Episodic Payment System for Certified Home Health Agencies
Billing Guidelines - Updated as of April 9, 2013
Episodic Payment System was effective May 1, 2012.
Authorized by Public Health Law 3614.13. Regulations are at NYCRR Title 10, Section 86-1.44.
Episodic Payment System applies to all CHHA patients age 18 and older, unless exempted by regulation.
Reimbursement is based on 60-day episodes of care, with adjustments for patient acuity (Case Mix Index) and regional wage differences.
CHHA Rate Codes used prior to May 1, 2012 are INVALID for patients 18 and older for dates of service beginning May 1, 2012 - claims using these codes will be rejected.
Medicaid continues to be the payer of last resort - episodic claims should reflect only those services which are not covered by Medicare or other insurers.
INTERIM CLAIMS AND FINAL CLAIMS
Providers can file an Interim Claim to receive 50% of the projected adjusted Base Price for the episode.
When a Final Claim is filed which contains the Transaction Control Number (TCN) for the corresponding Interim Claim, the Interim Claim will be negated and the Final Claim will be paid in full.
Interim and Final Claims must be indicated as follows:
"Type of Bill" (field #4 on UB-04) -
Third digit must be:
"2" for an Interim Claim or Adjusted Interim Claim
"9" for a Final Claim or Adjusted Final Claim
Do not use third digit of "7" for adjusted Episodic Claims.
Third digit of "8" can be used for voided claims.
- Amount paid will assume that Final Claim will not be a Low Utilization Claim and will not exceed Outlier Threshold (see below).
- Provider is not required to file an Interim Claim.
- Beginning date of Interim Claim must be first day of episode.
- Provider must report at least one Medicaid eligible service in fields 42-46 of UB-04.
- Interim Claim will be reversed 150 days after adjudication date if a corresponding Final Claim (with correct TCN) is not received.
- If an Interim Claim was filed, Final Claim should include the TCN for the Interim Claim
- All Medicaid-billable services during period of claim must be listed in field 42-46 (including services which were listed on Interim Claim).
- Rate Code on Final Claim can be different from Rate Code on Interim Claim.
- Final Claim will be paid in full and Interim Claim will be reversed in the same billing cycle (two remittance records).
- Final Claim must be filed no more than 90 days after end of claim period ("Through" date In field 6 of UB-04).
110 new Rate Codes have been created for the Episodic Payment System:
4810 through 4817
4919 (assessment visit with no OASIS - LUPA only)
4920 (maternity patients with no OASIS assessment)
Enter Rate Code in fields 39-41 with Value Code 24 (same as current fee-for-service billing). Only one Rate Code should be entered per claim.
Each Rate Code (except 4919 and 4920) corresponds with a Resource Group determined by the New York State Medicaid Grouper for Certified Home Health Agencies. A complete list of episodic rate codes is available here: http://www.health.ny.gov/facilities/long_term_care/reimbursement/chha/
Grouper uses 4 variables, based on the most recent OASIS assessment:
- Reason for assessment
- Clinical score
- Functional score
- Age of patient
Rate Code on claim must correspond with the applicable age group for the patient, based on the patient´s age on the "Through" date in field 6.
- This may require different Rate Codes on Interim Claim and Final Claim
A new Occurrence Code 50 has been created for the Episodic Payment System.
This code must be entered in UB-04 fields 31-34 with the date of the most recent OASIS assessment. The date must be no more than 65 days prior to the start date of the episode, and no more than 5 days after the start date of the episode.
EXCEPTIONS: Claims with Rate Codes 4919 (assessment only) and 4920 (maternity patients only) do not require Occurrence Code 50.
FULL EPISODES AND PARTIAL EPISODES
Claims in which the "From" and "Through" dates reflect a period of 60 days or more will result in payment for a full episode.
If the period of service is less than 60 days, payment will be pro-rated unless one of the following codes is reported in UB-04 Field 17 (Discharge Status):
01 - Discharged to Home or Self-Care
02 - Discharged/Transferred to Hospital
20 - Patient Expired
50 - Discharged to Hospice (Home)
51 - Discharged to Hospice (Medical Facility)
For these exceptions, the provider will receive a full 60-day payment.
NOTE: If a provider receives full payment for a partial episode, in accordance with these exceptions, and then readmits the patient within 60 days of the original episode start date, the provider must file a corrected claim and must include all services within 60 days of the original start date in a single episode.
Providers cannot use any of the five Discharge Status codes listed above if the patient is transferred to Managed Long Term Care or to another long-term care program (e.g. nursing home, Long Term Home Health Care Program, Personal Care Agency, Assisted Living Program).
