Home Health Billing
Notice of Admission Questions and Answers
Medicare requires HHAs to submit a one-time NOA instead of RAPs for new admissions starting on or after 1/1/2022. HHAs shall no longer submit RAPs, TOB 0322 for any HH periods of care with a “From” date on or after 1/1/2022. RAPs with a “From” date on or before 12/31/2021, will continue to be accepted.
- Does the NOA only need to be submitted once at the time of admission (or artificial admission) not every 30-day period?
Answer: The NOA only needs to be submitted when there is a new HH admission. It does not need to be submitted for every 30-day period of care. Medicare only requires one NOA (TOB 032A) for any series of HH periods of care beginning with admission to home care and ending with discharge. HHAs shall not submit an NOA for subsequent 30-day periods of care with the exception of the one-time NOA submission for beneficiaries receiving HH services in 2021 and continuing services in 2022. Refer to the Beneficiaries Receiving HH Services in 2021 and Continuing Services in 2022 section below.
- Can an HHA submit the NOA early?
Answer: No. NOAs that contain a future “Admission,” “From” or “Through” date will be returned to the provider. For new admissions, the NOA cannot be submitted until the HHA has obtained a verbal or written order from the physician/practitioner and conducted an initial visit at the SOC, which is the admission date.
- Regarding use of CC 47, when would a HHA transfer take place? Can we enter our NOA if the previous HHA has not processed their final claim or would this result in a late NOA?
Answer: In HH, a transfer is when a home health patient transfers from one HHA to another HHA within a 30-day period. In transfers from one agency to another, the receiving agency submits the NOA with condition code 47. This will close the prior admission period from the previous agency.
CC 47 may also be used when the beneficiary has been discharged from another HHA, but the period of care claim has not been submitted or processed at the time of the new admission to discharge the beneficiary.
- Besides CC 47, are there other condition codes an HHA should submit on an NOA?
Answer: No. The NOA will be returned to the provider if any condition code other than CC 47 is applied to the NOA. Unlike RAPs, NOAs will not edit for hospice elections and CC 07 (unrelated to the terminal condition) shall not be applied to the NOA. Period of care claims will continue to edit for hospice elections and CC 07 should only be applied to the home health claim in situations in which the HH services are completely unrelated to the termination condition.
- Will the NOA require a HIPPS code like RAPs?
Answer: A HIPPS code is only required on the NOA when billing via the 837I format (electronically). When billing electronically, use a placeholder HIPPS of ‘1AA11’.
- In 2021 we get a rejection if we put a different HIPPS on the final claim compared to the RAP. After NOA implementation, will we still get rejections if the final claim HIPPS for the first 30-day period doesn't match HIPPS on the NOA? What about the subsequent final claims submitted after the first 30-day period?
Answer: The HIPPS is not required on the NOA unless submitting via the 837I format, in which case HIPPS code ‘1AA11’ is used. Since the field where the HIPPS code is submitted is not a required field on the NOA, there is not a matching field requirement for the NOA/period of care claim. Subsequent period of care claims should be submitted with either a Grouper produced HIPPS code or any valid HIPPS under PDGM.
- Will there be a requirement to send a notice of discharge as well, like we do in hospice?
Answer: A HH discharge is determined by the period of care claim billed with a discharge patient status code. There is no separate billing requirement for a home health discharge.
- Does the principal diagnosis code reported on the NOA need to match the principal diagnosis on the initial period of care claim?
Answer: No, the principal diagnosis code reported on the NOA does not need to match the principal diagnosis reported on the initial period of care claim. Also, secondary diagnoses are not required on the NOA.
- Does the primary diagnosis code reported on the NOA need to be changed if the clinician changes the primary diagnosis after the NOA has been sent?
Answer: No, the NOA does not have to be canceled and resubmitted if the primary diagnosis is changed after the NOA was sent and processed. Keep in mind, the principal diagnosis reported on the period of care claim is what drives the clinical grouping under PDGM for the period of care.
