Article Detail - JA DME

Original Effective Date: 10/28/2003
Revision Effective Date: 11/01/2013

I. GENERAL INFORMATION

A. Background:
The CMS periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list which are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing. Medicare contractors include fiscal intermediaries (FIs), carriers, and durable medical equipment regional carriers (DMERCs).

The HH consolidated billing code lists are updated annually, to reflect the annual changes to the HCPCS code set itself. Additional updates may occur as frequently as quarterly in order to reflect the creation of temporary HCPCS codes (e.g., 'K' codes) throughout the calendar year. The new coding identified in each update describes the same services that were used to determine the applicable HH PPS payment rates. No additional services will be added by these updates; that is, new updates are required by changes to the coding system, not because the services subject to HH consolidated billing are being redefined.

B. Policy:
Section 1842(b)(6) of the Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency. This requirement is found in Medicare regulations at 42 CFR 409.100.

C. Code Changes for January 2004 Annual Update, effective for dates of service on or after January 1, 2004:

Added codes:
A4216, A4217, A4248, A4366, A4416, A4417, A4418, A4419, A4420, A4423, A4424, A4425, A4426, A4427, A4428, A4429, A4430, A4431, A4432, A4433, A4434, A4623, A6025, A6407, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A7520, A7521, A7522, A7523, A7524, A7525, A7526, 97755.

Deleted codes
A4319, A4323, A4622, A4712, K0581, K0582, K0583, K0584, K0585, K0586, K0587, K0588, K0589, K0590, K0591, K0592, K0593, K0594, K0595, K0596, K0597, K0621

A complete list of HCPCS codes subject to Home Health Consolidated Billing may be found at the following internet address: https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information.