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Home Health Billing Services

Home health billing operates under the Patient-Driven Groupings Model (PDGM) with OASIS-based case-mix classification, 30-day billing periods, LUPA thresholds, and a value-based purchasing program that directly impacts reimbursement.

AAPC Certified
HIPAA Compliant
All 50 States
Starting at 2.49%
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HIPAA Compliant
AAPC Certified
4.9/5 Rating
300+ Practices
PDGMPayment Model
OASISAssessment
30-DayBilling Periods
LUPAThresholds

Why Home Health Billing Requires Specialty Expertise

Home health billing under PDGM classifies patients into 432 case-mix groups based on admission source, timing, clinical grouping, functional level, and comorbidity. OASIS assessment accuracy directly determines reimbursement. The shift from 60-day to 30-day billing periods doubled claim volume while LUPA (Low Utilization Payment Adjustment) thresholds penalize agencies that fail to deliver the minimum number of visits per period.

Common Home Health CPT Codes

Our coders handle these home health codes daily. This is not an exhaustive list.

Code
Description
PDGM
Payment Model
OASIS
Assessment
30-Day
Billing Periods
LUPA
Thresholds

Home Health Billing Challenges We Solve

Common billing problems in home health and how our team handles them.

OASIS Assessment Accuracy

OASIS-E assessment items drive case-mix classification — inaccurate scoring directly reduces reimbursement by shifting patients to lower-paying groups.

LUPA Threshold Management

Each 30-day period has a LUPA visit threshold (typically 2-6 visits). Falling below it reduces payment from full episode to per-visit rates.

30-Day Period Billing

Doubled claim volume versus the former 60-day model creates more opportunities for timing and sequencing errors.

RAP Elimination Transition

The elimination of Request for Anticipated Payment requires agencies to manage cash flow without upfront partial payments.

Common Home Health Denial Reasons

We prevent these before submission and appeal aggressively when they occur.

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OASIS-E assessment items drive case-mix classification — inaccurate scoring directly reduces reimbursement by shifting patients to lower-paying groups
!
Each 30-day period has a LUPA visit threshold (typically 2-6 visits)
!
Doubled claim volume versus the former 60-day model creates more opportunities for timing and sequencing errors
!
The elimination of Request for Anticipated Payment requires agencies to manage cash flow without upfront partial payments

Revenue Opportunities Most Home Health Practices Miss

OASIS accuracy is the single largest revenue lever in home health billing. Agencies with dedicated OASIS review processes capture 8-15% more revenue per episode compared to agencies that submit assessments without clinical-coding review. For an agency billing 500 episodes per month at an average of $2,800 per episode, a 10% improvement in case-mix accuracy adds $140,000 per month — $1,680,000 annually. LUPA avoidance is the second major opportunity. LUPA periods reimburse at per-visit rates ($55-75 per visit) instead of the full 30-day payment ($1,400-3,500). Agencies averaging even 5% LUPA rates on 500 monthly periods lose $250,000+ annually compared to agencies managing LUPA thresholds proactively.

Payer-Specific Home Health Billing Tips

Medicare is the dominant payer for home health, reimbursing under PDGM through Medicare Administrative Contractors (MACs). Each MAC (CGS, Palmetto, NGS, WPS) has slightly different ADR patterns and documentation preferences. Understanding your MAC's audit focus areas reduces ADR response burden. Medicare Advantage plans are increasingly covering home health but use their own authorization and payment structures outside PDGM. UnitedHealthcare Medicare Advantage, Humana, and Aetna Medicare Advantage each have different visit authorization processes and fee schedules that typically reimburse 10-25% below traditional Medicare rates. Medicaid home health coverage varies by state with different service definitions, visit limits, and prior authorization requirements. We track MAC-specific audit patterns and MA plan requirements.

Home Health Billing Best Practices

Practical tips from our coding team to maximize reimbursement and minimize denials.

1
Submit the Notice of Admission (NOA) within 5 calendar days of the start of care — late NOA submission reduces payment by a percentage for each day past the deadline.
2
Monitor LUPA thresholds for every 30-day period. If a patient is one visit short of the threshold, coordinate with clinical staff to schedule the visit before the period closes. The difference between LUPA and full-episode payment averages $1,500-2,500.
3
Review OASIS functional items (GG scores) with clinicians before submission. Functional impairment level is a primary PDGM driver, and underscoring shifts patients to lower-paying groups.
4
Comorbidity adjustment requires secondary diagnoses that align with specific ICD-10 interaction categories. Ensure all active comorbidities are captured on the OASIS to maximize the comorbidity adjustment.
5
For early and late 30-day periods within the same certification, verify the admission source and timing variables are coded correctly — errors in these fields change the payment group assignment.

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What We Handle for Home Health Practices

PDGM case-mix classification and optimization
OASIS assessment review and accuracy auditing
30-day period claim submission and tracking
LUPA threshold monitoring and visit scheduling coordination
Home health value-based purchasing compliance
NOA (Notice of Admission) submission within 5 days
Recertification and discharge billing
ADR (Additional Documentation Request) response management

Why Choose Go Medical Billing for Home Health

Home health billing under PDGM demands clinical-coding integration that general billers lack. Our team reviews OASIS assessments for coding accuracy, monitors LUPA thresholds in real time, and optimizes case-mix classification to maximize appropriate reimbursement.

We serve home health practices in all 50 states, starting at 2.49% of collections. Our credentialing team handles payer enrollment, and our A/R specialists recover aging claims.

Home Health Billing by State

We handle home health billing in all 50 states. Select your state for location-specific payer details, Medicaid rules, and Medicare MAC policies.

CaliforniaTexasFloridaNew YorkPennsylvaniaIllinoisOhioGeorgiaNorth CarolinaMichiganNew JerseyVirginiaMassachusettsArizonaTennesseeMarylandIndianaMissouriWisconsinColorado
View all 50 states

Related Resources

Medical Billing & Coding ServicesA/R Recovery ServicesCredentialing & ContractingCase Studies & ResultsPricing

Frequently Asked Questions

Yes. We perform a clinical-coding review of every OASIS submission to ensure functional scores, clinical groupings, and comorbidity captures are accurate before the claim is generated.
We monitor visit counts against LUPA thresholds for every active 30-day period and alert clinical coordinators when a period is at risk of falling below the threshold, giving them time to schedule additional visits.

Get Expert Home Health Billing Support

Stop losing revenue to home health coding errors and preventable denials. Call 888-701-6090 for a free billing assessment.

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