- If the NOA is manually entered in DDE, does the HHA choose Home Health (option 26) or NOA/NOE (option 49) from the Claims Entry screen?
Answer: Either option will bring you to claims entry where you can enter the appropriate NOA information. Be sure to change the bill type to 32A.
- Does the NOA apply to Medicare Secondary Payer as well?
Answer: MSP billing is not required on NOAs. HHAs shall submit the NOA as Medicare primary and it will process without MSP editing.
Remember that beneficiaries who have Medicare as a secondary payer are still Medicare patients, and therefore all Medicare billing requirements must be met. The NOA is required for Medicare billing, regardless of whether Medicare is primary or secondary (or tertiary). All of the necessary MSP information should be submitted on the final period of care claim.
- Do you know which other payers will require NOAs? Which payers will "copy" the Medicare NOA rules?
Answer: The billing guidelines for the NOA apply to Original Medicare. You will need to contact any Medicare Advantage plans or other insurance plans to which the HHA submits claims to find out the details of their billing requirements.
- The NOA job aid states the NPI entered with the name in the Attending Physician field must be an individual NPI, not a group NPI. How do we determine if the physician's NPI is an individual NPI rather than a group NPI?
Answer: Please visit the NPI registry to verify this information.
- Is the end of the Admission Period when the patient is discharged? For example, there would not be a new admission when a patient is transferred to a hospital but remains on service, or at the end of a recertification period?
Answer: A home health agency has the option to discharge a patient when admitted to a hospital during the 30-day period, so if the HHA keeps the patient on service without discharging them, there would not be a new admission when the patient is back with the HHA. The NOA is only required for new admissions, so a patient remaining on service with the same HHA for multiple recertifications would not require an NOA for the recertification periods.
In most cases, if a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been a subsequent 60-day recertification, a new HH certification begins with the new start of care date after inpatient discharge. Please refer to Section 10.9 — Discharge Issues, of the HH Medicare Benefit Policy Manual for more information on discharges associated with inpatient admission overlapping into subsequent 60-day recertifications.
What happens if a patient is transferred within the 1st 30-day period and resumes care with the HHA in the 2nd 30-day period, but is coming in from a SNF? Guidance tells us to do a new start of care. What do we need to do with the new NOA implementation?
Answer: A home health agency has the option whether or not to discharge a patient when transferred to another facility for inpatient care. If the HHA chooses not to discharge the patient, there is no need to submit an NOA when the patient returns to the HHA. The NOA is only required for new admissions, so a patient remaining on service with the same home health agency for multiple recertifications would not require an NOA for the recertification periods.
Beneficiaries Receiving HH Services in 2021 and Continuing Services in 2022
- What do HHAs do for beneficiaries receiving HH services in 2021 and who will continue services in 2022?
Answer: For all beneficiaries receiving HH services in 2021 who will be continuing services in 2022, HHAs are required to submit an NOA with a one-time, artificial “admission” date corresponding to the “From” date of the first period of continuing care in 2022. Unlike a new admission, there is no requirement to perform a visit on the artificial “admission” date.
- For artificial admission NOAs, what admission date do we use on our claims?
Answer: The admission date on the NOA for services that carry over into 2022 should use the date that corresponds to the ‘From’ date of the new period of care. For example, if a patient began care on 12/15/2021 and the new period of care will begin on 1/16/2022, the NOA should use the same date as the ‘From’ date of the new billing period, i.e., 1/16/2022. The period of care claim starting on 1/16/2022 will also use the new artificial admission date, which will carry over to all subsequent claims for that beneficiary until discharge.
- Does the five-day submission requirement apply to the artificial NOA for periods spanning 2021-2022?
Answer: Yes, the five-day submission requirement applies to all NOAs, including those billed with an artificial admission date when a period of care carries over into 2022 from 2021.
