Home Health Billing Basics

HH Episode

A HH episode is a period of up to 60 days in which a HHA provides care for a Medicare beneficiary for whom a HH plan of care has been established by the beneficiary’s physician

• Episodes may be shorter than, but cannot exceed 60 days in length 
• If there is a continuing need for HH care, the beneficiary may receive care for an unlimited number of 60-day episodes

HH PPS

  • Pays HHAs a predetermined base payment for each 60-day episode of care for each Medicare beneficiary

– Adjusted for health condition and care needs of the beneficiary

 – Adjusted for geographic difference in wages for HHAs across the country 

     • Case-mix adjustment 

– Outliers ensure payment for beneficiaries with expensive care needs and unusually high costs

• Case-mix group assigned to a patient’s episode also referred to as an HHRG determined by data from the OASIS 

– HHRG reflected on HHA claim as a HIPPS code 

• HH PPS payment made in two installments 

– RAP (initial payment)

– Episode claim (final payment)

• HIPPS Coding

 – Position 1: Episode Sequence & Therapy Threshold 

 – Position 2-4: Clinical, Functional & Service Domains 

 – Position 5: Non-Routine Supply

Episode Sequence

• Episode Sequencing 

– Early: First or second episode in a sequence of adjacent episodes* 

– Later: Third or later episode in a sequence of adjacent episodes*

• *“Adjacent Episodes” are defined as being separated by no more than 60 days between claims