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New Home Health Billing Requirements in Effect

2/1/19 – Dave Macke

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As of January 1, 2019, Home Health Agencies (HHA) nationwide were subject to new billing requirements relating to the new Home Health Rural Add-on payment differential.  The percentage add-on is now based on three different percentages determined by the classification of the county.

High Utilization is the top quartile of episodes per 100 enrollees.  Low Population Density consists of counties with 6 or fewer people per square mile.  Any remaining counties fall under All Other.  Each rural county is classified into one of these three categories.

The Change Request (CR 10782) requires all HHA’s to assign new value Code 85 (County Where Service is Rendered) with the associated FIPS state county code for all Requests for Anticipated Payments, Home Health claims, and adjustments. The Code 85 is a 5 digit number unique to each county.  Code 85 must be entered in addition to Code 61 (Location Where Service is Furnished) – Core Based Statistical Area (CBSA) Number (or rural state code) for the location where the service is performed.  The original instructions from CMS were not clear.  Initially, it was thought that an HHA was required to enter the county code in Code 85, only if it was rural.  CMS has clarified that Code 85 must be completed for all home health claims – rural and urban.

Failure to include both codes will result in the return of the claim, identified with Code 37257, “Claim billed with missing or invalid FIPS county code. Please review the claim and make any necessary corrections.” It is imperative that your staff is immediately notified of these new requirements. The links below provide a detailed account of the Change Request and a path to the FIPS State and County Code database.

For further clarification regarding this Change Request, or for any matters related to Home Health reporting, please contact our Healthcare Reimbursement Team today!

Related Links

Change Request Additional Information - https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4190CP.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10782.pdf

CY 2019-CY 2022 Rural-Add-On Payment Designations - https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

*FIPS State and County Code Database - http://www.nber.org/data/ssa-fips-state-county-crosswalk.html

*Under “Source,” select the .xls file for 2017.  

2020 PDGM Change is Coming