COVID-19 Preventing Your Medicare Home Health Agency from Reporting Skilled Visits on the Claim – Maybe Your Agency Qualifies for Condition Code 54

Sharon Hamilton MS, RN, CFDS
Clinical Consultant, Briggs Healthcare

With a greater number of senior citizens aging in place it seems counter intuitive that the frequency of Medicare home-based visits is down. But agencies are reporting a sharp drop in visits due to factors like the moratorium of elective surgeries, family members being home to care for their elderly loved ones and seniors turning caregivers away over the fear of contracting the coronavirus. Consequently, frequency reduction means a reduction in revenue at a time when the cost of doing business is going up. For example; agencies are struggling to purchase greater quantities of personal protective equipment.

If your agency is experiencing this situation there may be some financial relief.  In times such as these, when circumstances prevent the home health agency (HHA) from delivering the skilled services planned for an episode, if the claim is for an episode where there were no skilled visits in the billing period, but a policy exception that allows billing for covered services is documented at the agency, then the agency would enter condition code 54. According to CMS, determining whether payment is allowable requires development of the claim. Section 40.1.3 in Chapter 7 of the Medicare Benefits Policy Manual, Pub. 100-02 states that: “Since the need for “intermittent” skilled nursing care makes the patient eligible for other covered home health services, the intermediary 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.”

Medicare requested the National Uniform Billing Committee to create a new code that would allow the HH agency to indicate upon submission that such documentation exists. Condition code 54 became effective on July 1, 2016 and is defined “No skilled HH visits in billing period. Policy exception documented at the HHA.” Submission of this code will streamline claims processing for both the payer and provider. Claims without skilled visits that are submitted without the new condition code will be returned to the provider. This will allow the HHA to either:

  • Add any accidentally omitted skilled services to the claim
  • Submit the claim as non-covered, if appropriate or
  • Append the new condition code.

These actions will prevent unnecessary reviews and denials for the HHA and allow Medicare to better target medical review resources. Requirements 1 and 2 below, implement the new condition code 54.

There are additional requirements that address unintended consequences. To learn more and access the source of this information click on the link below for Transmittal 3553.