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Billing by specialty

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Specialty billing

Home health billing services

Home health billing is claiming the visits a home health agency makes in each 30-day period of care, under Medicare’s Patient-Driven Groupings Model, with the assessment, orders and notices that payment depends on.

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Home health

The dates around a start of care

  1. 90 days beforeface-to-face window opens
  2. Start of careday 0
  3. Day 5notice of admission
  4. Day 30face-to-face window closes
Each 30-day period is paid by its PDGM group.

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Work out the dates around a start of care

The face-to-face window, the notice of admission and the first 30-day period, from one date.

The dates around a start of care

Medicare

Put in the start of care.

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The face-to-face encounter is with the certifying physician or allowed practitioner, who also signs the plan of care before the final claim.

Why is home health billing hard?

  • Payment is grouped, not itemized

    Under PDGM, each 30-day period is paid by group: the admission source and timing, the primary diagnosis, the functional scores from the OASIS assessment and the comorbidities set its HIPPS code. A primary diagnosis PDGM doesn’t accept sends the claim back.

  • The notice of admission is due in five days

    An agency must send Medicare a notice of admission within five calendar days of the start of care, and a late notice cuts the period’s payment for each day it is late.

  • Orders before the final claim

    The certifying physician or allowed practitioner must document a face-to-face encounter, from 90 days before to 30 days after the start of care, and sign the plan of care before the final claim is sent.

  • Too few visits change the payment

    A period with fewer visits than its group’s threshold is paid per visit, as a low-utilization payment adjustment, so the visits made need to match what was planned and documented.

  • An institutional claim

    Home health is billed on the institutional claim (the 837I or UB-04), with a revenue code for each discipline’s visits, not on the professional claim physicians use.

What Beeline handles for home health agencies

Home health billing questions

What is PDGM?
The Patient-Driven Groupings Model is how Medicare has paid home health since January 2020. Each 30-day period of care is placed in a payment group by its admission source and timing, the primary diagnosis, the patient’s functional level from OASIS and their comorbidities, and the group sets the payment.
What is a home health notice of admission?
The notice an agency sends Medicare at the start of care to establish the admission. It is due within five calendar days of the start of care, and for each day it is late Medicare reduces the payment for that period.
What is a face-to-face encounter in home health?
The visit, in person or by telehealth, in which a physician or allowed practitioner saw the patient for the main reason they need home health. It must happen from 90 days before to 30 days after the start of care, and the certifying practitioner documents it.
What is a LUPA?
A low-utilization payment adjustment. When a 30-day period has fewer visits than its payment group’s threshold, which is between two and six visits, Medicare pays per visit instead of the period’s full payment.

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