Home health Consolidated Billing Edits in Medicare Systems

20.2 - Home health Consolidated Billing Edits in Medicare Systems (Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21) In short, consolidated billing requires that only the primary HHA bill services under the home health benefit, with the exception of DME and therapy services provided by physicians, for the period of that period of care. The types of service most affected are nonroutine supplies and outpatient therapies, since these services are routinely billed by providers other than HHAs, or are delivered by HHAs outside of plans of care. Home health consolidated billing edits are applied when the period of care claim has been received and processed in CWF. Edits are applied differently depending on whether the HH patient was discharged/transferred at the end of the HH period or not. If the patient was discharged or transferred, the edits apply to dates of service between the period start date and the last billable service date for the period. The start date and last service date are excluded. If the patient is not discharged or transferred (patient status 30, “Still Patient”), the edits apply to dates of service between the period start date and the period end date. The start date is excluded but the end date is included. If any line item services subject to consolidated billing are identified within these dates, CWF sends information to the contractors that enables them to reject or deny those line items. Claims subject to consolidated billing may be identified in one of two ways. Claims may be edited when the HH PPS claim had been received before the claim for services subject to consolidated billing. In these cases, the line items subject to consolidated billing are rejected or denied prior to payment. Claims may also be identified when the HH PPS claim is received after the other claims subject to consolidated billing. In these cases, the claim for services subject to consolidated billing has already been paid. CWF then notifies the contractor to make a post-payment rejection or denial. For post-payment rejections of claims billed on institutional claims, recoveries will be made automatically in the claims process. For post-payment rejections of claims billed on professional claims, those contractors will follow their routine overpayment identification and recovery procedures. In the event a denial is reversed upon appeal, an override procedure exists to permit payment to be made. The contractor shall use the following remittance advice messages and associated codes when not paying outlier amounts under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four. Group Code: CO CARC: 97 RARC: N390 MSN: N/A Since home health consolidated billing is not an ABN situation, coding on incoming claims cannot allow Medicare systems to fully identify the payment liability for any denial. As described in §20.1, whether the denial is the liability of the primary HHA or the beneficiary is determined by whether the services are provided under arrangement and whether the beneficiary received notice of their potential liability. These denials are shown as provider liability on remittance advices (group code CO) to ensure therapy providers or suppliers explore whether a payment arrangement exists or can be made for the services. Despite this coding limitation, Medicare recognizes that ultimately beneficiaries may be liable for these services.