- When using an artificial admit date on periods of care that continue into 2022 from 2021, will the artificial admit date be the admit date on all claims going forward rather than the real admit date?
Answer: Yes. Since an admission in 2022 is required for the NOA, the guidance to bill an artificial admission date that corresponds to the ‘From’ date of the period of care in 2022 in essence changes the admit date for the periods of care going forward. For example, a new period of care beginning on 1/16/2022 requires an NOA with that date. The next period of care begins 2/15/2022 and care continues until the patient is discharged on 5/2/2022. The claims would be billed as follows:
- Admit date 1/16/2022; From and Through dates 1/16/2022-2/14/2022
- Admit date 1/16/2022; From and Through dates 2/15/2022-3/16/2022
- Admit date 1/16/2022; From and Through dates 3/17/2022-4/15/2022
- Admit date 1/16/2022; From and Through dates 4/16/2022-5/2/2022
Payment Reduction for Late NOA
- Is there a penalty for late NOAs?
Answer: Yes, there is non-timely submission payment reduction when the HHA does not submit the NOA within five calendar days from the SOC date. The NOA is considered timely-filed when submitted to the HH+H MAC within five calendar days from the admission date and accepted. “Accepted” is defined as processing and approving after the NOA is received. The date an NOA completes processing and approves is not used in calculating the NOA’s timeliness, only the date the NOA was received by the MAC.
- Will the exception process for a late NOA be the same as they were with the RAP?
Answer: Yes. MLN Matters MM12256 explains the non-timely payment reduction and exceptions for failure to send the NOA timely.
The MAC won't grant exceptions if:
- The HHA can correct the NOA without waiting for Medicare systems actions
- The HHA submits a partial/incomplete NOA to fulfill the timely-filing requirement
- CMS has clarified that a partial NOA would be a submission that is missing required fields or has invalid values in those fields
- the HHA has multiple provider identifiers and submit the identifier of a location that actually provide the service
- How do we determine the five calendar days for timely NOA submission? Is day one the start of care or the day after?
Answer: The start of care day is day zero - count five days after the start of care/admission date to determine the 5-day window for timely NOA submission.
- If the HHA submits the NOA timely, but needs to cancel it for an error, can we file an exception on the initial claim?
Answer: Yes. If the NOA was originally received timely, but was canceled with TOB 032D (Cancellation of Admission) and resubmitted to correct an error, enter Remarks to indicate this is the case, e.g., “Timely NOA, cancel and rebill.” Append modifier KX to the HIPPS code on the 0023 revenue line of the period of care claim. HHAs should resubmit the corrected NOA promptly – generally within two business days of canceling the incorrect NOA.
Examples of errors that would require the NOA to be cancelled and resubmitted:
- Incorrect "Admission", "From," or "Through" date
- Incorrect beneficiary
- Is the payment penalty for a late NOA only on the initial 30-day period?
Answer: The payment penalty may apply to more than one period of care claim, depending on when the NOA is submitted. For example, if an NOA is received on day 40, the penalty will be applied to the initial period of care, and the second 30-day period. Exception requests, if applicable, are required on each period of care claim for which the NOA was late.
- If an NOA is not submitted at all, would the home health agency forfeit payment for the entire admission period, not just for 30 days as currently under the No Pay RAP?
Answer: Keep in mind that billing the NOA is a requirement for billing period of care claims, including LUPA claims. If an HHA neglects to bill the NOA, they have not met the requirement to bill any period of care claims. If the NOA is late, there will be a penalty applied to the initial claim in the admission period (and any following period, depending on the NOA receipt date), so it is advisable to submit the NOA within 5 calendar days of the start of care/initial visit, or as soon as possible after that timeframe, to reduce the amount of financial penalty. For LUPAs, no per-visit payments shall be made for visits that occurred on days that fall within the period of care prior to the submission of the NOA.
- Is there any guidance about billing for an exception to the late NOA penalty when we find out the patient had switched from MA plan to Original Medicare after the fact?
