Home Health — PDGM Grouping, LUPA Prevention

Proven Results

• 39% Average Revenue Increase
• 94.6% Clean Claim Rate
• 50% Reduction in Denials
• 22 Days Faster Payment Collection

Common Billing Challenges

OASIS Documentation Complexity

Home health agencies struggle with accurate OASIS assessments that directly impact payment calculations and quality reporting.

RAP/NOA Timing Requirements

Request for Anticipated Payment and Notice of Admission submissions have strict timing requirements that are difficult to manage.

Episode Payment Calculations

PDGM episode-based payment model requires complex calculations and proper timing of claims for optimal reimbursement.

Medicare Compliance Audits

Home health agencies face frequent audits requiring extensive documentation and compliance with changing regulations.

Therapy Threshold Management

Managing therapy visit thresholds and proper documentation for skilled nursing and therapy services is complex.

HIS-ICD Coding Alignment

Aligning diagnosis codes with Home Health Groupings Model requires specialized expertise.

Our Solutions

OASIS-Certified Billing Team

Our specialized home health billing team includes OASIS-certified coders who understand the intricacies of home health documentation.

• Accurate OASIS assessments for optimal payment
• Proper case-mix weight calculations
• Quality reporting optimization
• Reduced OASIS deficiency rates

PDGM Payment Optimization

Expert management of Patient-Driven Groupings Model to maximize episode payments and ensure proper timing.

• Optimized 30-day episode payments
• Proper LUPA threshold management
• Accurate functional impairment coding
• Comorbidity adjustment maximization

RAP/NOA Management System

Automated tracking and submission of Requests for Anticipated Payment and Notice of Admission for timely reimbursement.

• On-time RAP submissions for cash flow
• Proper NOA documentation
• Automated deadline tracking
• Reduced submission errors

Compliance & Audit Support

Comprehensive audit preparation and compliance monitoring to protect against recoupments and ensure regulatory adherence.

• Audit-ready documentation review
• Medical necessity validation
• Regulatory compliance monitoring
• Appeal support for denials

Specialized Services

Skilled Nursing Billing

Expert billing for skilled nursing visits with proper documentation of medical necessity and care progression.

• Wound care billing
• IV therapy management
• Disease education
• Medication management

Therapy Services Billing

Specialized billing for PT, OT, and speech therapy with threshold management and functional outcome tracking.

• Physical therapy billing
• Occupational therapy
• Speech-language pathology
• Therapy threshold tracking

Hospice Care Billing

Compassionate billing for hospice services including routine care, continuous care, and respite care.

• Routine home care
• Continuous home care
• Respite care billing
• General inpatient care

PDGM Episode Management

Complete management of episode-based billing under the Patient-Driven Groupings Model.

• 30-day episode billing
• LUPA management
• Case-mix calculations
• Comorbidity coding

Common CPT Codes Reference

Key codes include G0179 (Physician re-certification of patient eligibility for Medica), G0180 (Physician certification for Medicare home health services), G0181 (Physician supervision of Medicare-covered home health servic), G0182 (Physician supervision of Medicare-covered hospice services, ), 99347 (Home visit, established patient, straightforward MDM), 99349 (Home visit, established patient, moderate complexity MDM), 99350 (Home visit, established patient, high complexity MDM), 99341 (Home visit, new patient, low complexity), 99343 (Home visit, new patient, moderate complexity), 99344 (Home visit, new patient, high complexity). Proper code selection requires understanding of bundling rules, NCCI edits, and modifier usage.

Expert Billing Insights

PDGM: Patient-Driven Groupings Model — How Home Health Is Paid

The Patient-Driven Groupings Model (PDGM), implemented January 2020, fundamentally changed Medicare home health billing. Under PDGM, home health episodes are 30-day periods (previously 60-day) grouped into payment categories based on clinical grouping, functional impairment level, admission source (community vs. institutional), and timing (early vs. late in the episode). There are 432 possible payment groups. Understanding PDGM is essential for home health agencies to predict expected payment and optimize documentation to ensure appropriate grouping.

