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Claim Page 01 — Entering a RAP or Claim

This information is applicable to claims submitted under the Home Health Prospective Payment System (HH PPS) with “From” dates of service prior to January 1, 2020. Refer to the Home Health Patient-Driven Groupings Model (PDGM) Web page for additional information, and resources for submitting a RAP and a final claim under PDGM, effective for claims with “From” dates on or after January 1, 2020.

Claim Page 01 (Map 1711) contains general patient information, condition codes, occurrence codes, occurrence span codes, and value codes.

Begin entering data on FISS Claim Page 01 and continue until the necessary fields are completed. The easiest way to move from field to field is to use your TAB key. Use the key and table below to determine what fields are required and what information to enter.

Claim Page 01 - Entering a RAP or Claim

Key:

RED = Required field
BLUE = Optional field
GREEN = Conditional field, depended on the type of claim
PURPLE = System generated field
BLACK = Not required field

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Field Descriptions for Claim Page 01 – Map 1711

Field Name/Requirement	Description
MID Required	Key the beneficiary's Medicare ID number as it appears on the beneficiary's eligibility file. See the Checking Beneficiary Eligibility Web page for more information on the applications that are available to assist HHAs with this and instructions for using them.
TOB Required	FISS Page 01 defaults the type of bill (TOB) to 322. You may need to change this depending on the TOB you are entering. If submitting a cancel (328) or adjustment (327) TOB, do not use FISS Option 26 to enter the billing transaction. FISS Option 33 or 53 should be utilized for these types of billing transactions. 320 – Nonpayment claim. 322 – Request for Anticipated Payment (RAP). 327 – Replacement of prior claim 328 – Void/Cancel of prior claim 329 – Final claim for HH episode. 34X – HHA visits provided on an outpatient basis. ('X' denotes the frequency of bill. Frequency indicators are accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual - www.nubc.org.
NPI Required	Key your home health agency's National Provider Identifier.
PAT CNTL # Optional	Up to 20 digits are available for you to key your internal account number for tracking purposes. This number will display on your Remittance Advice or your Electronic Remittance Advice.
STMT DATES FROM/TO Required	Key the beginning and ending dates for this billing period. In FISS, dates are entered in a month, day, year format (MMDDYY – example 061013 for June 10, 2013). To assist in calculating correct episode dates, access the "Home Health 60-Day Episode Calendar Schedule" quick resource tool. RAPs: use the same date for both the "from" and "to" dates. On the first RAP in an admission, the "from" and "to" date must be the date the first Medicare billable service occurred. On RAPs for subsequent episodes, the "from" and "to" date must be the first calendar day of the subsequent episode (day 61, 121, etc.) For all HH PPS claims (including No-RAP-LUPAs): enter the 60th day of the episode, or the date of discharge, death or transfer if prior to the 60th day in the "to" field. When billing continuous care episodes, there should not be a break in service dates between the "STMT DATES FROM" date of the prior final claim and the "STMT DATES FROM" and "TO" dates of the subsequent RAP. You may submit claims or No-RAP-LUPA claims for payment immediately after the last billable service date has been provided and signed orders have been obtained.
LAST Required	Key the beneficiary's last name exactly as it appears on the beneficiary's eligibility file.
FIRST Required	Key the beneficiary's first name exactly as it appears on the beneficiary's eligibility file.
MI Optional	Key the beneficiary's middle initial.
DOB Required	Key the beneficiary's date of birth (MMDDCCYY format) exactly as it appears on the beneficiary's eligibility file.
ADDR 1-6 Required	Key the beneficiary's full mailing address, including street name and number, post office box number or RFD, city and state.
ZIP Required	Key the beneficiary's zip code of the city and state where they reside.
SEX Required	Key the beneficiary's gender using the appropriate alpha character. M = Male F = Female
MS Optional	Beneficiary's marital status.
ADMIT DATE Required	Key the start of care date on which the Medicare covered home health services began. This date should reflect the first Medicare billable service of the initial episode and correspond with the start of care date on the Plan of Care. The date is keyed in a MMDDYY format.
HR Required	Key the 2-digit hour of admission using the 24-hour clock. For example, if the patient was admitted at 8:00 a.m., key 08. If their hour of admission was 2:00 p.m. enter 14. If the exact hour is not known, enter '01'.
TYPE Required	Enter the 1-digit code indicating the priority (type) of admission or visit. If you are unsure which code to enter, use code 9 (information not available).
SRC Required	Key the code indicating the beneficiary's point of origin (formerly the source of admission).
STAT Required	Key the beneficiary's status code. RAPs: key '30' as the patient status code. Final and No-RAP-LUPA claims: key the appropriate patient status code listed to reflect the patient's status as of the "TO" date of the episode.
COND CODES Conditionally Required	Condition codes. Note: Claim Page 01 displays space for 10 condition codes. However, FISS allows you to enter up to 30 condition codes by pressing F6 to scroll forward. When another insurer is primary to Medicare, additional coding may be required on your home health final claim. See the Medicare Secondary Payer Billing & Adjustmentsquick resource tool for more information.
OCC CDS/DATES Conditionally Required	Occurrence codes and dates. When another insurer is primary to Medicare, additional coding may be required on your home health final claim. See the Medicare Secondary Payer Billing & Adjustments quick resource tool for more information. Occurrence code 55 – Occurrence code 55 and date of death (MMDDYY) is required when a patient discharge status code of 20 (expired) is reported on a claim. (See MLN Matters article, MM7792).
SPAN CODES/DATES Conditionally Required	Occurrence span codes and dates.
FAC ZIP Required	Facility zip code of the provider or the subpart (9- digit).
VALUE CODES – AMOUNTS Required	Value code 61 and the core based statistical area (CBSA) code are required on all 32X type of bills. Record value code 61 and the CBSA that corresponds with the location where the service is provided. In situations where the beneficiary's site of service changes from one CBSA to another within the episode period, submit the CBSA code corresponding to the site of service at the end of the episode. Access the Home Health Payment Rates Web page for these calendar year codes. Value Code 85 (effective for services provided on or after January 1, 2019) and an associated Federal Information Processing Standards (FIPS) State and County Code are required on all 32X type of bills. Record value code 85 and the FIPS 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. As an example, looking at the Excel file, the FIPS State and County Code 19153 would be reported with value code 85 for Polk County in Iowa. Refer to MM10782 for additional information. When another insurer is primary to Medicare, additional coding may be required on your home health final claim. See the Medicare Secondary Payer Billing & Adjustmentsquick resource tool for more information.

