Like many people who called into CMS’s COVID-19 office hours April 6—the last in a series that have helped providers decipher pandemic coding and billing rules—a caller from a hospital system with a home health agency (HHA) asked about the mechanics of vaccine billing. How should the HHA bill for the vaccine when it’s administered to home health patients during the 60-day episode of care, and could the nurse also vaccinate caregivers while in the patient’s home?

According to the CMS officials on the call, Medicare pays separately for the vaccine administration. “Typically that would not be considered part of the episode,” a CMS official said. HHAs should use bill type 34x if patients have an active plan of care, and the nurses are permitted to vaccinate caregivers who are Medicare beneficiaries.

That’s an example of new revenue and compliance terrain for HHAs this year. Another biggie: For the first time, no HHAs are receiving reimbursement for requests for anticipated payments (RAPs), the upfront Medicare partial payments that have been an important cushion because home health care was paid on a 60-day episode of care until last year, when CMS shifted to payments every 30 days under the Patient-Driven Groupings Model (PDGM), the Medicare home health prospective payment system (PPS) implemented in 2020. But HHAs still must electronically file the RAP within five days of the start of care—and there are penalties for dropping the ball. CMS stopped forking over the money in part because of concerns they were a breeding ground for fraud.

“We knew this day was coming,” said Regina Alexander, director of IRO Services at BerryDunn. “It’s a no-pay RAP,” with penalties for being late. “It boggles the mind.”