BILLING Guideline for home health - 0571, 0572 revenue codes

Home Health/Home Infusion Agencies

Florida Blue defines home health care services as those services rendered to an individual in the home by health care professionals (e.g., nurses, therapists) or paraprofessionals (e.g., home health aides, physical therapy assistants) to achieve and sustain an optimum state of health and independence for that individual. For purposes of coverage, home health care is provided on a per visit basis, generally for no more than two hours at a time.

Revenue Codes Used

• Home Health Aide
o 0571
o 0572 - hourly

• If the agency does not bill on a calendar month basis, it prepares two bills. The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the New Year.


• All services must be itemized by date of service. Enter the appropriate revenue code and date for each service rendered.

• Physical therapy, speech therapy and occupational therapy services should be billed by the visit, not by the modality or hour, unless approved by Care Coordination.

• Reimbursement for visits provided by a health care professional of differing specialties is limited to one per day for each specialty, unless documented as medically necessary.

• Some plans, including BlueCard may require medical documentation for unlisted codes, such as 99600.

• Utilization of specific codes is strongly recommended to facilitate easier claims processing.


Home Health Billing Requirements for Non-Contracted Medicare Advantage

• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.

• Bill type "322-329"

• Health Insurance Prospective Payment System (HIPPS) code

• Treatment Authorization Code

• Core-Based Statistical Area (CBSA) must be included with value amount field for a value code 61


Billing for Infusion Services for Providers NOT participating in the CareCentrix Network:

Classified drugs must be submitted with valid CPT/HCPCS codes, HCPCS quantity, NDC Code, and NDC Quantity.

• Do not bill more than seven consecutive days on any claim line.

• Bill only primary drugs and S per diem codes related to infusion when professional nursing services are provided.

• Do not bill codes that are considered inclusive in the S per diem code.

• Corrected claims; if billing for additional dates of service or additional items, not included on the original claim, a corrected claim is required.

• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.

• Home health providers with several provider numbers should submit the provider number of the agency that provided the care. This will ensure claims are reimbursed correctly.

• Submit both revenue and CPT/HCPCS Codes. Claims submitted without both revenue and CPT/HCPCS codes or with invalid codes will be rejected at the claim or line level.

• Bill according to CPT/HCPCS definitions to determine appropriate coding, inclusive supply and item sizing. Claim lines must be split unevenly when units exceed 9999 to prevent duplicate denials.

• Do not bill more than 15 lines or 31-days of services on the same claim. If billing for services over a span of dates, bill once for that span (after span is complete) to include all services for the dates of service on one claim. Overlapping or repeating span dates causes duplicate denials.

• The home health agency should not submit a bill/claim for an inclusive period beginning in one calendar year and extending into the next calendar year.

• A separate line item should be submitted for each per diem for each date of service. To report units per diem, one unit should be billed for each line.


Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.


Home Health Agency Billing Guidelines

Blue Cross recognizes the need to maintain consistency of billing requirements for both Blue Cross and Medicare wherever possible. Therefore, we require home health agencies to file claims using the UB- 04 claim form (see instructions in the Claims Submission section of this manual) in accordance with Medicare guidelines with the following exceptions:

1. The revenues codes accepted by Blue Cross and which may be entered in UB-04 field 42 are limited, and revenue code descriptions  for field 43 have been modified. These modifications are necessary due to member contract/certificate variations.



Revenue codes 551 and 559 and their respective descriptions have been changed to identify services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). This change is necessary because reimbursement rates are different for RNs and LPNs.

Revenue code 261, IV Therapy Pump, requires a modifier in order for the correct type of service to be assigned (see page 76 and 77 for detailed information). The revenue codes with descriptions accepted by Blue Cross from participating home health agencies listed in this manual. The appropriate HCPCS or Procedure  code must be included in field 44 of the UB-04 when billing revenue codes with double asterisks (**), shown under the column heading “Code Reqd.” This is necessary for proper pricing and payment of the service. (Please refer to your Blue Cross Home Health Agency Member Provider Agreement and Reimbursement Appendix for information on reimbursement).

2. Accumulative billing of services will be accepted by utilizing a “From” and “Through” date with the total units of service for a specific revenue code or HCPCS code. However, some member contracts/ certificates and/or groups require that the individual date of service be shown for each day on which services where provided. When this situation applies, you will be notified when you authorize services and also via the written confirmation of the authorization.

Authorization is required for all home health care. Blue Cross requires 48 hours advance notice of all home health care to be provided. The authorization will include the service and/or code to be provided and in some cases, the quantity/units of services authorized. The services that we will generally approve are included in this manual and include the range of HCPCS/Procedure  codes that should be billed with the revenue code. To obtain authorization, please call Provider Services at 1-800-523-6435.

