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Specialty billing Home Health
The Rate Cut Isn't Your Only Problem. Late NOAs, avoidable LUPAs and coding gaps cost agencies money too, and unlike the rate cut, they're fixable.
Home health at a glance
The Real Problem
Here's the part most administrators miss: the rate cut is often a smaller problem than the money already going to late NOAs, avoidable LUPAs, and OASIS coding that doesn't capture how sick your patients really are.
MedixCode's home health billing services are built to close those gaps.
Where the Money Goes
Most agencies don't lose money in one big, obvious way. They lose it in small, quiet ways that add up every single month.
The Notice of Admission is due within 5 calendar days of the start of care. Miss it, and each day from the start of care until the NOA goes in costs 1/30 of that period's payment. Exceptions are up to CMS. Many agencies don't even realize this is happening until cash flow tightens.
If a patient doesn't get enough visits in their 30-day payment period, Medicare stops paying the full episode rate and switches to a lower per-visit rate instead. The LUPA threshold, between 2 and 6 visits, depends on the case-mix group.
Under PDGM, the functional impairment level comes from OASIS items, while the clinical group and comorbidity adjustment come from the diagnosis codes on the claim, and admission source and timing come from Medicare claims history. If OASIS answers or diagnosis codes don't reflect the documented condition, the case-mix weight is wrong, in either direction.
Many patients are in Medicare Advantage plans that may pay per visit instead of per period and often require prior authorization, which takes intake time to chase down.
Under PDGM, the primary diagnosis places the 30-day period in one of 12 clinical groups, which (with the other PDGM factors) determine one of 432 case-mix groups, and that grouping drives the payment. Code the symptom instead of the underlying condition, and the reimbursement drops even though the care didn't change.
How We Solve It
We built our home health revenue cycle management service around the exact points where agencies lose money, not around generic billing tasks.
We track each start of care against the 5-day clock and submit before the deadline, with a documented exception-request process for the edge cases that come up.
Our AAPC/CPC Certified Coders and Billers check that diagnosis codes match the clinical record and flag OASIS answers that don't match the documentation, so clinicians can review them. Your clinicians own the OASIS assessment.
We track visit counts against each case-mix group's threshold as the 30-day period progresses, and flag at-risk episodes while there's still time to act, not after the claim has already paid short.
There's no new software for your staff and no duplicate work in a separate portal. Your team sets our access, and the agency keeps ownership of its data.
Book a free consultation.
Book a Free Consultation2026 Payment Changes
With the 1.023% permanent and 3.0% temporary adjustments outweighing the 2.4% update, CMS estimates home health payments fall about 1.3% in 2026.
Net estimated effect: −1.3% in aggregate. The adjustments apply to the 30-day period rate, not to LUPA per-visit payments.
Source: CMS CY 2026 HH PPS final rule (CMS-1828-F), November 28, 2025; CMS OASIS-E2 guidance manual.
In a year where the rate is lower, losing money to coding gaps, late NOAs or missed LUPA thresholds hurts more.
Why MedixCode
Home health billing has its own rules, and we treat it that way.
FAQ
The home health billing questions we hear most often. More questions? See our FAQ
Medicare pays in 30-day periods. Payment depends on the clinical group from the primary diagnosis, comorbidities from the other diagnosis codes, the admission source and timing from Medicare claims history, and the functional impairment level from OASIS. Together they produce the HIPPS code.
A Low Utilization Payment Adjustment applies when a 30-day period has fewer visits than its case-mix group's threshold (2 to 6 visits, depending on the group). Medicare then pays each visit at the national per-visit rate instead of the period payment.
Within 5 calendar days of the start of care. If it's late, Medicare reduces the period's payment by 1/30 for each day from the start of care until the NOA is submitted, unless CMS grants an exception.
It's the code on the claim that tells Medicare which PDGM case-mix group the 30-day period falls in. It reflects the diagnosis codes, admission source, timing and the OASIS functional items, so accurate coding and OASIS answers that match the chart both matter.
OASIS-E2 is the current version of the Outcome and Assessment Information Set, effective April 1, 2026. It updates several items agencies use to document patient condition.
No. Medicare replaced the Request for Anticipated Payment (RAP) with the one-time Notice of Admission starting in 2022. We file NOAs and final claims.
Next Step
We'll talk through your NOA timeliness, LUPA rate and coding, and where revenue may be slipping.
Agencies can also email info@medixcode.com.
