Home Health Billing (PDGM) Services
30-day periods, NOA filing, HIPPS from OASIS-E1. Our home health billers and coders work inside HCHB, Kinnser, WellSky, MatrixCare Home Health, and Brightree. We bill 30-day periods, file the Notice of Admission, build HIPPS codes from OASIS-E1, watch LUPA thresholds, and chase aged AR for 800+ providers.
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0:48PDGM 30-day periods, OASIS-E1, and LUPA exposure are eating your cash.
PDGM shifted home health from 60-day episodes to 30-day periods in 2020 with no Request for Anticipated Payment cash advance. Now the Notice of Admission (NOA) is your only on-time filing protection. Miss it by even a day and the agency absorbs the penalty.
NOA late-filing penalties
The NOA must be filed within 5 calendar days of the Start of Care. Late NOAs reduce the period payment by 1/30th for every day past the deadline (CMS HH PPS Final Rule). Agencies that file even 2 days late lose 7 percent of that period.
LUPA thresholds cut payments
Each of the 432 PDGM case-mix combinations has its own LUPA threshold (Low Utilization Payment Adjustment). Fall below the visit count and the period drops to a per-visit rate instead of the case-mix payment, often a 60 to 70 percent revenue loss.
OASIS-E1 driving wrong HIPPS
OASIS-E1 became effective January 2025 with new social determinants of health items and revised functional scoring. One miscoded M item can change the functional impairment level, shift the clinical grouping, and change the HIPPS code and rate.
Tell us about your agency.
Send us your situation and our team will scope the right setup, usually within one business day. No obligation.
What is a home health PDGM billing service ?
A home health PDGM billing service is a remote billing team that works inside your home health EMR, files the Notice of Admission inside the 5-day window, builds HIPPS codes from your OASIS-E1 data, watches LUPA thresholds before the period closes, and submits the 30-day period claim through the 837i transaction set. Not a generic medical biller. A PDGM-trained specialist who understands the 12 clinical groupings, the 432 case-mix combinations, and the difference between an early and late 30-day period.
What your home health PDGM billing pod handles, day to day
Pick the queues that hurt most. Your PDGM pod absorbs them. Your in-house staff focuses on visit scheduling, clinician coverage, and survey readiness.
NOA submission inside 5 days
Files the Notice of Admission for every Start of Care episode. Tracks the 5-calendar-day window. Reports any potential late filing same day.
OASIS-E1 review and HIPPS
Reviews OASIS-E1 M items, builds the HIPPS code that ties to the right clinical grouping, functional impairment level, and co-morbidity adjustment.
30-day period claim build
Builds 837i institutional claims at period end. Reconciles the HIPPS code to the actual visits delivered. Submits before the period 60-day filing deadline.
LUPA threshold monitoring
Tracks the visit threshold for each of the 432 case-mix combinations. Flags periods at risk of LUPA before the period closes so clinical can plan visits.
Payment posting and ERA
Posts ERA 835 files. Reconciles to bank deposits. Splits secondary balances. Flags underpayments against the case-mix payment expected.
Eligibility and authorization
Runs 270 and 271 eligibility checks for Traditional Medicare and MA plans. Tracks MA plan auths and re-auth timing for periods 2 through N.
Denial management and appeals
Reads CARC and RARC codes on the 835. Drafts appeal letters for OASIS-related denials, medical necessity denials, and MA plan downgrades.
RCM reports and KPIs
Daily clean-claim rate by period, NOA on-time percent, LUPA percent of total periods, denial rate by payer, DSO, and AR over 90.
PDGM trained billers, not generic medical coders
Most outsourcing companies offer general medical coders and call them home health billers. We do not. Our PDGM specialists are tested on the 12 clinical groupings, the 432 case-mix combinations, OASIS-E1 M items, and at least one home health platform before placement.
PDGM trained, not generic
Every biller passes an assessment on 30-day periods, NOA filing windows, OASIS-E1 driven HIPPS coding, LUPA thresholds, and at least one platform from HCHB, Kinnser, WellSky, or Axxess before placement.
Stacked compliance posture
HIPAA + SOC 2 Type II + ISO 27001 + HITRUST. Plus alignment with 42 CFR 484 home health conditions of participation and 45 CFR 164.514 de-identification rules. Ask your current vendor for proof of all four.
2-Week Risk-Free Pilot
Industry offers no trial. We give you 14 days of live PDGM claim work at the same rate. Cancel before day 14, owe nothing. No annual contracts after.
Staffingly vs DIY in-house vs generic offshore vs onshore BPO
The real cost math for a single full-time home health biller or coder role at a mid-size agency.
From "let's talk" to live in 1 to 2 weeks
Six steps. Each one is documented. Nothing is mysterious.
Discovery call (15 min)
Tell us which PDGM pain is loudest. NOA late filings? LUPA percent too high? HIPPS rate downgrades? OASIS-E1 coding gaps? We map it on a shared call.
