Home Health Prospective Payment System (HH PPS) Consolidated

20 - Home Health Prospective Payment System (HH PPS) Consolidated Billing (Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21) Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, Medicare makes payment for all such items and services to a single HHA overseeing that plan. This HHA is known as the primary HHA for HH PPS billing purposes. The law states payment will be made to the primary HHA without regard as to whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements exist with the primary agency, or “otherwise.” Payment for all items is included in the HH PPS payment the primary HHA receives. Types of services that are subject to the home health consolidated billing provision: • Skilled nursing care; • Home health aide services; • Physical therapy; • Speech-language pathology; • Occupational therapy; • Medical social services; • Routine and nonroutine medical supplies; • Medical services provided by an intern or resident-in-training of a hospital, under an approved teaching program of the hospital, in the case of an HHA that is affiliated or under common control with that hospital; and • Care for homebound patients involving equipment too cumbersome to take to the home. Exception: Therapy services are not subject to the home health consolidated billing methodology when performed by a physician. Medicare periodically publishes Recurring Update Notifications that contain updated lists of nonroutine supply codes and therapy codes that must be included in home health consolidated billing. Medicare updates the lists annually, effective January 1, as a result of annual changes in HCPCS codes, unless the HCPCS changes do not affect home health services. The lists may also be updated as frequently as quarterly if this is required by the creation of new HCPCS codes mid-year. The HHA that submits an NOA successfully processed by Medicare claims processing systems will be recorded as the primary HHA for a given period in the CWF. If a beneficiary transfers during a 30-day period of care, then the transfer HHA that establishes the new plan of care assumes responsibility for consolidating billing for the beneficiary. A/B MACs (HHH) will reject any claims from providers or suppliers other than the primary HHA that contain billing for the services and items subject to consolidated billing when billed for dates of service within a period of care (see §20.2 for details). A/B MACs (HHH) will also reject claims subject to consolidated billing when submitted by the primary HHA as services not under an HH plan of care (using TOB 034x) when the primary HHA has already billed other services under an HH plan of care (TOB 032x) for the beneficiary. Institutional providers may access information on existing periods of care through the home health CWF inquiry process. See §30.1. Durable medical equipment is exempt from home health consolidated billing by law. Therefore, DME may be billed by a supplier or an HHA (including HHAs other than the primary HHA). Medicare claims processing systems will allow either party to submit DME claims, but will ensure that the same DME items are not submitted by multiple providers for the same dates of service for the same beneficiary. In the event of duplicate billing, the first claim received will be processed and paid. Subsequent duplicate claims will be denied. Medicare claims processing systems will also prevent payment for the purchase and the rental of the same item for the same dates of service. In this event, the first claim received, regardless of whether for purchase or rental, will be processed and paid. The exception to the above, however, is competitive bidding for certain DME. HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program, must either be awarded a contract to furnish the items in this area or use a contract supplier in the community to furnish these items. The competitive bidding items are identified by HCPCS codes and the competitive bidding areas are identified based on ZIP Codes where beneficiaries receiving these items maintain their permanent residence. Home health agency claims submitted for HCPCS codes subject to a competitive bidding program will be returned to the provider to remove the affected DME line items and the providers will be advised to submit those charges to the DME MACs, who will have jurisdiction over all claims for competitively bid items. Osteoporosis drugs are subject to home health consolidated billing, even though these drugs continue to be paid on a cost basis in addition to the HH unit of payment. For more detailed information, refer to §20.2.3 and §90.1.