Therapy Thresholds

• Number of therapy visits projected on the OASIS at the start of the episode is confirmed by therapy visits entered on final episode claim

• Three Thresholds 

 – 6 Visits

 – 14 Visits

 – 20 Visits

• Claims will be recoded based on actual number of therapy services provided

Supply Groups

• Supplies bundled into HH PPS payment

 – Routine supplies: used in small quantities for patients during usual course of home care 

 – Non-routine: needed to treat patient’s specific illness or injury according to plan of care 

• Non-routine supplies grouped based on if supplies were (or were not) provided and further scaled down into severity levels

Consolidated Billing

• HHA must bill for all home health services which includes: 

– Nursing and therapy services 

– Routine and non-routine medical supplies 

– HH aide services 

– Medical social services 

• All home health services paid on a cost basis included in PPS rate 

• Payment made to primary HHA regardless of whether or not items or services were furnished by the HHA

Home Health Prospective Payment System (HH PPS) Consolidated Billing

all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, Medicare payment for all such items and services is to be made to a single home health agency (HHA) overseeing that plan. This HHA is known as the primary HHA for HH PPS billing purposes.
The law states payment will be made to the primary HHA without regard as to whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements exist with the primary agency, or “otherwise.” Payment for all items is included in the HH PPS episode payment the primary HHA receives.
Types of services that are subject to the home health consolidated billing provision:

Skilled nursing care;
Home health aide services;
Physical therapy;
Speech-language pathology;
Occupational therapy;
Medical social services;
Routine and nonroutine medical supplies;
Medical services provided by an intern or resident-in-training of a hospital, under an approved teaching program of the hospital, in the case of an HHA that is affiliated or under common control with that hospital; and Care for homebound patients involving equipment too cumbersome to take to the home.
Exception: Therapy services are not subject to the home health consolidated billing methodology when performed by a physician.
Medicare periodically publishes Routine Update Notifications that contain updated lists of nonroutine supply codes and therapy codes that must be included in home health consolidated billing. The lists are always updated annually, effective January 1, as a result of changes in HCPCS codes, which Medicare also publishes annually. The lists may also be updated as frequently as quarterly if this is required by the creation of new HCPCS codes mid-year.