care until the individual is discharged from Medicare home health services, There is no upfront payment with the submission of the NOA. The NOA must be submitted timely. All HHAs must submit an NOA to their Medicare contractor within 5 calendar days from the start of care date to establish that the beneficiary is under a Medicare home health period of care and also to trigger home health consolidated billing edits required under section 1842(b)(6)(F) of the Act. For example, if the start of care date is January 1, 2022, the NOA would be considered timely-filed if it is submitted on or before January 6, 2022.
For CY 2022, submission of the NOA can be made when the following criteria have been met: (1) The appropriate physician’s or allowed practitioner’s written or verbal order that sets out the services required for the initial visit has been received and documented as required at §§ 484.60(b) and 409.43(d); (2) The initial visit within the 60-day certification period must have been made and the individual admitted to home health care.
A home health final claim is submitted after the NOA has processed, after the 30-day period has ended, or if the patient has been transferred or discharged. In addition, prior to submitting the final claim, ensure that:
- All services have been provided for the period and the physician has signed the plan of care and all verbal orders.
- Face-to-face encounter has been completed.
- The Outcome and Assessment Information Set (OASIS) is submitted and accepted in the state repository.
Low Utilization Payment Adjustments (LUPA)
Under PDGM, LUPA thresholds range between 2 and 6 visits; therefore, it is more challenging to predict when a period of care results in a LUPA.
Refer to Home Health LUPA Threshold: Bill Correctly for more information and the Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator (cgsmedicare.com).
Periods of Care with No Visits Expected
In cases when a beneficiary's plan of care requires that the beneficiary is seen every 6 weeks and there is a recertification, there may not be any visits in the first 30-day period of care. In this case, only submit a final claim for 30-day periods in which visits were delivered. A NOA should still be submitted. The NOA for a period with no visit will ensure the home health agency (HHA) remains recorded on Medicare's Common Working File (CWF).
Inpatient Stays Spanning the End of a 30-day Period
Discharging the beneficiary is not required if they had an inpatient stay that spans the end of the first 30-day period of care in a certification period. Submit the NOA and claim for the period following the inpatient discharge as if the 30-day periods were contiguous – submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge.
Claim Submission Data Elements
Centers for Medicare & Medicaid Services (CMS), Pub. 100-04, Ch. 10, section 40.2
The following provides the data elements required on a home health final claim. The following table provides the required fields when submitting the claim via Direct Data Entry (DDE).
Claim Submission Data Elements DDE FISS Claim Page 01 (Map 1711) |
||||||||||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
||||||||||||||||||||||||||||||||||
MID |
FL 60 |
Medicare ID – Enter the Medicare Beneficiary Identifier (MBI) number as it appears on the beneficiary's eligibility file. Refer to the Checking Beneficiary Eligibility Web page for details about the applications available to check eligibility. |
||||||||||||||||||||||||||||||||||
TOB |
FL 4 |
Type of Bill – Enter the final claim TOB 329. FISS Page 01 defaults to the home health claim TOB 322. Additional valid values are: 320 – Nonpayment claim |
||||||||||||||||||||||||||||||||||
NPI |
FL 56 |
National Provider Identifier – Enter your home health agency's NPI number. |
||||||||||||||||||||||||||||||||||
STMT DATES FROM and TO |
FL 6 |
Statement Covers Period "From and Through" – Enter the beginning and ending dates for this billing period.
Note: When billing continuous care periods, there should not be a break in dates of service between the FROM date of the prior final claim and the FROM and TO dates of the subsequent RAP. In situations where there is an inpatient stay that spans the end of the first 30-day period, submit the RAP and claim for the period following the inpatient discharge as if the 30-day periods were contiguous – submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge. |
||||||||||||||||||||||||||||||||||
LAST |
FL 8 |
Beneficiary's Last Name – Enter the beneficiary's last name exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
FIRST |
FL 8 |
Beneficiary's First Name – Enter the beneficiary's first name exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
DOB |
FL 10 |
Date of Birth – Enter the beneficiary's date of birth (MMDDCCYY format) exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
ADDR 1-6 |
FL 9 |
Address – Enter the beneficiary's full mailing address, including street name, number, post office box number, city and state. |
||||||||||||||||||||||||||||||||||
ZIP |
FL 9 |
Zip Code – Enter the beneficiary's zip code of the city and state where they reside. |
||||||||||||||||||||||||||||||||||
SEX |
FL 11 |
Sex – Enter the beneficiary's gender using the applicable alpha characters. M – Male; F – Female |
||||||||||||||||||||||||||||||||||
ADMIT DATE |
FL 12 |
Admission Date – Enter the start of care date, which will be the same date of admission that was submitted on the RAP for the period. (MMDDYY format) |
||||||||||||||||||||||||||||||||||
SRC |
FL 15 |
Source of Admission – Now referred to as the point of origin. Valid values:
The above codes represent those 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 |
||||||||||||||||||||||||||||||||||
STAT |
FL 17 |
Patient Discharge Status – Enter the appropriate patient status codes that reflects the patient status as of the "TO" date of the billing period. The following codes represent those 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
|
||||||||||||||||||||||||||||||||||
COND CODES (conditionally required) |
FL 18-28 |
Condition Codes – Enter any NUBC approved code to describe conditions that apply to the home health claim.
|
||||||||||||||||||||||||||||||||||
OCC CDS/DATE |
FL 31-34 |
Occurrence Code and Date – Enter the occurrence code (OC) 50 and the OASIS assessment completion date. OC codes 61 and 62 are optional. 50 (required) – On all final claims, report OC 50 and the OASIS assessment completion date (OASIS item MO090) for the start of care, resumption of care, recertification or other follow-up OASIS that occurred most recently before the claim "From" date.
