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
327 – Replacement (adjustment) of prior claim
328 – Void/cancel of prior 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.

• The "FROM" date must match the date submitted on the RAP for the same period. MMDDYY format
• For continuous 30-day periods, the "TO" date must be 29 days after the "FROM" date. In cases of discharge or transfer, report the date the discharge or transfer.

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.

• If OC 50 and date are missing from the claim, the claim will be sent to your return to provider (RTP) file for correction.

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.)
62 (optional) – Only reported on admission claims (e.g., claim "From" and "Admission" date match). Report OC 62 to indicate the "Through" date of a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long term care hospital (LTCH), or inpatient psychiatric facility (IPF) discharge within 14 days prior to the "From" date of the first 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.
85 – Enter 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 Crosswalk information to access the FIPS State and County Code.

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.

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:

• Visits provided exclusively to perform the OASIS assessment
• Visits provided exclusively for supervisory or administrative purposes
• Therapy visits provided prior to the required re-assessment

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

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
R – The release is limited or restricted
N – No release on file

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
NPI, L, F, M

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.

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.