How to use this home health billing cheat sheet
Home health billing has more moving parts than almost any other Medicare benefit. A single 30-day period of care depends on an accepted Notice of Admission, a matching OASIS assessment, a valid primary diagnosis, signed orders and correct codes on the UB-04 or 837I. Miss one and the claim returns to provider (RTP) or pays less than it should.
This cheat sheet pulls the most-used rules into one place. Print it, pin it near the billing desk or share it with new staff. It reflects Medicare fee-for-service rules under the Patient-Driven Groupings Model (PDGM) and the CY 2026 Home Health PPS rates. Always confirm current details with your Medicare Administrative Contractor (MAC): Palmetto GBA, CGS or National Government Services, depending on your region.
Key 2026 numbers to know
Item | CY 2026 value |
|---|---|
National standardized 30-day period rate | $2,038.22 |
Rate for agencies not reporting quality data | 2 percentage points lower update |
Skilled nursing per-visit rate | $176.96 |
Physical therapy per-visit rate | $193.42 |
Occupational therapy per-visit rate | $194.74 |
Speech-language pathology per-visit rate | $210.25 |
Medical social services per-visit rate | $283.64 |
Home health aide per-visit rate | $80.12 |
Labor-related share (wage-adjusted portion) | 74.9% |
LUPA thresholds | 2 to 6 visits, by case-mix group |
These base amounts are adjusted by each period's case-mix weight and the local wage index before payment. CMS has proposed a CY 2027 rate of $2,092.27, but the final rule had not been published as of this writing.
Critical deadlines
Task | Deadline | What happens if missed |
|---|---|---|
Notice of Admission (TOB 32A) | Within 5 calendar days of start of care | Payment reduced by 1/30 for each day late, from start of care to NOA receipt |
Initial assessment visit | Within 48 hours of referral or return home, or on the ordered start date | Condition of Participation deficiency |
Comprehensive assessment (start of care OASIS) | Within 5 days after start of care | CoP deficiency and claim-OASIS mismatch risk |
Resumption of care OASIS | Within 2 days after return from inpatient stay | Claim may not match assessment |
Recertification OASIS | Last 5 days of each 60-day certification period (days 56–60) | Gap in certified care |
OASIS submission to iQIES | Within 30 days of completion | Final claim can RTP for no matching assessment |
Face-to-face encounter | 90 days before through 30 days after start of care | Claim not payable |
Plan of care recertification | Every 60 days | No valid orders for continued care |
Medicare timely filing | 12 months from the service date | Claim denied as untimely |
Type of bill codes for home health
The type of bill (TOB) in form locator 4 tells Medicare what kind of transaction you are sending. The leading "3" means home health, the "2" means services under a plan of care and the last character is the frequency.
TOB | Purpose |
|---|---|
032A | Notice of Admission, once per admission |
032D | Cancel an NOA |
0329 | Final claim for a 30-day period |
0327 | Replacement or adjustment of a prior claim |
0328 | Void or cancel a prior claim |
0320 | Nonpayment claim |
034X | Services outside a home health plan of care, such as certain vaccines or Part B supplies |
Agencies stopped sending Requests for Anticipated Payment (RAPs) on TOB 0322 for periods starting on or after January 1, 2022. The NOA replaced them. The NOA pays nothing on its own, but it must be accepted before any period in that admission can pay.
How to decode a PDGM HIPPS code
Every final claim reports a five-character HIPPS code on revenue code 0023. That code identifies which of the 432 PDGM case-mix groups the period falls into.
Position | Meaning | Values |
|---|---|---|
1 | Admission source and timing | 1 = Community Early, 2 = Institutional Early, 3 = Community Late, 4 = Institutional Late |
2 | Clinical grouping from the primary diagnosis | A–L (12 clinical groups) |
3 | Functional impairment level from OASIS | A = Low, B = Medium, C = High |
4 | Comorbidity adjustment from secondary diagnoses | 1 = None, 2 = Low, 3 = High |
5 | Placeholder | Always 1 |
The 12 clinical groups are MMTA-Other, Neuro Rehabilitation, Wounds, Complex Nursing Interventions, Musculoskeletal Rehabilitation, Behavioral Health, MMTA-Surgical Aftercare, MMTA-Cardiac and Circulatory, MMTA-Endocrine, MMTA-Gastrointestinal and Genitourinary, MMTA-Infectious Disease, Neoplasms and Blood-Forming Diseases, and MMTA-Respiratory.
Here is a quick example. HIPPS 2EC21 means Institutional Early, Musculoskeletal Rehabilitation, High functional impairment, Low comorbidity adjustment. Remember that Medicare checks timing and admission source against its own claims history. If an inpatient claim exists that your agency did not report, Medicare may recode position 1, and the payment changes.
