CMS has issued a new condition code 54 “4 “No skilled HH visits in billing period” that will be effective July 1, 2016.
Currently, any home health claim WITHOUT a skilled visit is automatically returned to the provider. This will not change after July 1, 2016 on any claim that is the FIRST episode in a sequence of episodes or the only episode of care.
However, after July 1st, 2016 a home health agency can use code 54 for any SUBSEQUENT episode that may not include a skilled visit if there are factors that prevent the home health agency from providing a skilled visit, for example, a unforeseen inpatient admission. The home health will need to provide supporting documentation when using condition code 54.
Claims that don’t have condition code 54 and don’t include a skilled visit in the episode will be returned to the HHA. The HHA can add an overlooked skilled visit, submit the claim as non-covered, or add the condition code.