Home health PDGM billing: periods, notices and the claim sequence

How a period is paid

This page covers the Medicare side of home care and home health billing, the lane where every claim follows an admission and an assessment. Under PDGM, Medicare pays a national, standardized 30-day period rate, adjusted for case mix and for geographic wage differences. The case-mix group comes from five things: the admission source, whether the period is early or late in the admission, the clinical grouping of the principal diagnosis, the comorbidity level, and the functional impairment level derived from the OASIS assessment. The combination sets the group, and the group sets the rate.¹

Two adjustments change the number. When the visits in a period fall below the threshold for its group, the period is paid per visit instead, a low utilization payment adjustment. When a patient is transferred or discharged and readmitted inside a period, a partial period payment applies. Both are decided by the visit and admission data the agency submits.

The claim sequence

1. Referral and orders. A physician or allowed practitioner orders home health, and the agency confirms Medicare eligibility and that no other agency or hospice has an open episode.
2. Start of care and OASIS. The first visit, the full start-of-care assessment, and the OASIS submitted and accepted. The OASIS drives the functional score in the group.
3. Notice of Admission. Filed with the Medicare contractor and accepted within five calendar days after the admission date. A late notice reduces the period's payment for each day from admission until it is accepted.²
4. Plan of care and face-to-face. The plan of care signed by the certifying practitioner, and the face-to-face encounter documented inside the window the rules set around the start of care.
5. Period claim. After the 30 days end, the claim with the diagnoses, the visits and the dates, billed only once the OASIS, the orders and the encounter are in place.
6. Recertification. Every 60 days, a new certification for the next two periods, with the OASIS follow-up assessment.

Why home health periods go unpaid

• Late Notice of Admission. Payment cut by one-thirtieth for each day from admission until the notice is accepted, with no relief except the exceptions the rules allow.
• Claim returned for OASIS. The assessment not submitted, not accepted, or not matching the claim's dates and diagnoses.
• Face-to-face missing or out of window. The encounter not documented, by the wrong practitioner, or dated outside the allowed period.
• Orders unsigned. The plan of care or an interim order not signed before the claim was billed.
• Overlapping episode. Another agency or a hospice has an open election, or the patient was in a facility on billed dates.
• Coverage. Homebound status or skilled need not supported by the documentation the contractor's coverage determination asks for.³

The routine

• Admissions tracked by start of care with the notice deadline, the OASIS due date, the orders status and the face-to-face status on one line.
• Visit counts watched against the LUPA threshold for each period's group, so a period about to fall under it is a clinical decision, not a remittance surprise.
• Period claims released only when the four gates are met, and never on the last day of the period.
• Remittances posted and read; returned claims worked and resubmitted; denials traced to the gate that failed.
• Medicare Advantage authorizations tracked per plan alongside the Medicare sequence.
• A weekly report by payer: admissions, periods billed, periods paid, periods held and why.