Medicare PDGM, Medicare Advantage, Medicaid and commercial billing for Medicare-certified home health agencies, multi-branch providers and Medicaid home care companies.
Home health revenue is usually lost before a claim exists: an NOA filed on day seven, a missed visit that turns a 30-day period into a LUPA, or a plan of care still waiting for a signature. A late NOA cuts the period payment by 1/30th for every day from the start of care until it is filed. Late notices of election or admission caused 11% of hospice and home health payment losses (Luxen billing reviews). Luxen tracks every NOA, visit count and signed order so each period bills in full.
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Home health billing services manage Medicare PDGM claims, Notices of Admission, OASIS matching, LUPA and outlier rules, Medicare Advantage authorizations and Medicaid EVV for home health agencies. In 2026, Medicare pays a national standardized rate of $2,038.22 per 30-day period before case-mix and wage adjustments, and a late NOA cuts it by 1/30th a day.
Home health billing changes with the agency's setup and payer mix.
Also billed: Medicare Advantage per-visit contracts, commercial plans, remote patient monitoring reported on G0322, and private pay.
Most lost home health revenue never shows up as a denial. It is a period paid short or a final claim that cannot drop, so eligibility and prior authorization checks start at referral.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| NOA filed late | Type of bill 032A | Accepted after the 5-day window | About $67.94 per day from the start of care, on the CY 2026 national rate | Late notices of election or admission caused 11% of hospice and home health payment losses |
| One visit short of the LUPA threshold | Revenue code 0023 with HIPPS, 055x with G0299 | The period pays per visit instead of the period rate | $1,379.93 on the 3-visit example in the PDGM section | 5% of home health periods paid as LUPAs were one visit short of the threshold |
| Final claim with no matching OASIS | Type of bill 0329, OASIS items M0010, M0063, M0090 | The claim cannot match an accepted OASIS in iQIES | The full period, $2,038.22 national base rate | The top three denial reasons accounted for 58% of denied dollars in the average practice |
| Unsigned plan of care or face-to-face gap | G0180, 42 CFR 424.22 | Final claim held, or denied on medical review | The full period payment | Home health final claims waited a median 19 days for signed orders after the period ended |
| Medicare Advantage visits past the authorization | 042x, 043x, 055x with plan authorization | Visits delivered after the authorized count or end date | The contracted rate for each unauthorized visit | Missing or invalid prior authorization caused 17% of denials |
| Medicaid visit without an EVV match | State EVV aggregator record | Visit date, time or caregiver does not match the claim | The Medicaid visit or unit rate | 19% of denied claims were never reworked or appealed |
Medicare home health claims go on the UB-04 (837I) to your Medicare Administrative Contractor, not on a CMS-1500. Our certified medical coding team checks each line against the OASIS and the visit notes before release.
| Code | Claim | When it is used |
|---|---|---|
| 032A | Notice of Admission | Once per admission, within 5 calendar days after the start of care |
| 032D | NOA cancellation | Cancels an NOA sent in error |
| 0329 | Final claim | After each 30-day period ends, with the OASIS and signed orders on file |
| 0327 | Adjustment | Corrects a processed final claim |
| 0328 | Cancel | Voids a processed final claim |
Each final claim carries one five-position HIPPS code, valid only on revenue code 0023.
| Revenue code | Discipline | HCPCS codes |
|---|---|---|
| 042x | Physical therapy | G0151 PT, G0157 PTA, G0159 maintenance |
| 043x | Occupational therapy | G0152 OT, G0158 OTA, G0160 maintenance |
| 044x | Speech-language pathology | G0153, G0161 maintenance |
| 055x | Skilled nursing | G0299 RN, G0300 LPN, G0162 care plan management, G0493 and G0494 observation and assessment, G0495 and G0496 training and education |
| 056x | Medical social services | G0155 |
| 057x | Home health aide | G0156 |
Visits are reported in 15-minute units. Telecommunications services use the same revenue codes with G0320 (audio and video), G0321 (audio only) or G0322 (remote patient monitoring), required since July 1, 2023, but they are not visits for eligibility or payment.
PDGM pays for 30-day periods inside each 60-day certification. Five variables sort every period into one of 432 case-mix groups: admission source (community or institutional), timing (early for the first period in a sequence, late after that), 12 clinical groups, 3 functional impairment levels and 3 comorbidity levels.
The CY 2026 national standardized 30-day period payment is $2,038.22 for agencies that submit quality data. It is multiplied by the case-mix weight and wage-adjusted on the 74.9% labor-related share. CMS estimated a 1.3% aggregate cut ($220 million) for CY 2026.
