Home Health Denials for Incorrect Billing of 'Attending/Other' Names and NPIs

This article was previously published on the Palmetto GBA website due to an increase in Comprehensive Error Rate Testing (CERT) contractor denials related to improper billing of home health claims. As a reminder, this article is being republished to assist providers in understanding how to correctly bill home health claims.

Effective for billing periods with dates of service on or after March 1, 2020, Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) may certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care in addition to physicians, notwithstanding each state’s individual scope of practice. Therefore, these nonphysician practitioners (NPPs) information may be entered on the claim instead of a physician, as detailed below and if applicable. 

Please ensure that the claim (UB-04) is completed with the correct “Attending” and “Other” physician or NPP name/National Provider Identifier (NPI) as follows:

• The “Attending” provider name/NPI entered on the claim should match the physician or NPP name/NPI who signed the home health plan of care. If the physician or NPP name/NPI on the home health plan of care document does not match the claim, the previously paid claim will be adjusted to deny in full.
   
• The “Other” provider name/NPI entered on the claim should match the physician or NPP name/NPI who signed the certification/recertification for eligibility. If the physician or NPP name/NPI on the home health certification/recertification document does not match the claim, the previously paid claim will be adjusted to deny in full.
   
• If the physician or NPP who signed the plan of care is the same as the physician who signed the certification/recertification, then only the “Attending” provider name/NPI is required to be entered on the claim

Please refer to the Centers of Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication, Number 100-04 (Medicare Claims Processing Manual), Chapter 10, Section 40.2 (PDF, 825 KB) for further information about the above requirement.