Home Health Billing, Credentialing

Home health billing runs on 30-day periods instead of visits, and most of what an agency gets paid is decided before a single visit is billed. The referral source, the timing of the period, the primary diagnosis, and the functional scores in the OASIS assessment all set the payment group under Medicare’s Patient-Driven Groupings Model. A late notice of admission, a missing face-to-face note, or one visit too few can cut that payment or erase it, which is why home health agencies tend to lose money in intake rather than in collections.

Key Takeaways

How PDGM Pays a Home Health Period

Each 30-day period lands in one of 432 payment groups. Admission source splits community referrals from patients discharged from a hospital or post-acute stay in the prior 14 days, and timing separates the first period of care from later ones. The primary diagnosis places the period in one of 12 clinical groups, OASIS functional items set the impairment level, and secondary diagnoses can add a comorbidity adjustment.

The primary diagnosis carries more weight than anything else on the claim. A code that Medicare treats as vague or unacceptable as a primary diagnosis sends the claim back, and a diagnosis that doesn’t match the plan of care invites review. Coding has to follow the referral documentation and the OASIS start-of-care assessment.

Low-utilization payment adjustments apply when a period has fewer visits than its group’s threshold, which ranges from two to six. Those periods pay per visit instead of the full period amount, so one missed or rescheduled visit near the threshold can cost far more than the visit itself. Outlier payments work the other way, covering part of the cost of unusually expensive periods.

Notice of Admission, Certification, and Face-to-Face

The Notice of Admission opens the patient’s home health stay with Medicare and has to be submitted within five calendar days of the start of care. When it’s late, Medicare reduces the payment for each day from the start of care until the notice is filed, and those days can’t be recovered except through a narrow exception process.

The patient also has to be homebound and under a plan of care certified by a physician, nurse practitioner, clinical nurse specialist, or physician assistant. The certifying practitioner documents a face-to-face encounter related to the primary reason for home care, performed within 90 days before or 30 days after the start of care. Most face-to-face denials come from notes that don’t explain why the patient is homebound or why skilled care is needed, so agencies should review the referral notes before the first visit.

The certifying practitioner bills separately under Part B. G0180 covers initial certification, G0179 covers recertification, and G0181 covers care plan oversight of 30 minutes or more in a month. Physician practices that certify home care often bill those codes alongside visits covered on our geriatric medicine page.

Claim Codes and Revenue Codes

Home health agencies bill Medicare on the institutional claim, type of bill 032x, with a revenue code and a HCPCS visit code on each line. The visit codes changed years ago, and old code lists still circulate, so it’s worth checking which ones a billing system is using.

Each visit is reported in 15-minute increments on the line, and the visits on the final claim have to match what was documented. Medicare’s Review Choice Demonstration adds another step in some states, including Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma, where agencies choose pre-claim review, postpayment review, or another option before claims pay normally.

Medicaid, Medicare Advantage, and Commercial Payers

Medicaid home health and personal care services run under each state’s rules, and the 21st Century Cures Act requires electronic visit verification for Medicaid home health visits. A visit without a matching EVV record usually won’t pay, so the scheduling and EVV systems have to agree with what’s billed. Many states also deliver home health through Medicaid managed care plans that each set their own authorization rules.

Medicare Advantage plans don’t have to follow PDGM. Some pay per visit, some use their own episode rates, and most require authorization for the number of visits by discipline. Our post on payer contracts in home health covers how those rates and authorization terms get negotiated. Agencies that also provide infusion at home have separate rules covered on our home infusion therapy page.

What Changed for Home Health in 2026

CMS finalized a 1.3% aggregate decrease in Medicare home health payments for 2026, about $220 million. The base rate includes a 1.023% permanent cut and a 3% temporary cut that applies only to 2026, offset partly by a 2.4% market basket update. Agencies that don’t submit required quality data get a 0.4% update instead.

The same rule expanded the grounds for denying or revoking an agency’s Medicare enrollment and shortened the window for reporting adverse legal actions to 30 days. It also updated the expanded Home Health Value-Based Purchasing model’s measures, removing three HHCAHPS-based measures and adding a claims-based spending measure and three OASIS-based functional measures. OASIS-E2 replaced the prior version on April 1, 2026, and CMS’s all-payer OASIS transition means assessments are now required for skilled patients covered by any payer.

Home Health Agency Credentialing

Medicare certification and enrollment

A new agency enrolls with Medicare through the CMS-855A and has to pass either a state survey or a deemed accreditation survey from an organization such as ACHC, CHAP, or The Joint Commission. CMS screens new agencies at its highest risk level, which means a site visit and fingerprint-based background checks for anyone with a 5% or greater ownership stake. The agency also has to show initial reserve operating funds before its enrollment is approved.

Ownership changes

Medicare’s 36-month rule limits how a home health agency can be sold. When majority ownership changes within 36 months of the agency’s initial enrollment or its last majority ownership change, the agency generally has to enroll again as a new provider and go through a new survey, unless an exception applies. Buyers should check that timeline before closing.

Clinicians and Medicaid enrollment

Agency nurses, therapists, and aides don’t usually enroll with Medicare individually, because the agency bills under its own enrollment. Payers still expect the agency to verify each clinician’s license, background check, and competency, and some Medicaid programs and managed care plans credential the agency’s staff as part of the contract. Our team handles agency enrollment with Medicare, each state Medicaid program, and the managed care plans that cover the agency’s patients.

Home Health Billing FAQ

Medwave for Medicare-Certified Home Health Agencies

Most home health revenue problems start at intake, with a referral that doesn’t support homebound status, a primary diagnosis that won’t group, or a notice of admission filed on day six. Medwave reviews each of those before the first visit and tracks LUPA thresholds through the period. Our medical billing team holds a 98% clean claim rate, and our denial management team works additional documentation requests and Review Choice Demonstration submissions.

For new agencies and agencies changing hands, our medical credentialing team handles the CMS-855A, Medicaid, and managed care enrollments and averages 85 days to approval on payer enrollment. Our payer contracting team negotiates Medicare Advantage visit rates and authorization terms, and agencies that also partner with facilities can see our skilled nursing facility page.

Send us your agency’s payer mix and where your claims are getting stuck, and we’ll start with intake.