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Additional FISS Claim Pages

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Priority (Type) of Admission or Visit Codes

Code	Description
1	Emergency
2	Urgent
3	Elective
4	Newborn
5	Trauma
9	Information not available

Note: 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 - http://www.nubc.org/.

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Point of Origin (formerly Source of Admission) Codes

Code	Description
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

Note: The Point of Origin code used on the RAP should match the Point of Origin code on the final claim. 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.

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Patient Status Codes

Patient Status Code	Description
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

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Condition Codes

Code	Description
07	Treatment of Nonterminal Condition for Hospice Patient Enter this code if the beneficiary is a hospice enrollee and the services provided are not related to the terminal illness and you are seeking reimbursement under traditional Medicare benefits.
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 HHA, and the "FROM" date on your RAP/claim is on/after July 1, 2010. See the Beneficiary Elected Home Health Transfer Web page for additional information.
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 Matters® article, New Condition Code for Reporting Home Health Episodes with No Skilled Visits, for more information.
A6	PPV/Medicare Pneumococcal Pneumonia / Influenza 100% Payment Enter this code if a pneumonia vaccine (PPV) or influenza virus vaccine was given that should be reimbursed under a special Medicare program provision. This is an appropriate code only when the bill type is 34X and the revenue code is 0636. Note: Providers who submit roster bills electronically in FISS don't need to use condition code A6.
DR	Disaster Related This condition code identifies claims that are impacted, or may be impacted by specific payer policies related to a national or regional disaster.
M1	Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV) Enter this code to indicate your claim is a roster billing for a mass influenza and pneumococcal vaccination or pneumococcal pneumonia (PPV) program for multiple beneficiaries. Note: Providers who submit roster bills electronically in FISS don't need to use condition code M1.

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Expedited Review Condition Codes

The following condition codes are used in accordance with the Expedited Review process. For additional information on billing and claims processing requirements related to Expedited Determinations, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1, §150.3, and the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 30, §60.2.B and 260. Additional information is also available on the CGS Home Health Expedited Determination Process Web page.

Condition Code	Description	Used When The Claim Was Reviewed, And	Also Report:
C3	Partial approval of Medicare-covered services	Some days of the stay or services were denied.	Occurrence span code (OSC) M0 in FL 35-36 and the From and To dates of the approved stay.
C4	Services denied	All services beyond the intended discharge date were denied.	OSC 76 in FL 35-36 in cases where the beneficiary may be liable for payment and the dates of service, denoting the patient liability period. An appropriate patient status code indicating the patient's status with your agency as of the claim's "TO" date.
C7	Extended authorization of Medicare-covered services	An authorization for extending Medicare coverage for the services being provided was granted.

