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HIPAA: Home Health Code Conversion

HIPAA-mandated changes to the billing requirements for the Home Health Agencies (HHA) code conversion are effective for dates of service on or after June 1, 2016. These changes include use of the revenue codes and HCPCS Level II national codes. The following FAQs provide an overview of the conversion to revenue codes and HCPCS Level II codes, and point to resources for additional information.

  1. What does the conversion from HCPCS Level III local codes to revenue codes and HCPCS Level II codes mean?

    The conversion means that any provider submitting HCPCS Level III local codes for home health services will be required to submit claims using the specified revenue codes and HCPCS Level II codes for dates of service on or after June 1, 2016.

  2. What is HIPAA and how does it relate to HCPCS Level II codes?

    HIPAA is the acronym for the Health Insurance Portability and Accountability Act, passed by Congress in 1996. HIPAA does the following:

    • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
    • Reduces health care fraud and abuse;
    • Mandates industry-wide standards for health care information on electronic billing and other processes; and
    • Requires the protection and confidential handling of protected health information.
  3. Why is the transition happening?

    California has historically used thousands of HCPCS Level III or local (also known as interim) codes for billing and reimbursement of services and supplies. National codes, such as Current Procedural Terminology (CPT) codes and Healthcare Common Procedural Coding System (HCPCS) codes, are typically more general compared to local codes. Using CPT, revenue and HCPCS Level II codes will:

    • Simplify processes and decrease the costs associated with payment for health care services;
    • Improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (i.e., medical practices, hospitals and health care plans);
    • Provide standardization and consistency in medical service coding; and
    • Characterize a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.
  4. When will this transition take place?

    The effective date of service for this conversion from HCPCS Level III local codes to revenue codes and HCPCS Level II codes is June 1, 2016.

  5. What is a revenue code and why is it used?

    Revenue codes are codes that identify specific accommodations, ancillary services, unique billing calculations or arrangements. The revenue codes permit facilities to bill for services rendered and use of facilities—there are no procedure codes for many of these. HIPAA requires that payers (including Medi-Cal) accept revenue codes and utilize them in claim adjudication.

  6. Who is affected by the conversion?

    Any provider submitting home health claims for services with dates of service on or after June 1, 2016, or Treatment Authorization Requests (TARs) with requested dates of service on or after June, 1, 2016, will be required to use revenue codes and HCPCS Level II codes identified in the Home Health conversion table in the Correction: Home Health Conversion and Billing Instructions article of a previous Medi-Cal Update.

  7. How will the conversion impact my TARs on or after the effective date?

    Effective for dates of service on or after June 1, 2016, TARs using HCPCS Level III local home health codes will be no longer permitted. All TARs submitted with dates of service on or after June 1, 2016, will require the HCPCS Level II national home health service code.

  8. Will TARs need to be submitted with the HCPCS Level II national home health service code on or after the effective date?

    All home health services billing HCPCS Level II national home health service codes require an approved TAR on or after June 1, 2016.

  9. What happens if a revenue code is not included on the claim?

    Home health claims submitted without a revenue code on or after June 1, 2016, will be denied.

  10. How will the conversion impact claims billed with dates of service on or after the effective date?

    Effective for dates of service on or after June 1, 2016, all claims billed with HCPCS Level III home health codes will be no longer eligible for reimbursement.

    All TARs with home health local codes and a combination of HCPCS Level III and HCPCS Level II procedure codes, regardless of status (approved, retroactive or deferred), will be end-dated for dates of service on or after June 1, 2016. Providers are encouraged to submit new TARs or electronic TARs (eTARs) with the appropriate HCPCS Level II national code(s) prior to June 1, 2016.

    For additional information, providers should refer to the Correction: Home Health Conversion and Billing Instructions article of a previous Medi-Cal Update.

  11. If I submit a new TAR on or after June 1, 2016, which HCPCS Level codes do I use Level II or Level III?

    Providers submitting new TARs for service periods on or after June 1, 2016, should no longer use the discontinued HCPCS Level III codes for home health services. New TARs must use the HCPCS Level II national code for service periods on or after June, 1, 2016.

  12. What billing policy changes should I expect to see with HCPCS Level II codes on or after June 1, 2016?

    For dates of service on or after June 1, 2016, home health billing policy will be updated to accommodate the following HCPCS Level II codes. The HCPCS codes are shown with their corresponding revenue code; however only the HCPCS code will be used for TAR purposes.

    Revenue Code HCPCS Level II Code or CPT Code Authorization
    0270 A9999 TAR is required
    0421 G0151 TAR is required
    0431 G0152 TAR is required
    0441 G0153 TAR is required
    0551 G0154 TAR is required
    0561 G0155 TAR is required
    0571 G0156 TAR is required
    0580 99501 Authorization not required
    0580 99502 Authorization not required
    0583 G0162 Authorization not required
    0589 G0162 Authorization not required
    0589 99600 TAR is required
  13. Will the home health code conversion impact the current home health rates?

    No. There will be no change in rates for home health services in relation to the code conversion.

  14. Will CA-MMIS accept claims submitted with HCPCS Level II national home health service codes and revenue codes prior to the effective date?

    No. Claims submitted with revenue codes in the revenue code field and a HCPCS Level II national home health service code in the procedure code field for dates of service prior to June 1, 2016, will not be reimbursable.

  15. Where do I find more information related to the home health code conversion from Level III HCPCS local codes to Level II HCPCS codes?

    Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, available 8 a.m. to 5 p.m., Monday through Friday.
    For additional information, providers may:

    • Routinely check the Medi-Cal Update provider bulletins
    • Routinely check the Provider Training Calendar on the Medi-Cal Learning Portal for announcement of upcoming Home Health webinars
  16. Frequency limits on the new HHA Revenue/HCPCS Level II Code combination are listed below:

    Revenue Code HCPCS Level II Code or CPT-4 Code Frequency Limitation
    0270 A9999 N/A
    0421 G0151 N/A
    0431 G0152 N/A
    0441 G0153 N/A
    0551 G0154 N/A
    0561 G0155 N/A
    0571 G0156 N/A
    0580 99501 One paid claim every six months
    0580 99502 One paid claim every six months
    0583 G0162 Max of 4 units (15 minute increments of paid claim[s])
    0589 G0162 Max of 4 units (15 minute increments of paid claim[s])
    0589 99600 N/A