- Avoiding Reason Code 38200
- Correcting Reason Code 37253
- Incarcerated or Unlawfully Present in the U.S. Claim Rejections (U538H, U538Q)
- Billing the Home Health Period of Care Claim - PDGM
- Disposable Negative Pressure Wound Therapy Services Under Home Health
- Home Health Prospective Payment System Booklet
- Home Health Third Party Liability Demand Billing
- Home Health Demand Billing
- Notice of Admission Questions and Answers
- Billing the Home Health Notice of Admission Electronically
- Billing the Home Health Notice of Admission via DDE
- Home Health Transfers
- Home Health Agency Transfer and Dispute Protocol
- Late Notice of Admission - The Exception Process
- Reporting Home Health Periods with No Skilled Visits
- Telehealth Home Health Services: New G-Codes
- Reporting Site of Service Codes for Home Health Care
- PDGM Resources
- Billing G-Codes for Therapy and Skilled Nursing Services
- Correcting and Avoiding Reason Code 38157: Duplicate Request for Anticipated Payment
- Correcting and Avoiding Reason Code C7080: Inpatient Overlap
- Completing the Advance Beneficiary Notice for Home Health Agency Demand Claims
- The Medicare Home Infusion Therapy Benefit and Home Health Agencies
- Home Health Therapy Billing
- Home Health Billing When a New MBI is Assigned
- 30-Day Home Health Therapy Reassessment Schedule
Home Health Therapy Billing
Table of Contents
- Home Health Therapy Billing
- 32X TOB: Billing Therapy Under a Home Health Plan of Care
- 34X TOB: Billing Therapy Under a Therapy POC (patient not under HH POC)
- Related Content
Home Health Therapy Billing
This billing guide will assist HHAs in determining the proper information to submit on claims for PT, OT or SLP services provided under a home health POC on a 32X TOB or a therapy plan of care (when not under a home health POC) on a 34X TOB. Therapy services billed under the 34X TOB are paid under the MPFS.
The codes listed within this billing guide are only those most frequently applicable to home health therapy claims. For a complete list of codes, see the NUBC manual. The NUBC maintains the UB-04 data element specifications and revenue code tables. They may be contacted for subscription to the UB-04 on the NUBC website.
32X TOB: Billing Therapy Under a Home Health Plan of Care
Discipline Revenue Codes (UB-04 FLs 42-43)
| Code | Description |
|---|---|
| 042X | Physical Therapy – identifies services by physical therapists. |
| 043X | Occupational Therapy – identifies services by occupational therapists. |
| 044X | Speech-Language Pathology – identifies services by speech language pathologists |
Discipline HCPCS Codes (UB-04 FL 44)
| Code | Description |
|---|---|
| G0151 | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes |
| G0152 | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes |
| G0153 | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes |
| G0157 | Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes |
| G0158 | Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes |
| G0159 | Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes |
| G0160 | Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes |
| G0161 | Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes |
Service Units (UB-04 FL 46)
For HCPCs which have descriptions with time specifications, use the following chart to determine the number of units to report for the total amount of time.
| Units | Number of Minutes |
|---|---|
| 1 | ≥ 8 minutes through 22 minutes |
| 2 | ≥ 23 minutes through 37 minutes |
| 3 | ≥ 38 minutes through 52 minutes |
| 4 | ≥ 53 minutes through 67 minutes |
| 5 | ≥ 68 minutes through 82 minutes |
| 6 | ≥ 83 minutes through 97 minutes |
| 7 | ≥ 98 minutes through 112 minutes |
| 8 | ≥ 113 minutes through 127 minutes |
34X TOB: Billing Therapy Under a Therapy POC (patient not under HH POC)
Occurrence Codes and Dates (UB-04 FLs 31-34)
| Code | Description |
|---|---|
| 17 | Date the occupational therapy plan was either established or last reviewed |
| 29 | Date the physical therapy plan was either established or last reviewed |
| 30 | Date the speech-language pathology therapy plan was either established or last reviewed |
Discipline Revenue Codes (UB-04 FLs 42-43)
| Code | Description |
|---|---|
| 042X | Physical Therapy – identifies services by physical therapists. |
| 043X | Occupational Therapy – identifies services by occupational therapists. |
| 044X | Speech-Language Pathology – identifies services by speech language pathologists |
Discipline HCPCS Codes(UB-04 FL 44)
Applicable outpatient rehabilitation HCPCS codes reimbursed under MPFS can be found under the Therapy Services portal on the CMS website.
HCPCS Modifiers (UB-04 FL 44)
| Code | Description |
|---|---|
| GN | Services delivered under an outpatient speech-language pathology plan of care |
| GO | Services delivered under an outpatient occupational therapy plan of care |
| GP | Services delivered under an outpatient physical therapy plan of care |
| KX* | Beneficiary has exceeded the therapy cap; however, the therapist attests that the services are reasonable and necessary and there is documentation of medical necessity in the beneficiary’s medical record |
| *Services billed on a 34X bill type for those beneficiaries who are not homebound or are not under a home health POC are subject to the therapy cap. For claims over the cap, therapy service providers may submit claims with the KX modifier, when an exception is appropriate, for services furnished through 12/31/2017. | |
Service Units (UB-04 FL 46)
When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units. For HCPCs which have descriptions with time specifications, use the following chart to determine the number of units to report for the total amount of time.
| Units | Number of Minutes |
|---|---|
| 1 | ≥ 8 minutes through 22 minutes |
| 2 | ≥ 23 minutes through 37 minutes |
| 3 | ≥ 38 minutes through 52 minutes |
| 4 | ≥ 53 minutes through 67 minutes |
| 5 | ≥ 68 minutes through 82 minutes |
| 6 | ≥ 83 minutes through 97 minutes |
| 7 | ≥ 98 minutes through 112 minutes |
| 8 | ≥ 113 minutes through 127 minutes |
Functional Reporting (UB-04 FL 44)
Functional reporting requires billing of certain G-codes that are used to report a beneficiary’s functional limitation being treated and whether the report is on the patient’s current status, projected goal status or discharge status.
Functional reporting required for certain DOS:
- At the outset of a therapy episode of care, i.e., on the claim for the DOS of the initial therapy service;
- At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
- On the DOS when an evaluative or re-evaluative procedure is furnished and billed;
- At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., this may occur when the beneficiary discontinues therapy unexpectedly.
Each reported G-code must contain the following revenue line information:
- Functional severity modifier
- Therapy modifier indicating the related discipline (i.e., GO, GN or GP)
- Date of the related therapy service
- Nominal charge, e.g., a penny
A complete list of the Functional Reporting G-codes and Severity/Complexity Modifiers can be found on the Functional Reporting section of the CMS website.
Related Content
- Information on billing as it specifically relates to therapy services can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5
- Information on billing as it specifically relates to home health claims and notices can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10
- General billing instructions for completing the UB-04 can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25
Reviewed 5/20/2024