Home Health Billing Under PDGM: 30-Day Periods, the Notice of Admission, OASIS and LUPA Explained

The structure of a home health episode

A certification period is sixty days; payment is made in two thirty-day periods within it. Each period is paid a case-mix adjusted amount based on a HIPPS code generated from the OASIS assessment and the claim. Recertification continues the episode in further sixty-day certifications, each with two payment periods.

Before the first claim: eligibility and orders

• Homebound status and the need for intermittent skilled nursing or therapy, documented by the certifying physician or allowed practitioner.
• Face-to-face encounter related to the primary reason for home health, within ninety days before or thirty days after the start of care, documented in the certifying practitioner’s record.
• Plan of care signed and dated by the certifying practitioner. Orders must be signed before the final claim is submitted.
• Eligibility check in the Medicare system for an open home health episode with another agency, Medicare Advantage enrollment and hospice election.

The Notice of Admission

The NOA (type of bill 32A) replaced the Request for Anticipated Payment. It must be submitted and accepted within five calendar days of the start of care. For every day it is late, Medicare reduces payment for the period by one-thirtieth of the period amount, and a very late NOA can wipe out the period entirely. Submit the NOA the day of the start-of-care visit; do not wait for the OASIS. Exceptions exist for circumstances beyond the agency’s control and must be requested on the claim.

OASIS and the HIPPS code

The start-of-care OASIS (and the recertification OASIS each sixty days) drives the functional impairment score and is submitted to iQIES. The HIPPS code on the claim is built from five elements:

1. Admission source and timing — community or institutional, early (first thirty-day period) or late.
2. Clinical grouping — determined by the principal diagnosis on the claim (musculoskeletal rehabilitation, neuro rehabilitation, wounds, behavioral health, complex nursing, medication management and so on). Some diagnoses are not accepted as principal and return the claim.
3. Functional impairment level — from specific OASIS items.
4. Comorbidity adjustment — none, low or high, based on secondary diagnoses.

Coding accuracy on the claim therefore sets the payment. An unspecified or unacceptable principal diagnosis is a returned claim; a missed comorbidity is lost revenue.

LUPA

Each case-mix group has a low utilization payment adjustment threshold of between two and six visits. A period with fewer visits than its threshold is paid per visit at national rates instead of the period amount, which is a large difference. Agencies manage this clinically (visit frequency matched to need) and operationally (missed visits made up within the period, discharge timing). Know the threshold for each patient’s group at the start of the period.

Final claims

The final claim for each period (type of bill 329) carries all visits with HCPCS codes and units, the HIPPS code, the principal and secondary diagnoses, and the occurrence codes for the period. Submit after the period ends and the orders are signed. Timely filing for Medicare is twelve months, but cash flow argues for days, not months.

Medicare Advantage and Medicaid

Medicare Advantage plans often require prior authorization for home health and may pay per visit or by their own episode method rather than PDGM. State Medicaid home care programs (in New York, Certified Home Health Agencies, LHCSAs and managed long-term care plans) have their own authorization, unit and documentation rules, and electronic visit verification requirements. An agency serving all three populations is running three billing systems.

Denials and returns we see most

• NOA late or rejected, with the daily reduction applied.
• Face-to-face encounter missing, outside the window or unrelated to the primary reason.
• Principal diagnosis not acceptable for grouping.
• Plan of care unsigned at the time of the final claim.
• Overlapping episode with another agency.
• Visits billed without matching EVV records (Medicaid).

Home health agencies are one of the practice types Core MB has billed for longest. See the medical billing service, or ask us about an agency-specific review.