61 (optional) – Report OC 61 on admission claims and continuing claims, if applicable, to indicate the "Through" date of an acute care hospital discharge within 14 days prior to the "From" date of the HH claim. (See Note below.) Note: If OC 61 and 62 are not submitted, Medicare systems will use inpatient claim history to assign institutional payment groups based on the most current information. |
||||||||||||||||||||||||||||||||||
FAC. ZIP |
FL 1 |
Facility Zip Code – Enter the 9-digit zip code of the provider or the subpart. |
||||||||||||||||||||||||||||||||||
VALUE CODES |
FL 39-41 |
Value Codes and Amounts – Enter the following value codes/amounts. 61 – Enter 61 and the Core Based Statistical Area (CBSA) code that corresponds to the state and county code of the beneficiary’s place of residence at the end of the period of care. Access the Home Health Payment Rates Web page for these calendar year codes. Note: When entering a value code that represents a number rather than a monetary amount, enter the number followed by two zeros. For example, to indicate a CBSA code 99916, the number would be keyed as 9991600 or 99916.00. |
Claim Submission Data Elements |
||
---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
REV |
FL 42 |
Revenue Code – Enter the revenue code 0023 to report the HIPPS code. Only one 0023 revenue code line is entered. The HIPPS code must match the one submitted on the RAP for the period. Also report revenue codes for all services provided to the patient within the period. |
HCPC |
FL 44 |
Healthcare Common Procedure Coding – Enter the HIPPS code for the 0023 revenue code line (must match the same as RAP). For HCPCS codes as appropriate for all other reported revenue codes for the service provided. |
MODIFS |
FL 44 |
Modifier – Add modifier KX to the 0023 revenue code line to request an exception to a late RAP submission. |
TOT UNITS |
FL 46 |
Total Units – No units of service are required on the 0023 revenue code line. Units for service provided should reflect the number of 15-minute increments. For the Q code revenue code line, enter 1. |
TOT CHARGE |
FL 47 |
Total Charge – Enter the total charge for each revenue code line. The total charge for revenue code 0023 must be zero. For Q codes, enter a nominal charge (example – $0.01). |
NCOV CHARGE |
FL 48 |
Noncovered Charges – Enter any noncovered charges for each revenue code. Examples of noncovered charges on may include:
|
SERV DATE |
FL 45 |
Service Date – For the initial periods of care, enter the date of the first covered service provided on the 0023 revenue code line (same as RAP). For all other services provided, report the date (MMDDYY format) for each revenue code line. For Q codes, the service date entered must match the date of the first visit date in the episode. For subsequent periods of care, report the date of the first visit, regardless of whether it's a covered or noncovered visit. If the corresponding RAP for the subsequent period was submitted at the same time as the initial RAP was submitted (calendar year 2021 exception), report a service date on the 0023 revenue code line that matches the date submitted on the RAP. Reference: MM11855 |
Claim Submission Data Elements |
||
---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
CD |
N/A |
Primary Payer Code – If Medicare is the primary payer, enter "Z" for Medicare. NOTE: If Medicare is the secondary payer and enter the appropriate MSP payer code. |
PAYER |
FL 50 |
Payer – When "Z" is entered in the CD field, FISS will automatically insert the payer name "Medicare" in this field. |
RI |
FL 52 |
Release of Information – Enter the appropriate valid value: Y – Provider has on file a signed statement permitting the provider to release data to other organizations |
DIAG CODES |
FL 67A – Q |
Diagnosis Codes – Enter the appropriate ICD code for the principal diagnosis code and any other diagnosis codes for conditions that coexisted when the plan of care was established. The diagnoses submitted on the claim and OASIS diagnoses are not expected to match in all cases. |
ATT PHYS |
FL 76 |
Attending Physician – Enter the NPI and name (last, first name required, middle initial optional) of the attending physician that established the plan of care with verbal orders. |
REF PHYS NPI, L, F, M |
FL 78 and 79 |
Referring Physician – Enter the NPI and name (last, first name required, middle initial optional) of the physician who certifies/recertifies the patient's eligibility for home health services. This is only required if the physician who certifies/recertifies is different than the physician who signs the plan of care. |
Claim Submission Data Elements |
||
---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
INSURED NAME |
FL 58 |
Insured Name – Enter the patient's name as shown on the Medicare card. |
CERT/SSN/MID |
FL 60 |
Medicare ID – Enter the Medicare Number as it appears on the Medicare card if it does not automatically populate. |
TREAT. AUTH. CODE |
FL 63 |
Treatment Authorization Code – Not required under PDGM. |
Updated: 12.15.22