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Best guidelines for home healthcare medical billing and coding

Best Guidelines For Home Healthcare Medical Billing And Coding


Home healthcare is about providing medical care to the patient when he cannot visit the hospital. This usually happens when patients cannot leave their homes due to illness, surgery, injury, or a chronic health issue. The main goal of providing a Home Health Facility is to keep the patient healthy under severe circumstances. It has been observed that Medicare, Medicaid, and other insurance companies often cover these types of services. However, there are some rules and regulations in providing such services because any failure to comply with these regulations makes the medical billing and claim reimbursement process very complex.

In order to qualify for a Home healthcare facility, there are specific rules. For instance, the patient must be home bound, which means he should only be able to visit the hospital with help. There is a team of professionals who declare the patient Home bound and make him eligible to provide Home healthcare. If the patient is unable to leave home, it is not possible to make essential things like appointments, religious activities, or family events. All these matters are discussed carefully before declaring a patient is Home bound.

Can I get a Home Healthcare facility?

Yes, if you meet certain conditions and make doctors believe that it is difficult for you to visit the hospital, then a Home Healthcare facility can be taken. In such cases, the professionals like Medicare, Medicaid, and insurance companies can cover these services.

Home healthcare covers various health-related facilities. For instance, it specifically involves occasional assistance from skilled professionals from nurses, physical therapists, occupational therapists, or other kinds of healthcare professionals like speech therapists. All these healthcare professionals well examine the patient before providing specific treatment. These professionals create a care plan for the patient and monitor progress in the health care over time. By and large, it can be said that all this leads to providing quality health care to the customer while staying at home.

What kinds of healthcare services can I get at home?

There are different kinds of healthcare services that you can get at home. For instance, you can invite doctors, Nurses, Therapists, and other healthcare professionals depending upon your need. There are key benefits of Home healthcare facilities.

Doctor’s Visits

Sometimes, a doctor can come to your house to check on you and treat you for your illness. From the medical billing and coding perspective, this is a crucial event. This is because of the fact that the visits of doctors generate billings, which also involve insurance providers in the process. For that reason, there must be a clear understanding between the doctor and insurance providers. All regulations and rules must be kept in mind.

Nursing Care

If you are alone and unable to take care of yourself, you can also call Nursing Care. This is the most common type of home healthcare. However, it also carries the same complexities from the medical billing and coding perspective. A nurse will make a plan with your doctor to take care of you at home that will certainly generate medical bills and codes. The services provided by the Nurse can include changing dressings, providing anti biotics on wounds, giving medicine on time, monitoring the health status, and other health related services. All these services make the medical coding and billing process complex.


This is one of the kind of advantages that comes with Home Healthcare. For instance, if you need to learn how things can get better after being sick, therapists can help you in an effective manner. Physical therapists can work with you to get your muscles and joints working better. Occupational therapists can also help the patients in meeting their daily tasks like eating, bathing, and getting dressed.

Social Support

Social workers can give you advice and find resources to help you get better. Sometimes, they even manage all the different services you need if your health is very complicated.

Home Health Aides

Home Health Aides can help a patient in meeting his basic personal needs. These needs might include getting out of bed early in the morning, walking, and dressing. Some of them have special training that helps them to do more advanced care in a professional manner.

The Significance of Medical Billing and Coding in Home Healthcare

A home healthcare provider has diverse tasks to manage, like any other hospital and healthcare department. However, it is also important to note here that all these facilities are quite similar to the facilities provided in the hospitals. For that reason, the medical billing and coding process in such circumstances becomes more crucial. The visiting doctor or any other healthcare professional should generate good medical billing codes for claim reimbursements.

The medical billing and coding process in the home Health is a matter of great concern. A general medical coding and billing process starts with documenting the patient’s diagnosis. In the very first phase, the health issues concerning the patient are checked and deeply examined. This is crucial for setting the scope of the entire medical billing and coding process.

Once the correct diagnosis code is determined, the medical billing process begins. Medical billing codes are generated under the supervision of billing professionals. Following those steps, these codes are sent to the insurance company for claim reimbursements. There are important points that must be considered in the medical billing and coding concerning Home Healthcare.

Precision of Coding

The challenge in medical coding and billing is precise diagnosis recording. The code must accurately represent the care given to the patient. Because it sets the scope of entire billing processes and the success or failure of a claim depends on the precision of medical coding. Inaccurate medical coding submitted for medical billing increases the chance of claim rejection first hand.

This is not only frustrating but also time consuming. In the professional world, time equals the money. In simple words, frequent errors arising in medical coding can lead to great financial losses. On the other hand, accurate medical coding from the beginning of the medical billing process plays a positive role. It not only saves money but also provides better service to patients.

