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Home Health No-Payment Billing (Condition Code 21)

Home health agencies may continue to seek denials for entire claims from Medicare using condition code 21 in cases where a provider knows all services will not be covered by Medicare. Such denials are usually sought because other payers require that providers obtain a Medicare denial notice before they will consider payment.

In certain cases, providers may use no-payment claims in association with an Advance Beneficiary Notice (ABN) involving custodial care (home health aide or housekeeping services) or when services do not meet the Medicare covered benefit definition (i.e., routine foot care). A no-pay bill also may be submitted when the benefit has terminated during a previous episode period, and the physician, beneficiary, and provider are all in agreement the benefit has terminated or does not apply. In such cases, HHAs can use the ABN for notification to the beneficiary with the beneficiary selecting the option indicating both services and Medicare billing is desired.

In situations where your claim was returned because there is no corresponding OASIS assessment (reason code 37253), and the home health agency determines the claim did not meet the condition of payment (no OASIS), condition code 21 should not be submitted.  Refer to the MM11272, Home Health (HH) Patient-Driven Groupings Model (PDGM) Additional Manual InstructionsExternal PDF article for billing instructions.  

Billing Requirements

In a no-payment situation (condition code 21), a RAP should not be submitted. In addition to the usual information required on Medicare claims (e.g. patient's name, billing provider's NPI, diagnosis codes, etc.), the following information must be submitted on a no-payment bill. Refer to the Home Health Claims Filing Claim Pages 01-06 for complete billing information. For services on or after January 1, 2020, refer to the Submitting a Final Claim under the Home Health Patient-Driven Groupings Model Web page. 

Field Name UB-04 Field Locator (FL)

Description

TOB 4

Type of bill (TOB)

Use 3X0 (with appropriate 2nd digit 2, or 4)

STMT DATE FROM/TO 6

"FROM" and "TO" dates of service

Use billing dates that conform to other payer billing requirements.

Note: Refer to the "Simultaneous Covered and Noncovered Services" information below if you have non-covered services in the same period as covered services.

STAT 17

Patient status code

Enter 01 (discharge to home or self-care)

COND CODES 18-28

Condition codes;

Enter 21

REV 42

Revenue code

Refer to the Home Health Revenue Codes list for all the revenue codes and descriptions.

No payment bills must include 1 line with revenue code 0023 with the appropriate Health Insurance Prospective Payment System (HIPPS) code. In addition, all services and the appropriate revenue code(s) submitted for denial must be line item billed.

Revenue code 0001 (Total units/Charges) is entered as the last revenue code line of the claim.

HCPC 44

Healthcare Common Procedure Coding System (HCPCS)

Key the appropriate 'G' HCPCS code and 'Q' HCPCS code that corresponds with the service(s) being billed. Refer to the Home Health HCPCS Codes list for the HCPC codes, descriptions, and to which revenue code they apply.

Key the HIPPS code on the 0023 revenue code line.

For services prior to January 1, 2020, if an OASIS assessment wasn't completed, report the lowest weighted HIPPS code: 1AFK1.

For services on or after January 1, 2020, enter any valid HIPPS code.

SERV DATE 45

Enter the date the service was provided (MMDDYY). Dates must fall within the FROM and TO dates being billed.

For the Q HCPC code line, enter the date of the first visit date in the episode.

For the 0023 revenue code line, enter the date of the first visit being billed.

TOT UNIT 46

Enter the total units provided as required by the revenue code billed.

Units can reflect the number of 15-minute increments.

For the Q HCPC code line, enter 1 as the unit.

TOT CHARGES 47

Except for the following, enter the total charges billed per revenue code.

  • For the 0023 revenue code line, enter zeros.
  • For the Q HCPC code line, enter a nominal charge (example – $0.01)
NCOV CHARGES 48

Enter the noncovered charges per revenue code. NOTE: no-payment bills may only contain noncovered charges.

REMARKS 80

Enter the reason(s) why the services submitted are not coverable by Medicare and the reason the no-pay bill is being submitted. Enter your initials and the date the remarks were entered.

TREAT AUTH CODE 63

Under the Home Health Patient-Driven Groupings Model (PDGM), the OASIS Matching Key is not required for home health periods of care beginning January 1, 2020.

For home health episodes prior to January 1, 2020, enter the billing transaction's 18 position OASIS Matching Key output from the Grouper software. If an OASIS assessment wasn't completed, report an 18-digit string of the number as follows: 11AA11AA11AAAAAAAA

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Simultaneous Covered and Noncovered Services

In some cases, providers may need to obtain a Medicare denial notice for noncovered services delivered in the same episode/period of care as covered services. In these instances, submit the appropriate HH PPS RAP and claim for the covered services provided during the episode/period of care. The statement covers period on the no-payment claim (condition code 21) must match the statement covers period on the covered claim in order to avoid FISS duplicate bill editing. FISS and CWF will allow such duplicate claims to process due to all services on the no-payment claim submitted as noncovered.

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Additional Resources

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Updated: 03.09.20

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