• PDGM payment period: 30 days (not 60) — two 30-day periods per traditional 60-day episode
• Clinical grouping: OASIS assessment drives grouping — accurate coding of primary and secondary diagnoses critical
• Functional grouping: OASIS functional scores (mobility, ADLs) affect payment — document accurately
• LUPA (Low-Utilization Payment Adjustment): fewer than threshold visits triggers lower payment

Face-to-Face Encounter Requirement and Physician Certification

Medicare home health requires a face-to-face encounter with a qualifying practitioner (physician, NP, PA, CNS, or certified nurse midwife) within 90 days before or 30 days after the start of home health care. This encounter must be documented specifically to certify homebound status and medical necessity. The certifying physician must also sign the Home Health Plan of Care (CMS-485) within 30 days of start of care. Failure to meet these requirements results in retroactive denial of the entire episode.

• Face-to-face window: within 90 days before or 30 days after start of home health
• Documentation must include: homebound status, medical condition, and need for skilled services
• CMS-485 (Plan of Care): physician must sign within 30 days of SOC — track diligently
• Physician recertification (G0179): every 60 days — face-to-face not required for recertification

OASIS Accuracy and Its Impact on Payment and Quality Star Ratings

The OASIS (Outcome and Assessment Information Set) is the cornerstone of home health documentation and payment. OASIS items drive PDGM clinical grouping, functional impairment level, and CMS's Home Health Quality Reporting Program (HHQRP) star ratings. Inaccurate OASIS coding — either upcoding or undercoding — affects payment integrity and quality scores. Comprehensive OASIS training for clinicians is essential. ICD-10 coding on OASIS must reflect the primary reason for home health (not just the most acute condition).

• OASIS coding: primary diagnosis drives PDGM clinical grouping — select appropriate ICD-10
• Functional items (M1800-series): grade patient's actual functional status — do not estimate
• OASIS item M1033 (risk of hospitalization): affects quality measure reporting
• Start of Care OASIS due within 5 days of SOC — late OASIS affects care period payment

Payer-Specific Billing Tips

Medicare Part A (Primary Home Health Payer)

• Medicare home health: Part A benefit — no copay for eligible beneficiaries
• Homebound definition: leaving home requires considerable effort; must be documented clearly
• Skilled services required: skilled nursing, PT, OT, SLP, or social work must be needed
• PDGM 30-day periods: bill each 30-day period separately with updated OASIS if conditions change

Medicaid

• Medicaid home health is optional state benefit — coverage varies widely
• Medicaid HCBS waiver programs cover personal care and homemaker services — not billed as home health
• Dual-eligible patients: Medicare pays for skilled home health; Medicaid may wrap for non-skilled services
• Prior authorization required for most Medicaid home health episodes

Commercial Payers

• Commercial home health: typically covered with physician order and prior auth
• Post-surgical home health: often covered for limited episodes after hospitalization
• Visit limits: most commercial plans cap home health visits (20–60 per year) — track per patient
• Home health aide services: most commercial plans do not cover unless skilled nursing also required

Home Health Quality and Compliance

• HHCAHPS surveys: patient satisfaction affects star ratings and value-based purchasing payments
• Value-based purchasing (HHVBP): 5% of Medicare payments at risk based on quality performance
• RAC audits target home health: face-to-face documentation and homebound status most audited
• Physician billing for home health oversight (G0181): frequently missed revenue stream

Related Billing Resources

• Geriatrics Billing
• Physical Therapy Billing
• Pulmonology Billing
• Compliance & HIPAA Audits
• Eligibility Verification
• CPT Codes Reference Guide
• ICD-10 Codes Reference

Key Services

• home health billing
• home healthcare billing
• visiting nurse billing
• home care billing
• OASIS billing