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Claim Change Reason Codes and Corresponding Bill Type

When submitting adjustment (327)/cancellation (328) bill types, HHAs enter one of the following required reason codes in a condition code field locator. Use a code that represents why the adjustment/cancellation is being submitted and also corresponds with the type of bill in FL4.

NOTE: Use one claim change reason code per claim. If more than one code is necessary to reflect the reason for the change or if the following codes do not apply, use reason code D9. When reason code D9 is used, an explanation of the adjustment/cancellation must be recorded in the Remarks field (FISS Claim page 04)

Code	Description
D0	Changes to Service Dates (FL6) TOB 327 *do not use for adjusting line item DOS, use D9 instead
D1	Changes to Charges TOB 327 *adding or removing charges (do not use for adjusting units, use D9 for units)
D2	Change in Revenue Codes/HCPCS/HIPPS TOB 327 *to change revenue HIPPS or HCPCS codes. (Use D9 to add a revenue or HCPCS)
D5	Cancel to correct Medicare ID number or provider number TOB 328
D6	Cancel Duplicate or OIG Overpayment TOB 328
D9	Any Other Change or Multiple Changes TOB 327 Remarks (FL84) required
E0	Change in Patient Status TOB 327

RAPs (type of bill 322) can be cancelled, but not adjusted. Final claims and No-RAP-LUPA claims (329) can be adjusted or cancelled.

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Occurrence Codes and Dates

Use the following occurrence codes on home health outpatient therapy claims (type of bill 34X).

Code	Description
55	Date of Death – Occurrence code 55 and date of death is required when the Patient Discharge Status Code indicates death (20 expired).
Use the following occurrence codes on home health outpatient therapy claims (type of bill 34X).
11	Onset of symptoms/illness and the date of symptom onset.
17	Date occupational therapy (OT) plan established or last reviewed.
29	Date outpatient physical therapy (PT) plan established or last reviewed
30	Date outpatient speech-language pathology (SLP) plan established or last reviewed
35	Date treatment started for PT
44	Date treatment started for OT
45	Date treatment started for SLP

Note: Claim page 01 displays space for 10 occurrence codes/dates. However, FISS allows you to enter up to 30 occurrence codes/dates by pressing F6 to scroll forward.

A complete listing of all occurrence codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

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Value Codes and Amounts

When entering a value code that represents a number rather than a monetary amount (e.g., value code 61, 85), enter the number followed by two zeros. For example, value code 61 represents the Core Based Statistical Area (CBSA) or geographical area where the home health services were provided. To indicate a CBSA code 99916, the number would be keyed as 9991600 or 99916.00.
Claim Page 01 displays space for 9 values codes/amounts. However, FISS allows you to enter up to 36 value codes/amounts by pressing F6 to scroll forward.

When entering a dollar amount, you may type or omit the decimal point as you choose (i.e., $45.92 can be keyed as 45.92 or 4592; $1500.00 can be keyed as 1500.00 or 150000). However, it is important to ensure that the appropriate cents value is entered, regardless of whether the decimal point is used.

Value Code

Description

Location Where Service is Furnished (Core Based Statistical Area) (CBSA)

The CBSA code should be used on all 32X type of bills. Record value code 61 and the CBSA code that corresponds with the location where the service is provided.

Multiple occurrences of value code 61 are not allowed. In situations where the beneficiary's site of service changes from one CBSA to another within the episode period, submit the CBSA code corresponding to the site of service at the end of the episode.

Access the Home Health Payment Rates Web page for these calendar year codes.

Note: Final claims with "Through" dates on or after January 1, 2015, should use 2015 CBSA codes. The CBSA code submitted on the Request for Anticipated Payment (RAP) does not need to match the CBSA code submitted on the final claim; therefore, it is not necessary for providers to cancel the RAP when it is submitted with a different CBSA code.

County where service is rendered (Federal Information Processing Standards (FIPS) State and County Code.

The FIPS code should be used on all 32X type of bills with services provided on or after January 1, 2019. Record value code 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. As an example, looking at the Excel file, the FIPS State and County Code 19153 would be reported with value code 85 for Polk County in Iowa. Refer to MM10782 for additional information.

Note: The above code represents that 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.

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Updated: 12.11.19