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Home Health Billing & Coding Services
Home Health Billing Built for PDGM Grouping, NOA Deadlines and OASIS-Matched Claims
How Does Home Health Billing Work?
Home health billing means coding each patient's primary diagnosis so it groups under PDGM, filing the Notice of Admission within 5 days of the period start, matching OASIS to the claim, and holding final claims until the plan of care and face-to-face encounter are signed. Qualigenix runs that cycle for home health agencies with coders at 98.9% coding accuracy and an over- and undercoding rate under 2%.
01
PDGM Grouping Errors
PDGM sorts each 30-day period into one of 12 clinical groups based on the primary diagnosis. A primary diagnosis CMS treats as a questionable encounter doesn't group, and the claim comes back. A secondary diagnosis that isn't coded can also drop the comorbidity adjustment.
02
RCD and MA Authorizations
Agencies in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma bill under CMS's Review Choice Demonstration, which requires pre-claim review or postpayment review of Medicare home health claims. Medicare Advantage plans often authorize visits by discipline, and visits past the authorized count go unpaid.
03
NOA Timing and LUPAs
Each 30-day period needs a Notice of Admission filed within 5 calendar days of the period start date. A late NOA cuts payment by one-thirtieth for each day it's late. A period with fewer visits than its LUPA threshold, between 2 and 6 depending on the case-mix group, pays per visit instead of the full period rate.
04
Telecom Visit Reporting
Since July 1, 2023, agencies must report telecommunications services on the claim: G0320 for audio-video, G0321 for audio-only and G0322 for remote patient monitoring. These lines don't count as visits for payment or LUPA, and a claim that reports one without an in-person visit line in the same discipline is returned.
05
Episode & Hospice Overlaps
A patient already open with another agency, or elected into hospice, changes who can bill and for what. Agencies that skip the eligibility check at intake find out when the claim rejects for an overlapping period.
06
Face-to-Face & Plan of Care
Medicare requires a face-to-face encounter within 90 days before or 30 days after the start of care, related to the primary reason for home health. The record also has to show the patient is homebound and that the certifying practitioner signed the plan of care. A missing signature holds the final claim.
07
OASIS Mismatch Denials
Home health denials often trace back to OASIS answers that don't match the HIPPS code on the claim, functional scores the visit notes don't support, and certifications or recertifications that were never signed.
08
CoPs & HHVBP
Home health agencies bill under the Medicare Conditions of Participation in 42 CFR Part 484. Since 2023, the expanded Home Health Value-Based Purchasing model adjusts each agency's Medicare payments up or down based on quality measures that include OASIS data.
How Qualigenix Keeps Agency Claims Moving
Qualigenix checks each home health period for grouping, timing, authorization and documentation before the final claim goes out. Each fix below answers one of the gaps above, in the same order.
PDGM Coding Review
Coders assign the primary and secondary diagnoses from the referral and the start-of-care visit, then confirm the period groups to a valid clinical group before billing. Qualigenix holds 98.9% coding accuracy with over- and undercoding under 2%.
Pre-Claim Review Support
For agencies in Review Choice Demonstration states, Qualigenix submits pre-claim review requests or manages the postpayment option the agency chose. For Medicare Advantage, staff track authorized visits by discipline and request more before the count runs out.
NOA Filing and Tracking
Qualigenix files each Notice of Admission within the 5-day window and tracks every open 30-day period against its LUPA threshold, so the agency sees low-visit periods while there's time to act.
Telecom Code Reporting
Coders report G0320, G0321 and G0322 lines under the right discipline's revenue code and confirm each claim carries an in-person visit line in the same discipline.
Intake Eligibility Checks
Staff check Medicare eligibility, open home health periods and hospice elections before the start of care. Overlaps get resolved before the agency's first visit, not after the claim rejects.
Certification Tracking
Qualigenix tracks each face-to-face encounter date, homebound documentation and plan-of-care signature, and holds the final claim until all three are in the record.
Denials and ADRs
Qualigenix answers additional documentation requests by their deadlines and appeals denials the record supports. Qualigenix overturns 79% of denials across the 50,000 denials it works each month, with an average appeal turnaround under 9 days.
OASIS-to-Claim Audits
Scheduled audits compare OASIS responses with visit notes and the billed HIPPS code. Qualigenix holds a 98.6% compliance and audit pass rate.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
Home Health Coding for Every Discipline
Qualigenix codes and bills every claim type and discipline a home health agency bills Medicare, Medicare Advantage and Medicaid for.
Routine foot care
11720 and 11721 (nail debridement), 11055, 11056, 11057 (paring or cutting of benign hyperkeratotic lesions), paired with a qualifying systemic diagnosis and class findings, and the correct Q7, Q8, or Q9 modifier.
How We Keep Home Health Billing Compliant
Qualigenix keeps home health billing compliant by billing only periods the record supports under Medicare's home health rules. Each final claim is checked for a timely NOA, a face-to-face encounter in the 90-day or 30-day window, homebound documentation and a signed plan of care. Coders confirm the OASIS supports the HIPPS code and that telecommunications lines are reported the way CMS requires. Underbilling costs the agency revenue it earned, and overbilling invites audits and repayment demands. Qualigenix holds a 98.6% compliance and audit pass rate with an over- and undercoding rate under 2%, and all patient data is handled under HIPAA-compliant security controls.
0%
Audit Pass Rate
<0%
Variance Threshold
Why Home Health Agencies Choose Qualigenix
Home health claims fail on documentation more than on codes, so Qualigenix coders check the OASIS, the certification and the visit notes along with the diagnosis. Medicare's own audit data shows where home health claims go wrong.
0%
Improper Payment Rate
0%
From Doc Gaps
0%
From Coding Errors
$0B
Paid in Error
QUESTIONS BUYERS ASK
Qualigenix quotes home health billing after reviewing your census, payer mix, Review Choice Demonstration status and current A/R, so the fee reflects the work your agency needs. Most agencies start with a free billing audit, and the quote follows from it.
Medicare cuts the period's payment by one-thirtieth for each day from the period start until the NOA is filed. Qualigenix files each NOA within the 5-day window to avoid that reduction.
Qualigenix tracks the face-to-face encounter date, homebound documentation and plan-of-care signature for each patient, and holds the final claim until all three are in the record.
Yes. Qualigenix bills unbilled periods first, then works aging A/R by payer and age, starting with claims closest to timely filing limits. Across Qualigenix clients, days in A/R dropped from 54 to 36.
For agencies in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, Qualigenix submits pre-claim review requests or manages the postpayment review option the agency chose, and tracks each request to an affirmation before billing.
Yes. Coders compare OASIS responses with the visit notes and the HIPPS code before the final claim goes out, and send mismatches back to the clinician for correction.
Qualigenix works across 133 EMR/EHR platforms, including the systems home health agencies commonly use. We confirm your setup on the first call.
Qualigenix onboarding averages 6 days, covering agency software access, EDI setup with your Medicare Administrative Contractor and a first review of open periods. Call 786-259-0231 to schedule a free billing audit and start.