BEGINNING AND ENDING DATES OF EPISODES:
New Patient - Episode begins on date of first Medicaid eligible service. If patient is discharged before 60 days, episode ends on date of last Medicaid eligible service. If care continues beyond 60 days (into second episode), first episode ends on 60th day.
Continuing patient - Second or subsequent episode begins on the day after the end of the previous episode, even if there is no Medicaid eligible service on that date. End date follows the same rules as "New Patient" (above).
Special rule for May 1, 2012: if patient was under care in April 2012 and care is continuous, first episode can begin on May 1, 2012 even if there is no Medicaid eligible service on that date.
USE OF PARTIAL EPISODES TO SYNCHRONIZE WITH MEDICARE:
For new patients, or for episodes beginning May 1, 2012, providers may, at their discretion, submit a claim for an episode of less than 60 days in order to align episode start dates for dual eligibles.
REPORTING MEDICAID ELIGIBLE SERVICES
Calculation of Outlier Claims and Low Utilization claims (LUPAs) will be based on this information.
Underlying Medicaid eligible services (visits, hours, etc.) should be reported in UB-04 fields 42-46. Interim Claim must include at least one service line. Final Claim should include all Medicaid-billable services during period of claim.
The following Revenue Codes should be used in field 42:
0551 Nursing - Visit
0421 Physical Therapy - Visit
0441 Speech Pathology - Visit
0431 Occupational Therapy - Visit
0572 Home Health Aide - Hour
0579 Shared Aide - Quarter Hour
0559 AIDS Nursing - Visit
0780 Telehealth Services - Day
0590 Telehealth - Installation
0581 MOMS Health Supportive Services - Visit
Service Price will be based on statewide weighted average rates for each of these codes.
A separate line must be used for each date and each Revenue Code.
Service units reported per day are subject to the same limitations that applied to the corresponding rate codes prior to May 1, 2012. For example:
Home Health Aide - no more than 24 hours per day
Nursing and Therapies - no more than 3 visits per day
Providers should continue to report Procedure Codes in this section and may report their usual and customary charges, but such charges will not be used in the claims payment calculation.
LOW UTILIZATION AND OUTLIER CLAIMS
If the total Service Price, based on information reported in fields 42-46, is $500 or less, the provider will be paid a "Low Utilization Payment Amount" (LUPA) equal to the total Service Price, adjusted by the regional Wage Index Factor.
If the total Service Price exceeds the outlier threshold for the billed Rate Code, the provider will be paid the normal episodic price (base price adjusted for Case Mix Index and Wage Index Factor), plus 50% of the amount by which the total Service Price exceeds the outlier threshold. This outlier component of the claim payment also will be adjusted by the Wage Index Factor.
LUPAs and outliers in partial episodes will be paid as follows:
LUPA - No change in the $500 threshold. If total Service Price is $500 or less, provider receives total Service Price, adjusted for Wage Index Factor, regardless of length of episode.
OUTLIERS - Outlier thresholds will not be pro-rated for partial episodes. Total payment will be computed based on a 60-day episode, then pro-rated for the number of days in the episode.
WAGE INDEX FACTORS
All payments are adjusted by the applicable Wage Index Factor (WIF).
There are 10 WIFs, for the 10 Labor Market Regions defined by the NYS Department of Labor.
The WIF applied to each claim is based on the existing Locator Code shown by the billing agency, not on the patient´s home address.
The WIF is applied to 77% of the total claim (this is the estimated portion of total CHHA costs which are labor-related).
Two new fields will be added to the Home Health paper remittance. These are Header Service End Date and Base Rate Source Code.
The Base Rate Source Code will be added to the 835 electronic remittance in the Loop 2100 REF - OTHER CLAIM RELATED IDENTIFICATION segment. The REF01 field will be defaulted to CE (Class of Contract Code).
The REF02 field will show the Base Rate Source Code.
The claim´s Base Rate Source Code is used to indicate which method was used to calculate the payment:
- HI - Interim Claim
- HL - LUPA Claim
- HO - Outlier Claim
- HE - Full Episode Claim (not LUPA or Outlier)
- PE - Partial Episode (pro-rated)
- PO - Partial Episode with Outlier Payment
- SE - Partial Episode Paid as Full Episode (not LUPA or Outlier)
- SO - Partial Episode Paid as Full Episode (Outlier)
There has been no change in Medicaid policy regarding supplies which may be billed by a CHHA. Supplies must be billed on a separate claim, not on the episodic claim.
SURPLUS / SPENDDOWN
Providers should continue to report these amounts in fields 39-41 of UB-04.
MEDICARE CROSSOVER CLAIMS
These are not part of the episodic payment system and there has been no change in the manner in which they are processed.
If rates, case mix weights, outlier thresholds, or wage index factors change during the claim period, the claim will be priced according to the values in effect on the beginning date of the claim.