Ensure MBS Helps You Best In Medical Billing And Coding

In order to excel in the field of Home Healthcare, a strong understanding of home medical billing and coding is essential. Ensure MBS offers exceptional guidelines and content to make you thrilled in the medical billing and coding process. It has a team of professionals who are proficient in managing claims and denials.

Ensure MBS provides the essential tools for your journey in medical billing and coding. Whether you’re entering the home health field or a traditional hospital setting, it all begins with that first step. Don’t hesitate to reach out to Ensure MBS today!

Top 10 Home Healthcare HCPCS codes

Although there are different types of Home health codes, the top 10 codes that are being used have been discussed in this article.

  1. T1019 – This is a Personal care services Code.
  2. G0299 – This code is used for billing the Skilled nursing services by an RN.
  3. G0151 – This code is used for billing the Services by a qualified physical therapist.
  4. G0300 – This code is used for billing the Skilled nursing services by an LPN.
  5. G0156 – This code is used for billing the Home health/hospice aide services.
  6. Q5001 – This code is used for billing the Hospice or home health care in the patient’s home
  7. G0152 – This code is used for billing the Services by a qualified occupational therapist
  8. S5125 – This code is used for billing the Attendant care services
  9. G0157 – This code is used for billing the Services by a qualified physical therapist assistant
  10. S9131 – This code is used for billing the Physical therapy in the home, and this is generated on a daily basis.

Home Healthcare Medical Billing and Coding

In the realm of home healthcare medical billing, there are various codes and classifications that play a crucial role in managing and processing claims efficiently. These codes and classifications ensure that services are billed accurately. This also ensures that patients receive the care they need on time. Some of these essential codes have been explored down there.

Type of Bill (TOB)

The Type of Bill is often referred to as TOB. It is a kind of code that specifies the nature of a healthcare claim. From home healthcare, TOB codes are essential because they help in differentiating various types of claims. For instance, if there is a need for a contractor adjustment, the TOB might be 3XG or 3XI.

These codes are outlined in CMS Pub. 100-04, Chapter 10. It is important to consider that the second digit of Home Healthcare Prospective Payment System (HHPPS) TOBs may change from 2 to 3 spontaneously by the Fiscal Intermediary Standard System (FISS).

Core Based Statistical Area (CBSA) Value Code

The Core Based Statistical Area (CBSA) Value Code is used to identify geographic regions for Medicare medical billing purposes. It helps in determining the payment rate for services that are being provided in specific areas. Considering the fact that Medicare is the primary or secondary payer, it is crucial to focus on other value codes, such as those detailed in CMS Pub. 100-04.

Priority of Admission/ Visit Codes

Priority of Admission codes are crucial for indicating the requirements concerning the visits to the location of the patient. These codes help healthcare providers to primarily focus on the care perspective. For instance, code 1 might signify an emergency admission, and code 4 could indicate a newborn admission. Both of these codes are entirely different. Therefore, making mistakes in Understanding these codes can lead to claim denials and claim rejections.

Patient Status Codes

Patient Status Codes are used to describe the health condition of the patients. These codes also reflect the outcome associated with the home healthcare treatment. These codes provide vital information about whether a patient was discharged home, transferred to another facility, or left against medical advice. These codes are crucial because these codes reflect the journey of a patient through different health conditions. It also helps the insurance companies to determine the skill level of the medical care provider that is involved in the Home healthcare.

Common Revenue Codes and HCPCS /HIPPS Rate Codes

Revenue codes are used to classify services or items provided during the treatment phase. These codes help in identifying the type of service and its associated cost. Similarly, HCPCS (Healthcare Common Procedure Coding System) codes are used to describe specific healthcare services, such as medical procedures or supplies. They are crucial for accurate medical billing and reimbursement.

Common Home Healthcare Billing Errors by Reason Code

Medical billing errors can lead to claim denials or delays in reimbursement. Understanding common medical billing errors and their resolution is essential. For example, a status code 30 is used if the medical bill is submitted within 60 days. However, if a medical bill is submitted after 60 days of service, the status code must change. This can lead to claim rejection. That is the reason timely medical billing helps in preventing claim rejections.

By and large, it can be said that these codes are the backbone of home healthcare medical billing. They help in accurately documenting and processing claims. These codes are crucial and help in ensuring that patients receive timely and appropriate care. Healthcare providers, billers, and coders must be educated about these codes to deal with the complex Home healthcare. By following these guidelines, the healthcare system can operate efficiently. This streamlined process helps the hospital to provide quality care to patients along with a fair or clean reimbursement process.