BAA + platform access
Business associate agreement signed. Role-based access provisioned in HCHB, Kinnser, WellSky, MatrixCare Home Health, Brightree, or Axxess.
Workflow shadow (2 to 3 days)
Your PDGM pod shadows your billing lead and clinical intake. NOA cadence captured. OASIS review queue logged. Escalation rules locked.
Parallel pilot starts
Week 2 to 3. Your PDGM pod runs alongside your team. Daily 15-minute sync. You see every NOA filed, every HIPPS built, every 30-day period claimed.
Decision point (end of week 2)
Pilot results reviewed. Go or no-go. No penalty if you cancel. Most agencies keep going.
Full handoff, cadence locked
NOA on-time percent, LUPA percent, denial rate, DSO, and AR over 90 KPIs in your inbox. Weekly review with your account lead. Monthly QA audit.
How Staffingly works, in practice
Inside the workA trained Staffingly specialist works inside your existing platform, with clear escalation back to your team.
One Flat Weekly Rate. No Surprises.
Dedicated senior care schedulers at a fixed weekly cost. Per scheduler FTE, per week. No contracts, no minimums, no hidden fees.
Want to compare against an in-house hire? Use the savings calculator.
Frequently asked questions
Why did home health move from 60-day episodes to 30-day periods, and what changed in 2020?
The Patient-Driven Groupings Model (PDGM) took effect January 1, 2020 under the CMS Home Health PPS Final Rule. It replaced the 60-day episode under HHRG with a 30-day period payment structure tied to 432 case-mix combinations. Each 60-day certification now generates two 30-day periods. The case-mix is built from timing, admission source, clinical grouping (12 options), functional impairment level, and co-morbidity adjustment.
What is the Notice of Admission (NOA), when must it be filed, and what happens if it is late?
The Notice of Admission replaced the RAP for episodes starting January 1, 2022. The NOA must be filed within 5 calendar days of the Start of Care. There is no cash advance with the NOA. If the NOA is filed late, the period payment is reduced by 1/30th for each calendar day past the deadline. A 5-day late NOA cuts roughly 17 percent off that period. Subsequent 30-day periods in the same certification do not require a new NOA.
How is the HIPPS code calculated under PDGM, and what drives it?
The HIPPS code is a 5-character code that maps to one of the 432 PDGM case-mix combinations. It is built from timing (early or late), admission source (community or institutional), clinical grouping (12 options), functional impairment level (derived from OASIS-E1 M items), and co-morbidity adjustment (none, low, or high based on secondary diagnoses).
How does OASIS-E1 impact billing, and what changed in January 2025?
OASIS-E1 became the active assessment instrument on January 1, 2025. It added new social determinants of health items, revised functional scoring items, and updated several M items used in PDGM HIPPS calculation. The functional impairment level is calculated from specific OASIS-E1 M items including M1810, M1820, M1830, M1840, M1850, M1860, and M1033. One miscoded M item can shift the functional level and change the HIPPS code and period payment.
What is a LUPA, and how do I avoid one?
A Low Utilization Payment Adjustment (LUPA) happens when the number of visits delivered in a 30-day period falls below the LUPA threshold for that period's case-mix combination. Each of the 432 PDGM combinations has its own threshold (typically 2 to 6 visits). When LUPA triggers, the period drops from the case-mix payment to a per-visit payment, often a 60 to 70 percent revenue reduction. Our billers monitor visit counts mid-period and flag LUPA risk.
How do you handle the second 30-day period and recertifications?
Each 60-day certification generates two 30-day periods. Period 1 is early and Period 2 is late in PDGM timing. No new NOA is needed for Period 2 within the same certification. For recertification at day 56 to 60, a new OASIS Recertification assessment drives a new HIPPS code for the next certification. We build the period 2 claim at day 30, the recertification HIPPS at day 60, and the period 3 claim at day 90.
How does pricing work for home health PDGM billing?
Per PDGM specialist FTE, per week. Per-skill pricing for biller, coder, AR follow-up specialist, and denial analyst roles. No setup fees. $399 Standard, $349 Volume (3 or more), $299 Enterprise (10 or more). Add or remove specialists by the week. No annual contracts.
What is included in the 2-Week Risk-Free Pilot for home health PDGM billing?
Two weeks of live PDGM billing and RCM work running in parallel with your business office. Full reporting on NOA on-time percent, clean-claim rate by period, LUPA percent of total periods, denial rate, and AR over 90 reduction. No setup fee. No penalty if you cancel before day 14.
President and CEO, Staffingly, Inc. 25+ years in IT consulting and healthcare BPO operations. One of the earliest US operators to set up an RPO/BPO delivery network in India. Leads AI-driven home care workflows that help agencies, home health providers, and multi-branch operators cut admin cost without compromising care.