Occurrence, condition and value codes you will use most
Code | Type | Use |
|---|---|---|
50 | Occurrence code | Required on every final claim with the OASIS completion date (M0090) of the most recent assessment before the claim "From" date |
61 | Occurrence code | Hospital discharge within 14 days before the period; supports an institutional admission source |
62 | Occurrence code | Discharge from a skilled nursing facility, inpatient rehab facility or long-term care hospital within 14 days |
47 | Condition code | Patient transferred from another home health agency |
61 | Value code | CBSA code where the service was furnished |
85 | Value code | FIPS county code; required on all HH PPS claims |
KX | Modifier | Added to the HIPPS code on revenue code 0023 to request a late NOA exception |
A missing occurrence code 50 is one of the most common RTP reasons on home health claims. Build a pre-bill edit for it.
Revenue codes and visit G-codes
Each visit line pairs a revenue code with a HCPCS G-code and 15-minute units.
Discipline | Revenue code | Common G-codes |
|---|---|---|
Skilled nursing | 055X | G0299 (RN), G0300 (LPN), G0493 and G0494 (observation and assessment), G0495 and G0496 (training and education), G0162 (management and evaluation) |
Physical therapy | 042X | G0151 (PT), G0157 (PTA), G0159 (maintenance program) |
Occupational therapy | 043X | G0152 (OT), G0158 (OTA), G0160 (maintenance program) |
Speech-language pathology | 044X | G0153 (SLP), G0161 (maintenance program) |
Medical social services | 056X | G0155 |
Home health aide | 057X | G0156 |
HIPPS line | 0023 | Five-character HIPPS code |
CMS also requires reporting of services delivered by telecommunications technology on home health claims with dedicated G-codes. Report them on the correct discipline revenue line, but do not count them as billable visits toward the LUPA threshold.
Pre-bill checklist for every 30-day period
Run every claim through this list before it leaves the building:
NOA accepted and processed for the admission.
Primary diagnosis is a valid PDGM code, coded to the highest specificity and supported by the record.
OASIS completed, locked and accepted in iQIES; occurrence code 50 date matches M0090.
Face-to-face encounter documented and dated within the allowed window.
Plan of care and all interim orders signed by the certifying physician or allowed practitioner.
Visit count compared with the LUPA threshold for the HIPPS group.
Occurrence code 61 or 62 reported when the patient had a qualifying institutional stay.
Value codes 61 and 85 present and matching the patient's location.
Visits on the claim match visit notes, dates and disciplines in the EMR.
No overlapping hospice, inpatient or other HHA episode in the Common Working File.
Common denials and quick fixes
Problem | Likely cause | Fix |
|---|---|---|
RTP for missing occurrence code 50 | OASIS date not pulled into claim | Add pre-bill edit; rebill with M0090 date |
Late NOA reduction | Intake or eligibility delay | Submit NOA same day as start of care whenever possible |
No matching OASIS | Assessment not accepted in iQIES | Check iQIES validation reports before billing |
Questionable encounter primary diagnosis | Symptom or unspecified code used as primary | Query clinician for a more specific, groupable diagnosis |
Recoded HIPPS position 1 | Unreported inpatient stay | Check eligibility and inpatient history at intake |
Unsigned orders hold | Physician signature backlog | Track orders daily; escalate after 7 days |
Overlapping episode | Patient transferred or on hospice | Verify eligibility in HETS or the MAC portal before NOA |
When a cheat sheet is not enough
A quick reference helps with daily claims, but it cannot replace a team that works Medicare, Medicare Advantage and Medicaid rules every day. Many agencies keep this page handy and still hand the heavy lifting to a dedicated home health billing service, especially when ADRs, Targeted Probe and Educate reviews or Review Choice Demonstration submissions arrive.
Providers comparing home health billing services across the country often want local payer expertise too. Agencies seeking home health billing in Palm Springs work with Medi-Cal managed care plans and seasonal patient flows. Texas providers evaluating home health billing companies in Houston face heavy Medicare Advantage authorization volume. New York agencies need home health billing services in NYC that understand managed long-term care plans and New York Medicaid rules.
The Trucare Home health billing service team uses checklists like this one as a baseline, then adds payer-specific edits, OASIS-to-claim reconciliation and daily NOA tracking on top.
FAQs
What TOB do I use for a home health NOA? Use TOB 032A, submitted once per admission within five calendar days of the start of care.
What does the fifth character of a HIPPS code mean? Nothing for payment. It is a placeholder and is always 1 under PDGM.
Is occurrence code 50 required on every claim? Yes. Every final claim must report occurrence code 50 with the OASIS completion date from M0090.
How are late NOAs penalized? Medicare reduces the wage-adjusted 30-day payment by 1/30 for each day from the start of care until the NOA is received.
Sources: CGS: Submitting a final claim under PDGM; CGS home health billing codes sheet; CMS MLN Matters MM14304; IHA CY 2026 HH PPS final rule summary; CMS CY 2027 proposed rule fact sheet.
