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Issue Number - Name
0158-Outpatient Therapy Services During Home Health: Unbundling
Review Type
Automated
Provider Type
Outpatient Facility
MAC Jurisdiction
All A/B MACs
Date Approved
06/04/2019

Description

On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042X, 043X, 044X.

Affected Codes

CPT/HCPCS codes billed with Revenue codes 042x, 043x or 044x

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening 
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
6. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20- Home Health Prospective Payment System (HH PPS) Consolidated Billing
7. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2.2 - Therapy Editing