Each case-mix group has a LUPA threshold set at the 10th percentile of visits, never below 2. A period under its threshold is paid per visit. The only or first period in a sequence gets an add-on to its first SN, PT, OT or SLP visit.
| Discipline | CY 2026 national per-visit rate | LUPA add-on factor |
|---|---|---|
| Skilled nursing | $176.96 | 1.7200 |
| Physical therapy | $193.42 | 1.6225 |
| Occupational therapy | $194.74 | 1.7238 |
| Speech-language pathology | $210.25 | 1.6696 |
| Medical social services | $283.64 | Not applied |
| Home health aide | $80.12 | Not applied |
Worked example: a first period in a case-mix group with a threshold of 4 gets only 3 skilled nursing visits. The add-on raises the first visit to $304.37 ($176.96 × 1.7200), so the period pays $658.29 before wage adjustment, against $2,038.22 at a case-mix weight of 1.0000. One missed visit cost $1,379.93.
A late NOA reduces the wage and case-mix adjusted period payment by 1/30th for each day from the start of care until the NOA is filed, about $67.94 a day on the national rate. No LUPA visits are paid for the late days, and those days cannot be billed to the patient (42 CFR 484.205(j)). For events outside the agency's control, the exception request goes on the claim with the KX modifier on the HIPPS line.
An outlier payment starts when imputed visit cost exceeds the period payment plus a fixed-dollar loss amount (FDL ratio 0.37 in CY 2026). Medicare pays 80% of the cost above that, counts no more than 8 hours of care per day, and caps outliers at 10% of an agency's total home health PPS payments. A transfer, or a discharge and readmission within the same 30-day period, triggers a partial period payment prorated by days. Our denials and AR recovery team reworks periods paid short.
Most held home health revenue is a documentation problem, not a coding one.
The certifying practitioner signs the plan of care and certifies that the patient is homebound, needs skilled services and is under their care. Recertification is due at least every 60 days. The certifying practitioner bills G0180 for certification, G0179 for recertification and G0181 for 30 minutes or more of care plan oversight in a month, on their own professional claim.
The patient must meet both homebound criteria in the Medicare Benefit Policy Manual, Chapter 7, section 30.1.1:
The patient also needs intermittent skilled nursing, physical therapy, speech-language pathology or continuing occupational therapy (section 30.4). Covered home health services cost traditional Medicare patients nothing, so there is no copay to collect on a Medicare period. Medicare Advantage and commercial plans set their own cost sharing.
It cuts payment. The period payment drops by 1/30th for each day from the start of care until the NOA is filed, and those days cannot be billed to the patient (42 CFR 484.205(j)). On the CY 2026 national rate that is about $67.94 a day. Timely filing caused 6% of denials, and only 4% of those were recovered (Luxen claim audit).
One NOA covers a series of periods from admission to discharge, and a new one is needed only after a discharge (Medicare Claims Processing Manual, Chapter 10, section 10.1.10.3). Extra NOAs add rework without protecting payment. Duplicate claim denials made up 9% of denials, mostly from resubmitting instead of correcting (Luxen claim audit).
Not since PDGM began on January 1, 2020. Periods are grouped on admission source, timing, clinical group, functional level and comorbidities, not therapy visit counts (CMS, Home Health Patient-Driven Groupings Model). Revenue now rides on diagnosis coding and OASIS scores. Coding and modifier errors caused 21% of denials (Luxen claim audit).
They do not. G0320, G0321 and G0322 are reported on the claim but are not home visits for eligibility or payment (CMS MLN MM12805). Swapping an in-person visit for a call can turn a full period into a LUPA. 5% of home health periods paid as LUPAs were one visit short of the threshold (Luxen claim audit).
A physician, NP, CNS, PA or certified nurse-midwife may perform it, and under the CY 2026 rule a physician may do so without being the certifier (42 CFR 424.22). Waiting on the certifier's own visit delays the start of care and the final claim. Home health final claims waited a median 19 days for signed orders after the period ended (Luxen billing reviews).
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
We work inside the systems your agency already runs, with no migration.
We sign the BAA before access.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Luxen findings for home health agencies:
Unsigned orders and incomplete plans of care were holding up months of home health revenue. Luxen created a documentation-aging queue and reduced claims waiting to bill from $189,000 to $31,000 in four months.
Director of Operations, regional home health agency
Completed visits in the scheduling system did not always match finalized clinical notes. Luxen introduced a weekly reconciliation, identified 286 unbilled visits, and recovered $74,500.
