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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-FCExternal website). The PDGM changes 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.Ā  Select the topic below to access.

When to Submit a Final Claim (With FROM dates on or after January 1, 2020)

A home health final claim is submitted after the Request for Anticipated Payment (RAP) has been 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

RAP Payment Recouped (prior to January 1, 2021)

When the RAP is processed, a split percentage payment of 20 percent is made for initial and subsequent periods of care. When the final claim is submitted timely and processes, the RAP payment will be recouped and the final claim will receive the full PDGM payment.

The RAP payment will be recouped, if the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP.

Requesting an Exception for an Untimely RAP Submission (Effective January 1, 2021)

Starting in CY 2021, a payment reduction will apply when the HHA does not submit the RAP within 5 calendar days from the start of care date ("admission date" and "from date" on the claim will match the start of care date) for the first 30-day period of care in a 60-day certification period, and within 5 calendar days of the "from date" for the second 30-day period of care in the 60-day certification period. The payment reduction will be equal to a 1/30th reduction to the 30-day period payment amount for each day from the home health start of care date/admission date, or "from date" for subsequent 30-day periods, until the date the HHA submits the RAP.

When the final claim is processed with the payment reduction applied, the value code QF will display the penalty amount.

An HHA may request an exception if the RAP is filed more than 5 calendar days after the period of care. The four circumstances that may qualify for an exception are:

  • Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA's ability to operate
  • An event that produces a data filing problem due to a CMS or CGS system issue that is beyond the control of the HHA
  • A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from CGS.
  • Other circumstances determined by CMS or CGS to be beyond the control of the HHA.

To request an exception, enter information supporting the circumstance (listed above) that applies to the RAP in the REMARKS field on the Claim (FISS Claim page 04). For example, if the RAP to a claim was originally received timely but the RAP was canceled and resubmitted to correct an error, enter in the REMARKS field "Timely RAP, cancel and rebill". Add modifier KX to the HIPPS Code reported on the revenue code 0023 line. HHAs should resubmit corrected RAPs promptly (generally within 2 business days of canceling the original RAP). Refer to Examples of Denied/Granted RAP Exception Requests for assistance.

If the information provided in the REMARKS field is not clear, CGS will request documentation by generating a non-medical review additional development request (non-MR ADR). HHAs will need to submit documentation supporting the exception request. When a non-MR ADR is generated, the claim will be moved to status/location S B6001. To learn more about how to check for non-MR ADRs, refer to the "Accessing Additional Development Request (ADR) Information" section in the FISS Guide Chapter 3: Inquiry MenuPDF.

Rights for Unfavorable Exception Requests

If the review of the information provided in the REMARKS field, or the submitted documentation does not support the exception request, the penalty will still apply. At that point, the home health agency may appeal the penalty amount applied to the final claim. Do not submit an appeal request for the RAP. Refer to the 1st Level of Appeal – Redetermination web page for additional information.

Refer to MM11855 – Penalty for Delayed Request for Anticipated Payment (RAP) Submission – ImplementationPDF for more information.

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. Effective January 1, 2021, if a RAP is submitted and is untimely, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. However, if a RAP is not submitted, and your claim is processed as a no-RAP LUPA claim, no penalty will apply. The payment reduction cannot exceed the total payment of the claim.

Refer to Home Health LUPA Threshold: Bill Correctly for more information.

Timely Filing of Final Claim (prior to January 1, 2021)

If the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by FISS and will be recouped. If the RAP payment is canceled, the RAP will need to be resubmitted. In addition, in cases when no visits are made during a 30-day period of care, the RAP will be auto-canceled to recover the payment. See MM1152External PDF for additional information.

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 RAP should still be submitted. The RAP 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 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.

Claim Submission Data Elements

Centers for Medicare & Medicaid Services (CMS), Pub. 100-04, Ch. 10, section 40.2External PDF

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
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:

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

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 ManualExternal Website

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 ManualExternal Website

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

COND CODES (conditionally required)

FL 18-28

Condition Codes – Enter any NUBCExternal Website approved code to describe conditions that apply to the home health claim.

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 home health agency.

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 MattersĀ® article, New Condition Code for Reporting Home Health Episodes with No Skilled VisitsExternal PDF, for more information.

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 appropriate Core Based Statistical Area (CBSA) code that corresponds with the location where the service is provided 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 CrosswalkExternal Website 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.


Claim Submission Data Elements
DDE FISS Claim Page 02 (Map 1712)

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:

  • 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: MM11855External PDF


Claim Submission Data Elements
DDE FISS Claim Page 03 (Map 1713)

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
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.


Claim Submission Data Elements
DDE FISS Claim Page 05 (Map 1715)

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: 05.10.2021

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