Home Health Agency Revenue Codes Accepted by Blue Cross and Blue Shield of Louisiana Visit charge is defined as a consecutive period of time up to two hours during which home health care is rendered. Hourly charges exceeding two hours require additional authorization from Blue Cross.

Hourly charges for home health aides and private duty nursing (in shifts of at least eight continuous hours) must be billed using the revenue codes appropriate to the level of professional training.

Medicare home healthcare coverage and solution for Medicare denial

Does Medicare cover home health care?

Medicare will cover home health care if
(a) your care requires intermittent or part-time skilled services, physical therapy or speech
therapy;
(b) you are confined to your home and;
(c) your doctor says you need home health care.
Once it has been determined that you are eligible for home health coverage, you can
begin to receive home health aide services in addition to skilled care. These include
(a) household services essential to your health care at home;
(b) help with medications that you would normally take yourself;
(c) simple procedures that are an extension of therapy services; and
(d) personal care including help with daily activities.


What should I look for if claim denied by Medicare?
If your Medicare coverage is restricted incorrectly, you risk losing your home health care
completely, or receiving less care than you actually need. If you are denied coverage for any of
these reasons, be suspicious and challenge the denial:

(a) Duration denials: There are no time limits on how long you can receive home health
services. If you have a chronic condition, you have a good chance of getting the coverage you need.
As long as you need skilled care at least once every 2 months, you are entitled to home health care
coverage.

During this time, you are not required to improve or reach certain goals established by your plan
of care. It is enough if your care prevents or slows your health from getting worse, or helps you stay
at your current level of functioning. This is particularly important if you are receiving skilled
rehabilitation.

(b) “Not medically reasonable” denials: Medicare intermediaries often use their own
judgment to decide if certain skilled care is medically reasonable. Your own doctor, and not an
insurance company, should decide what care you need.
The Medicare evaluator or "intermediary" should not substitute its judgment for your
doctor’s in determining what care is needed. Medicare highly values and will usually accept the
opinion of the treating physician in determining the reasonableness and need for the health
services furnished by providers.

(c) “Not homebound” denials: Medicare sometimes improperly denies coverage to
individuals who are homebound and unable to leave home to obtain necessary care. If you
cannot leave your home without help from an individual or supportive device (such as crutches
or a wheelchair), you are considered homebound.
This is also true if it is not medically advisable for you to leave your home without
assistance. You do not need to be bedridden, but should be normally unable to leave home. In
certain circumstances, you can still be considered homebound even if you attend an adult day
care program outside your home.

(d) "Family members can provide the needed care" denials: Your family is under no
obligation to give you the kind of care provided by home health agencies. Likewise, you do not
have to accept the services of a family member. In some cases, having a family member provide
the care you need is not only inappropriate but also dangerous.

(e) "No improvement" denials: Medicare coverage is available even if you are not going to
improve medically and you need skilled care to prevent or delay further deterioration or preserve
your current capabilities.

To get coverage for care that maintains your current capabilities, it should be described in terms
of reaching a goal, such as the goal of maintaining or preventing further deterioration.

(f) Supervision by a skilled practitioner: To qualify for Medicare coverage based on
supervision by a skilled practitioner, all that is required is that a registered nurse, licensed practical
nurse, physical or occupational therapist, speech pathologist or audiologist generally supervise
skilled nursing and rehabilitation services.
A supervisor does not have to be physically present or on the premises when services are
performed.

(g) Coordinating a plan of care: Medicare regulations say that your overall condition must be
considered and that skilled personnel may be necessary to perform and coordinate a series of tasks
that, taken individually, would not require a skilled professional.

(h) Observation and assessment as a skilled service: Observation and assessment are
considered to be skilled services when the skills of a technical or professional person are
required to identify and evaluate your need for additional medical procedures.
For example, a patient with congestive heart failure may need continuous close
observation to detect signs of deterioration, abnormal fluid balance or a bad reaction to
medications.
Likewise, patients discharged from a hospital while in a complicated and unstable
condition after surgery may need continued skilled monitoring to watch for post-operative
complications.

(i) Management and evaluation of care plan: Management and evaluation is a skilled
service when the skills of a technician or professional are periodically required to evaluate and
manage the home health aide services you receive. In other words, the skilled professional
oversees the unskilled services to make sure that they are effective.
For example, a nurse’s management and evaluation skills would be needed to monitor the
diet, fluid intake and other health-related needs of an Alzheimer’s patient. The services could be
provided by unskilled home health aides with the skilled nurse managing the services and
periodically evaluating the patient.