In August 2012, the Office of Inspector General (OIG) issued report OEI-04-00240, entitled
"Inappropriate and Questionable Billing by Medicare Home Health Agencies." One
recommendation of this report was to improve existing edits to prevent inappropriate payments on HH claims that overlap claims for inpatient hospital stays or SNF stays.
Change Request (CR) 8699 which improves safeguards to prevent payment of HH services when a beneficiary is an inpatient of a hospital or Skilled Nursing Facility (SNF). Make sure that your billing personnel are on the alert for overlapping claims
The Centers for Medicare & Medicaid Services (CMS) requested and received example claims
from the OIG in order to research ways to improve the edits in Original Medicare claims
systems that identify such overlaps. This review identified two gaps in current Medicare
1. The edit that rejects HH claims when they have dates overlapping an inpatient stay
(other than the admission date, discharge date, or a date during an occurrence span
code 74 period indicating a leave of absence) does not consider inpatient stays in a
swing bed (Type of Bill 018x); and
2. Medicare systems only identify overlaps with inpatient stays when the inpatient
hospital or SNF claim was received before the HH claim.
CR8699 contains no new policy but revises the Medicare systems to close gaps to prevent
inappropriate payments on HH claims. The “Medicare Claims Processing Manual,” Chapter
10 (Home Health Agency Billing) will be changed to state the following:
• Beneficiaries cannot be institutionalized and receive home health care
simultaneously. Claims for institutional inpatient services (inpatient hospital, SNF,
and swing bed claims), have priority in Medicare claims editing over claims for HH
• If an HH Prospective Payment System (PPS) claim is received, and Medicare's
Common Working File (CWF) finds dates of service on the HH claim that fall
within the dates of an inpatient, SNF, or swing bed claim (not including the dates of
admission and discharge and the dates of any leave of absence), Medicare systems
will reject the HH claim. The HHA may submit a new claim removing any dates of
service within the inpatient stay that were billed in error.
• If the HH PPS claim is received first and the inpatient hospital, SNF, or swing bed
claim comes in later, but contains dates of service duplicating dates of service within
the HH PPS episode period, Medicare systems will adjust the previously paid HH
PPS claim to non-cover the duplicated dates of service.
The following remittance advice codes will be used for any HH visits non-covered as a
result of CR8699:
• Group code: CO
• Claim Adjustment Reason Code: 96 (Non-covered charge(s))
The official instruction, CR8699 issued to your MAC regarding this change may be viewed
on the CMS website.