Home Health Billing

Reporting Home Health Periods with No Skilled Visits

Eligibility for the Medicare HH benefit requires that the beneficiary have a need for intermittent skilled nursing care, PT, SLP, or a continuing need for OT. The need for skilled care makes the patient eligible for other covered HH services (dependent services), i.e., HH aide visits, medical social services, medical supplies, and DME. These services must be billed along with skilled services on the HH claim.

Impact to HHAs

CMS recognizes that there may be circumstances in which the HHA is not able to deliver the skilled services planned for the period of care, e.g., an unexpected inpatient admission. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3 states:

Since the need for "intermittent" skilled nursing care makes the patient eligible for other covered home health services, the Medicare contractor should evaluate each claim involving skilled nursing services furnished less frequently than once every 60 days. In such cases, payment should be made only if documentation justifies a recurring need for reasonable, necessary, and medically predictable skilled nursing services.

Condition code 54 indicates the HHA provided no skilled services during the billing period, but the HHA has documentation on file of an allowable circumstance. HHAs should include condition code 54 on HH final episode claims billed with no skilled services in conjunction with qualifying dependent services. Claims without skilled visits that are submitted without condition code 54 will be returned for correction.

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Revised 5/23/2024