Revenue Cycle Manager, multi-branch home health provider
Full engagements are written up in our dental practice case study and our ambulance billing case study.
Every Medicare-certified agency is in the expanded Home Health Value-Based Purchasing Model. Performance two years earlier moves payment by as much as 5% in either direction, and CY 2025 was the first payment year, based on CY 2023. The CY 2026 rule removed three HHCAHPS measures and added three OASIS-based bathing and dressing measures plus a Medicare spending per beneficiary measure. Accurate OASIS functional scores protect the period payment now and the adjustment later.
Agencies in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma bill under the Review Choice Demonstration with Palmetto GBA, which CMS extended for five more years from June 1, 2024. Agencies start with pre-claim review or postpayment review of every period. Those at a 90% affirmation rate or better, on at least 10 requests or claims in a 6-month cycle, can move to selective postpayment review or a 5% spot check. State payer detail is on our Texas medical billing companies, Florida medical billing companies and Illinois medical billing companies pages.
Section 12006 of the 21st Century Cures Act requires EVV for Medicaid home health care services, with a January 1, 2023 deadline and good-faith exemptions that ran to January 1, 2024. EVV records six items: service type, recipient, date, location, provider, and start and end times. Each state sets its own EVV claim edits, so we reconcile the aggregator record to the claim before billing.
On July 1, 2026, CMS proposed a 2.4% aggregate increase ($420 million) for CY 2027, keeping a temporary 3.0% reduction to the rate and proposing no new permanent adjustment.
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, based on payer mix, admission volume and Medicaid EVV workload. No setup or exit fee.
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| Medicare PDGM periods | $90,000 | $2,700 | $5,400 |
| Medicare Advantage | $33,000 | $990 | $1,980 |
| Medicaid and waiver visits | $18,000 | $540 | $1,080 |
| Commercial and private pay | $9,000 | $270 | $540 |
| Total | $150,000 | $4,500 | $9,000 |
| Cost | In-house billing office | Luxen |
|---|---|---|
| Cost basis | Fully loaded in-house billing cost 7.9% of collections for practices under $2M, or $11,850 a month at $150,000 | $4,500 to $9,000 a month ($54,000 to $108,000 a year) |
| When a biller leaves | Open biller roles took a median 67 days to fill | No gap in coverage |
| Denial follow-up | 42% of practice managers said nobody owns denial follow-up full time | A named owner for every denial |
| Terms | Employment commitments | Month to month, 30 days notice |
| Partner type | PDGM and OASIS depth | NOA and LUPA tracking | Terms |
|---|---|---|---|
| In-house billing office | One or two billers | Manual, varies by staff | Payroll and turnover |
| Generalist billing company | Physician claim focus on the CMS-1500 | Rarely tracked | Often annual |
| Specialty home health billing company | PDGM experience | Usually tracked | Some charge setup fees |
| EHR vendor RCM | Vendor workflows | Built into the software | Bundled with the software contract |
| Luxen | Certified coders for UB-04, HIPPS and G-codes | Daily NOA and visit count checks | Month to month, 30 days notice |
Compare medical billing companies on these points, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Medicare-certified agencies bill on the UB-04 (837I). One Notice of Admission goes out on type of bill 032A within 5 calendar days after the start of care, then a final claim on type of bill 0329 for each 30-day period, with the HIPPS code on revenue code 0023 and visit lines by discipline. Submitting the matching OASIS is a condition of payment.
Luxen charges 3% to 6% of collections, with no setup or exit fee. For an agency collecting $150,000 a month, that is $4,500 to $9,000 a month. By comparison, fully loaded in-house billing cost 7.9% of collections for practices under $2M in Luxen billing reviews.
About 2 weeks from a signed BAA to working claims, with first recovered payments in about 3 weeks. We start with unbilled periods, late NOAs and the oldest open final claims, then take over new admissions. Your agency keeps its EHR and Medicare contractor access.
Yes. We work inside Homecare Homebase, WellSky, Axxess, MatrixCare, PointClickCare, KanTime and other home health EHRs with no migration. We use your OASIS records, iQIES reports and direct data entry access, and we sign the BAA before access.
Medicare pays a partial period payment, prorated from the first to the last billable service date and divided by 30. It applies when a patient transfers to another agency, or is discharged and readmitted within the same 30-day period, and the claim uses patient discharge status 06. For a transfer, the receiving agency files its own NOA with condition code 47.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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