Common Medical Codes Used In Home Healthcare

CPT Codes

CPT codes 99324 – 99337 cover visits to places like rest homes, assisted living facilities, and nursing homes. These visits happen in the living space or a designated area of the patients. To request this service for the first time, it should come from the patient and any other family member of the patient who is legally authorised to make a request. Visiting healthcare providers are not allowed to directly solicit residents. There are rules and guidelines specified under HCPCS /HIPPS that limit the role and responsibilities of the patient, healthcare provider, and insurance company. For instance, an inappropriate form of solicitation generally includes knocking on doors or making unsolicited phone calls to patients.

Home Visit Codes

CPT codes 99341 – 99350 specifically deal with home visits. As the name specifies, these codes are used when doctors make visits to the house of a patient. These codes ensure that the services should be unique and not duplicating. That’s means these codes help the doctors to generate multiple medical billing codes for the same kind of healthcare facility. Similarly, these codes also prevent doctors from generating identical medical billing codes for two different kinds of services.

Apart from that, it has also been observed that home healthcare services and services from a physician or qualified non-physician practitioner (NPP) can happen on the same day. Such medical treatment can lead to duplicate or incorrect medical billing. However, these codes ensure that all billing codes must be unique.

Key Guidelines

There are three important guidelines for effectively managing the medical billing and coding process.

  1. The first guideline is concerning to additional healthcare professionals. For instance, when a patient is already receiving home healthcare, the primary treating doctor works closely with the home health agency. In this ongoing treatment, the other healthcare professionals are unlikely to be involved in the care of these beneficiaries.
  2. Diagnostic tests done during a home or domiciliary visit must be ordered or personally conducted by the physician or qualified NPP who is serving as the provider of record.
  3. The provider of record is responsible for managing the entire disease process during his visits.

Home Healthcare Revenue Cycle Management

Home Healthcare Qualification

This is the first stage of Home healthcare revenue management. At this stage, it is imperative to determine if a patient really qualifies for Home healthcare. This is a comprehensive process in which the doctor determines if the patient is unable to make frequent visits to the hospital or has some chronic disease.

In-Take Process

The patient intake process involves collecting information like personal and clinical data, insurance, and payments before making visits to the location of the patients. This is a crucial step in the revenue cycle because it determines the accuracy and scope of the entire billing process and directly contributes to revenue. All this substantial information helps in ensuring payment availability, assigning a care team, and scheduling visits.

Collection of Orders and Referrals

Before accepting a patient, the intake coordinator gathers essential documents. For instance, the coordinator may ask for medical history, home healthcare orders, medication lists, and patient demographics.

Real-Time Eligibility and Benefits Verification

The insurance team checks if the insurance plans of the patient cover specific care. In order words, at this stage, the eligibility of the patient, policy details, and risk of claim denials are discussed in detail.

Plotting of Healthcare Providers and Services

This is also a crucial step in the home healthcare revenue management cycle. Once eligibility is confirmed, home healthcare services are assigned to appropriate healthcare provider. Meeting schedules are set as per the requirements of the patient. This step is considered imperative because assigning appropriate healthcare professionals to a patient increases the satisfaction level.

Prior Authorisations Requirement

Prior authorisation is very crucial because it eliminates the risk of claim denial in further. However, this process step increases the complexity of medical billing processes, but it also reduces the risk of claim delays and claims denials. If insurance companies feel any doubt, they can ask for prior authorisations. In this process, the eligibility and expertise of the healthcare provider are examined.

QA Verification

Quality Assurance ensures the accuracy of orders for nursing and therapy. Corrections are made if necessary.

OASIS Review: OASIS is a standardized assessment tool. This tool is used to ensure accuracy and compliance. This tool is quite helpful in tracking the patient’s health status over time and allows the insurance providers to assess the quality of home healthcare.

Medical Coding: Diagnoses are coded based on referral information, and the severity is marked as per agency guidelines.

Orders Management: Home care orders from physicians are collected and sent for signature, which is necessary for billing and audits.

Charges and Billing: Medical Billing staff use medical codes and terminology to prepare and submit claims to insurers. They ensure claim accuracy and proper medical coding before submission.

Payments: Medicare contractors send payments and remittance advice electronically or in paper format to healthcare providers.

Rejections and ADRs: Rejected claims mean they need correction before payment. Additional development requests (ADR) may be needed to determine medical necessity.

Medicare DDE: Medicare DDE (Direct Data Entry) is a system for submitting claims and checking claim statuses.

Suspended Claims: Claims under review by Medicare are in “suspense.” Providers often don’t need to act, but corrections may be required.

