What makes home health billing different
Home health billing runs on Medicare's institutional claim rules rather than the physician fee schedule. An agency bills a 30-day period of care under the Patient-Driven Groupings Model (PDGM), and payment depends on assessment data, diagnoses and paperwork completed by the agency and the certifying practitioner. Hospice works on a separate per-day model with its own election, certification and filing rules.
Because both benefits pay for a period or a day instead of a single visit, one missing signature or late notice can affect weeks of care. Our medical billing services for agencies are organized around those period-level checks, not just claim-by-claim posting.
PDGM billing: how a home health period is paid
PDGM billing starts from the 30-day period, which CMS treats as the unit of payment. Each period is assigned to a payment group using the admission source (community or institutional), timing (early or late period), a clinical group based on the principal diagnosis, a functional impairment level drawn from OASIS, and a comorbidity adjustment. The result is a HIPPS code reported on the claim under revenue code 0023.
If the agency provides fewer visits than the threshold set for that payment group, Medicare pays a standardized per-visit amount instead of the period payment, known as a low-utilization payment adjustment (LUPA). Tracking visit counts against the threshold while the period is still open lets clinical managers see where a planned visit was missed.
| Item | What it means for the claim |
|---|---|
| Notice of Admission (TOB 032A) | Submitted once per admission and accepted within 5 calendar days after the admission date |
| Final claim (TOB 0329) | Billed for each 30-day period with the HIPPS code and visit lines |
| Adjustment / cancel (TOB 0327 / 0328) | Used to correct or cancel a processed period claim |
| Revenue code 0023 | Carries the HIPPS code that sets the period payment |
| Revenue codes 042x, 043x, 044x | Physical therapy, occupational therapy and speech-language pathology visits |
| Revenue codes 055x, 056x, 057x | Skilled nursing, medical social services and home health aide visits |
Home health and hospice codes and rules specific to this specialty
Visit lines on both home health and hospice claims use HCPCS G-codes by discipline, reported in 15-minute units. The nursing codes separate RN from LPN time, which also matters for the hospice service intensity add-on in the last seven days of life.
| Code | Descriptor (summary) | Revenue code |
|---|---|---|
| G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes | 055x |
| G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes | 055x |
| G0151 | Services of a qualified physical therapist in the home health or hospice setting, each 15 minutes | 042x |
| G0152 | Services of a qualified occupational therapist in the home health or hospice setting, each 15 minutes | 043x |
| G0153 | Services of a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes | 044x |
| G0155 | Services of a clinical social worker in the home health or hospice setting, each 15 minutes | 056x |
| G0156 | Services of a home health or hospice aide, each 15 minutes | 057x |
Diagnosis coding carries more weight here than in most specialties. Under PDGM, a principal diagnosis that does not map to a clinical group returns the claim, and vague or symptom-only codes can place a period in a group that does not reflect the care provided. Comorbidity codes should be documented and supported, not added for grouping alone.
Hospice billing: election, NOE and benefit periods
Hospice billing begins with the patient's election statement and the certification that life expectancy is 6 months or less if the illness runs its normal course. Medicare covers two 90-day benefit periods followed by an unlimited number of 60-day periods. A face-to-face encounter is required before the third benefit period recertification and each one after, no more than 30 calendar days before it.
The Notice of Election (TOB 81A or 82A) must be accepted by the MAC within 5 calendar days after the hospice admission date. When it is late, Medicare does not pay for the days from admission until the NOE is accepted, and those days become the hospice's liability.
| Level of care | Revenue code | Billing note |
|---|---|---|
| Routine home care | 0651 | Higher daily rate for days 1 to 60 of the election, lower rate from day 61 |
| Continuous home care | 0652 | At least 8 hours of care, mostly nursing, in a 24-hour day during a crisis |
| Inpatient respite care | 0655 | No more than 5 consecutive days per respite stay |
| General inpatient care | 0656 | Provided in a Medicare-certified hospice unit, hospital or skilled nursing facility |
Documentation and long term care billing overlaps
For home health, Medicare requires a face-to-face encounter no more than 90 days before or within 30 days after the start of care, a certification that the patient is homebound and needs skilled intermittent services, and a plan of care signed by the physician or allowed practitioner. OASIS assessments at start of care, resumption, recertification, transfer and discharge feed both quality reporting and the payment group.
Many hospice patients live in nursing facilities, which is where hospice work meets long term care billing. The hospice bills its level of care while the facility's room and board follows separate rules that differ between Medicare, Medicaid and private pay, so both parties need an agreed split. We confirm payer source and any Medicaid room-and-board arrangement at admission through insurance eligibility checks.
Common denials and how we prevent them
CMS compliance data point to insufficient documentation and medical necessity as the main reasons home health payments are found improper. Most of these problems are visible before the claim leaves the agency.
- Late NOA or NOE: submissions logged the day of admission and checked for acceptance, not just transmission
- Missing or unsigned face-to-face documentation: encounter date and practitioner confirmed against the start of care
- Homebound status not supported: visit notes reviewed for the functional detail an auditor looks for
- Principal diagnosis returned under PDGM: codes checked against the clinical grouping before the final claim
- Hospice claims out of sequence or overlapping another provider's dates: benefit period and election history verified first
- Additional documentation requests: record assembled and tracked against the response date
When a claim is denied, our denial management team corrects it or appeals with the certification, plan of care and visit notes, and the root cause is fed back to intake so the same gap does not repeat.
Credentialing for agencies and hospices
Home health agencies and hospices enroll in Medicare as institutional providers, and certification depends on a state survey or a deemed accrediting organization. Medicaid, Medicare Advantage and commercial plans each need their own enrollment or contract, and claims sent before an effective date are usually denied.
Our credentialing and enrollment team follows a tracked nine-stage process, from document collection through payer applications and follow-ups to final approval, and keeps revalidation and ownership-change filings on a calendar.
How Fastora works with home health and hospice providers
As a home health billing company, Fastora works inside your existing EHR under the user access you grant, with no software to install. Certified billing and coding professionals handle each claim, and you get a dedicated account contact, transparent dashboards and a monthly review call.
Agencies that need a hospice billing company for a growing hospice line can use the same team for NOEs, level-of-care billing and benefit period tracking. Start with a free billing assessment of recent periods, and see how quotes are built on our pricing page.
EVV compliance and billing
Electronic visit verification — EVV — is the visit-capture system behind the claim. Caregivers clock in and out in the home, increasingly with GPS or telephony stamps, recording the visit the payer will later match to the billed claim. When EVV data is missing or mismatched, the claim for that visit stalls or denies — so the billing workflow starts with the visit record, not the claim form. We check that visits captured in your EVV system flow through to claims with matching dates, times and services, and flag the gaps before submission.
Choosing a home health or hospice billing company
Home health medical billing and hospice medical billing look similar from the outside — both are episode-based, both lean on assessment documentation — but the claim rules diverge quickly. A home health billing company lives with RAP and final claims, NOA timing, and OASIS-driven payment groups; a hospice billing company handles the notice of election, level-of-care billing, and the physician certification cadence. We do both, which matters for agencies that run the two service lines side by side and need one team that knows where the rules split. A free medical billing audit will show where your episodes are leaking revenue; pricing explains how an agency quote is built.