Answer: Yes. Since Original Medicare begins as of the first visit after the MA enrollment period ends, the NOA will need to be billed with the date of the first visit under Original Medicare, and all visits from that point are billed to Original Medicare.
In cases where the HHA did not find out the patient had disenrolled from their MA plan until well after the fact, or until the HHA gets a denial from the MA plan, the NOA should be submitted as soon as possible. The corresponding period of care claim is then billed with the KX modifier and the following statement in Remarks: “CR12256 disenroll MA XX/XX/XXXX.” The XX/XX/XXXX date should be the day the MA coverage ended, e.g., “CR12256 disenroll MA 12/31/2021.”
- What should an HHA do if they have a late RAP submission reject because the period “From” date is between 12/1/2021 and 12/31/2021 and the calculated 30-day end date falls within another agency’s January 2022 HH admission date (opened by an NOA)?
Answer: This scenario would be caused by a late RAP submission for a period beginning in December 2021, that was received after a January 2022 NOA was already received and processed for another agency. The HHA with the late RAP should contact the other agency and request they cancel and resubmit their NOA with condition code 47. An NOA timeliness exception applies to the resubmitted NOA in this case. A RAP timeliness exception may apply if it meets one of the exception reasons for late RAPs.
Period of Care Claim Billing
Will we continue to bill period of care claims on a 30-day period basis?
Answer: Yes. Billing the 30-day period of care claims under PDGM is not changing. HHAs will continue to be required to submit a 30-day period of care claim when there are services provided for that period.
What if a patient transfers to inpatient facility care in the first 30-day period and we are expecting the patient to come back to home health but the patient doesn’t return? We realize this in the 3rd 30-day period. What do we need to do with the new NOA implementation?
Answer: Once the HHA is aware of the discharge situation, they should adjust their last claim to replace patient status 30 with the appropriate discharge status code. Please see CR12424 for further instruction on reporting discharges and transfers during a period where no visits were provided. Claim change reason code, CC E0 (Change in Patient Status), should be used on the adjustment.
What if an HHA provides care in a 30-day period of care and then the beneficiary is discharged deceased in the next 30-day period of care, but no billable visits were provided in the next 30-day period?
Answer: If the cause of the discharge in the next 30-day period is the beneficiary’s death, the HHA should not report patient status 20 (expired) on the claim. This would result in an incorrect date of death being recorded in Medicare systems and potentially affect claims from other providers. The HHA should report patient status 01 on the claim for the last 30-day period in which visits occurred. Use adjustment CC E0 for the adjustment.
How will periods of care with “no visits expected” work in 2022 and beyond? In 2021, HHAs submit the RAP to open the period and that would show the beneficiary was under HH.
Answer: Since the NOA creates an admission period, there is no need to submit anything for the periods of care in which no services are expected. If, at the end of the 30-day period, no visits were provided there would be no claim for that period.
When a patient is discharged from a home health period and is readmitted, does the original final claim with discharge information need to be submitted prior to the NOA for the new admission?
Answer: You are not required to submit the discharge claim from the previous period when readmitting to the same home health agency. When the HHA submitting a new NOA is the same provider that has the open admission period, the system will recognize that and not RTP or reject the new NOA. The HHA can submit the NOA before the prior claim.
Is an NOA required for Home Health Demand Denials (TOB 329 with condition code 20) and/or Home Health No-Payment Billing (TOB 320 with condition code 21)?
Answer: Yes, an NOA is required in both of these situations for dates of service on and after 1/1/2022.
- There are chapters that include billing instructions for specific disciplines. These are within certain Publications in the IOM. Information on billing as it specifically relates to Home Health is in CMS IOM Publication100-04, Medicare Claims Processing Manual, Chapter 10, “Home Health Agency Billing”
- MLN Matters® Article: MM12256: Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA)
- MLN Matters® Article: MM12424: Home Health Notices of Admission – Additional Manual Instructions