Claims Correction (T-Status): When claims contain errors, they are returned to providers for corrections. This often involves fixing patient information.

Rejected Claims: Claims that can’t be paid in their current state due to errors or eligibility issues.

A/R Follow-ups and Denials: Providers follow up on unpaid claims (A/R) and address denials is quite imperative. This is because of the reason, the denials can be resubmitted after making certain corrections. However, improper denials can lead to time wastage and exhaust resources.

Selecting The Best Medical Billing Company

There are five crucial steps to selecting a medical billing services provider for home healthcare medical billing and coding.

Billing Expertise

It is imperative to Look for a provider with not only medical billing and management experience but also specialisation in the field. It is an important step because having access to professionals results in high-quality service and successful outcomes.

Quick Turnaround

A proficient team, efficient systems, and ample resources should enable the medical billing services to plan and execute support services quickly. This minimises the risk of delays in processing.


The medical billing services must have the capability to adapt and grow as per the requirements of healthcare. That means the company should not have restricted aspects that can frustrate patients in the future. It must have up-to-date knowledge of technological advancement and good medical billing software. The company should offer specialised medical billing and financial solutions that can deal with specific requirements.

Tech Savvy

Technological advancement is really crucial because selecting a company that stays up-to-date with the latest software and technology is always productive and beneficial. This ensures fast and efficient medical coding input and collection processes, reducing delays.

Personalised Services

Every customer deserves individualised attention. Having a dedicated manager who offers personalised support not only fosters transparency but also provides you with a clear understanding of your performance.


Home healthcare is about providing medical assistance to patients who cannot visit a hospital due to illness, surgery, injury, or chronic health issues. The primary goal is to maintain the health of the patient under these circumstances. Medicare, Medicaid, and other insurance companies often cover these services. However, strict regulations must be followed to ensure smooth medical billing and claim reimbursement.

In order to qualify for home health care, specific rules apply. For instance, Patients must be “home bound,” That’s means they cannot leave home without assistance. A team of professionals assesses and certifies the home bound status of a patient. This is usually done by considering factors such as appointments, religious activities, and family events. Home healthcare includes various services, such as occasional assistance from skilled professionals, physical therapists, and occupational therapists. These professionals are capable enough to examine the health condition of the patient. Following that, they create care plans and monitor progress. All this ultimately provides quality healthcare at home.

In the home health field, accurate medical billing and coding are crucial for successful claim reimbursement. The process starts with documenting the diagnosis details of a patient. This is essential for ensuring that the codes are accurately represented. Precise coding can easily prevent claim rejection and save time and money. To excel in home healthcare, a strong understanding of medical billing and coding is essential. Ensure MBS offers guidelines and support in this regard. Ensure MBS, with a team of professionals, is well proficient in managing claims and denials.

By and large, it can be concluded that home health care is a vital service for patients who are unable to visit hospitals. However, It requires precise medical billing and coding to ensure proper reimbursement. Last but not least, understanding and following guidelines always help in accurate medical coding and selecting the right medical billing partner for delivering quality home healthcare.

Frequently Asked Questions

What is Home Healthcare Service?

Home healthcare is typically provided to patients who are unable to visit a hospital due to illness, surgery, injury, or chronic health issues. Eligibility often depends on meeting specific criteria, such as being “home bound,” as assessed by a team of healthcare professionals.

What types of services are offered in home healthcare?

Home healthcare includes a range of services. Some primary services include Visits to Doctors, nursing care, and all kinds of therapy, such as physical, occupational, and speech. In the meantime, home healthcare can also offer social support and assistance from home health aides.

What is medical billing and coding work in home health care?

Medical Billing and coding in home healthcare starts with documenting the diagnosis of a patient. It is then followed by generating accurate billing codes. These codes are crucial for reimbursement. Errors in medical coding can lead to claim rejection. For that reason, it is imperative to focus on precision and compliance with the regulations.

Can I get insurance coverage for home healthcare?

Yes, many insurance plans are available in this regard. For instance, Medicare, Medicaid, and private insurance companies are available that cover home healthcare services. However, it is important to note that eligibility and coverage specifics can vary. For that reason, it is essential to consult with the insurance provider to understand potential risks and benefits.

How to select best medical billing services company for home healthcare?

Selecting the best medical billing services provider for home healthcare requires understanding of basic claim reimbursement process. In order to select the best medical billing services company, it is essential to consider factors like medical billing expertise of the target Company, improvement time, scalability, technology proficiency, and personalised support. A competent medical billing partner like Ensure MBS is crucial for efficient operations and timely reimbursement.

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