Skip to Main Content

Print | Bookmark | | Font Size: + | –

Submitting a Final Claim under the Home Health Patient-Driven Groupings Model

When to Submit a Final Claim

Home Health Agencies (HHAs) submit a Notice of Admission (NOA) to Medicare:

  • When the HHA:
    • Obtains a verbal or written order from the physician that contains the services required for the initial visit.
    • Conducts an initial visit at the start of care.
  • For any series of home health periods of care beginning with admission to home care and ending with discharge.
  • Within 5 calendar days after the admission date.

HHAs submit a final claim after:

  • The NOA processes.
  • The 30-day period ends or the patient transfers or discharges.
  • The HHA provides all services for the period and the physician signs the plan of care and all verbal orders.
  • The face-to-face encounter is complete.
  • The Outcome and Assessment Information Set (OASIS) is submitted and accepted in the state repository.

Low Utilization Payment Adjustments (LUPA)

See Home Health LUPA Threshold: Bill Correctly and the Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator for additional information.

Periods of Care with No Visits Expected

When a beneficiary's plan of care requires a visit every 6 weeks and there’s a recertification, a visit may not occur in the first 30-day period of care. The HHA should:

  • Still submit an NOA for a period with no visit.
  • Only submit a final claim for 30-day periods that include a visit.

Inpatient Stays Spanning the End of a 30-day Period

Discharging the beneficiary isn’t required if an inpatient stay 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 (i.e., From date = day 31, even if it falls during the inpatient stay and the first visit date occurs after the hospital discharge).

Claim Submission Data Elements

CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 10, section 40.2External PDF

The tables below identify the data elements and corresponding Direct Data Entry (DDE) fields required on a home health final claim.

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. See Checking Beneficiary Eligibility for details.

TOB

FL 4

Type of Bill – Enter the final claim TOB 329. FISS Page 01 defaults to 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 To" – Enter the beginning and ending dates for this billing period.

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

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 zip code for the beneficiary’s address.

SEX

FL 11

Sex – Enter the beneficiary's gender:

M – Male; F – Female

ADMIT DATE

FL 12

Admission Date – Enter the start of care date (i.e., date of admission submitted on the NOA for the period). (MMDDYY format)

SRC

FL 15

Point of Origin – Enter the code that identifies the referral source for this admission or visit. See Home Health Billing Codes.

STAT

FL 17

Patient Discharge Status – Enter the code that identifies the patient’s discharge status as of the "TO" date of the billing period. See Home Health Billing Codes.

COND CODES (conditional)

FL 18-28

Condition Codes – Enter code(s) to describe any conditions or events that apply to this billing period. See Home Health Billing Codes.

OCC CDS/DATE

FL 31-34

Occurrence Codes & Dates –

50 (required) – Enter 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.)

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 aren’t present, 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 provider’s 9-digit zip code.

VALUE CODES

FL 39-41

Value Codes & Amounts

61 – Enter 61 and the Core-Based Statistical Area (CBSA) or special 500XX code that corresponds to the state and county of the beneficiary’s place of residence at the end of the period of care. See Home Health Payment Rates to access code lists per calendar year.

85 – The county-based rural add-on applied to home health services provided in rural (non-CBSA) areas expired for periods and visits on or after January 1, 2024. See MM10782External PDF and MM13411External PDF for additional information.

Note: Enter the code followed by two zeros in the amount field (e.g., XXXXX00 or XXXXX.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 Codes – Enter the appropriate codes to explain each charge reported on the claim. See Home Health Billing Codes.

HCPC

FL 44

HCPCS/HIPPS Codes – Enter the HCPCS and HIPPS codes that describe the services provided to the patient during the billing period. See Home Health Billing Codes.

MODIFS

FL 44

Modifier – To request an exception for a late NOA submission, add modifier KX to the HIPPS code reported with revenue code 0023.

TOT UNITS

FL 46

Total Units – Units of service aren’t required on the revenue code 0023 line. Otherwise, report the number of times the procedure or service was performed based on the HCPCS code description (i.e., 15-minute increments or 1 for Q codes).

TOT CHARGE

FL 47

Total Charges – Enter the total charges for each revenue code line. The total charge for revenue code 0023 must be zero.
For Q codes, enter a nominal charge (e.g., $0.01).

NCOV CHARGE

FL 48

Noncovered Charges – Enter any noncovered charges for each revenue code. Examples of noncovered charges may include:

  • Visits provided to perform the OASIS assessment only
  • Visits provided for supervisory or administrative purposes only
  • 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 revenue code 0023 line (same as NOA). For all other services, report the date of service (MMDDYY format) for each revenue code line.

For Q codes, the service date 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.

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, enter the appropriate MSP payer code.

PAYER

FL 50

Payer – When "Z" is entered in the CD field, FISS will automatically insert "Medicare" in this field. Otherwise, enter the payer’s name.

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 and any other 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 beneficiary's name as it appears on the Medicare or other insurance card.

CERT/SSN/MID

FL 60

Medicare ID – Enter the Medicare (or other insurer) Number as it appears on the Medicare (or other insurer) card.

TREAT. AUTH. CODE

FL 63

Treatment Authorization Code – Not required under PDGM.

Updated: 01.06.2025

spacer

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