Home Health Billing Checklist: Forms, Codes, and Documentation Must-Haves

Accurate home health billing is essential for maintaining regulatory compliance, avoiding claim denials, and preserving the financial stability of a Medicare-certified home health agency. Billing under the Patient-Driven Groupings Model (PDGM) is complex and highly regulated, requiring correct forms, codes, documentation, and timing. CMS surveyors, MAC auditors, and UPICs routinely cite agencies for insufficient documentation, incorrect HIPPS codes, missing signatures, invalid face-to-face encounters, or unverified orders.

This comprehensive billing checklist outlines everything your home health agency must have in place to submit Medicare claims correctly. All citations use Option A full URLs inside the sentence.

1. Required CMS Forms for Home Health Billing

Medicare home health claims rely on specific required forms. Surveyors and MACs verify that each required form is properly completed, signed, dated, and stored in the clinical record.

CMS-485 / Plan of Care (or EMR equivalent)

The POC must meet requirements under 42 CFR 484.60 (https://www.ecfr.gov/current/title-42/section-484.60).

Required elements include:

• Diagnoses

• Visit frequencies

• Measurable goals

• Orders

• Patient-specific interventions

• Physician signature and date (required for billing)

• Changes in condition reflected in POC updates

CMS-486 Medical Review Form

Used for certain audits and medical review situations. Must accurately reflect the patient’s care needs and clinical documentation.

CMS-1450 (UB-04) Claim Form

The official institutional claim form required for Medicare billing.
UB-04 format requirements are referenced at:
https://www.cms.gov/Medicare/Billing/MedicareBillingForms

CMS-2567 (Survey Deficiency Form)

While not part of billing, deficiencies related to billing processes may appear on a CMS-2567.
Sample form: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf

2. Mandatory Documentation for Every Billable Claim

To bill Medicare, agencies must meet the fundamental documentation requirements outlined in 42 CFR 424.22 – Requirements for Home Health Services (https://www.ecfr.gov/current/title-42/section-424.22).

The following must exist before billing:

Valid Face-to-Face Encounter (F2F)

Required under 42 CFR 424.22(a)(1)
https://www.ecfr.gov/current/title-42/section-424.22

F2F encounter must:

• Occur 90 days before or 30 days after SOC

• Be performed by an allowed practitioner

• Include documentation supporting homebound status and need for skilled care

• Contain patient-specific clinical findings

Certification & Recertification Statements

Physician certification is required under 42 CFR 424.22(a)(2)
https://www.ecfr.gov/current/title-42/section-424.22

The certification must include:

• Need for skilled services

• Homebound status

• Plan of care established and reviewed by a physician

• Physician signature and date

Complete OASIS Documentation Requirements

OASIS must be completed and locked according to 42 CFR 484.55
https://www.ecfr.gov/current/title-42/section-484.55

Required OASIS timepoints:

• SOC

• ROC

• Recertification

• Transfer

• Death

• Discharge

Homebound Status Documentation

Must meet CMS’s definition in the Medicare Benefit Policy Manual Chapter 7:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

Documentation must prove:

• Patient requires assistance to leave home

• Leaving home is a taxing effort

• Patient leaves home infrequently

Skilled Need Documentation

Notes must show why the patient requires skilled nursing, therapy, or medical social work.

CMS requires this under 42 CFR 409.42
https://www.ecfr.gov/current/title-42/section-409.42

3. Required Codes for Home Health Billing

Billing under PDGM uses HIPPS codes, occurrence codes, revenue codes, and diagnosis codes (ICD-10).

a. HIPPS Codes (Home Health PDGM Codes)

HIPPS codes are based on OASIS and diagnosis groups.
Details: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center

Surveyors check that MOR (Medicare Outlier Review) and QIES/OASIS data match the HIPPS billed.

b. ICD-10 Diagnosis Coding

Diagnosis coding must reflect:

• Primary reason for skilled care

• Secondary comorbidities affecting the plan of care

Diagnosis coding guidelines:
https://www.cdc.gov/nchs/icd/icd10cm.htm

Incorrect diagnosis selection can trigger PDGM payment errors.

c. Revenue Codes

Key home health revenue codes include:

• 042x – Physical therapy

• 043x – Occupational therapy

• 044x – Speech therapy

• 055x – Skilled nursing

• 057x – Home health aide

Revenue code instructions referenced at:
https://www.cms.gov/Medicare/Billing/CMSBillingCodes

d. Occurrence Codes

Required codes include:

• 61 – Certification period start

• 62 – Recertification period start

• 32 – Occurrence related to F2F (if applicable)

Details: https://www.cms.gov/Medicare/Billing/MedicareBillingCodes

4. Required Documentation for PDGM Billing

Under PDGM, payment is driven by documentation supporting:

• Functional impairment level

• Clinical grouping

• Comorbidity adjustment

• Timeliness of RAP/NOA and claim submission

NOA (Notice of Admission)

Required under CMS Change Request 12477:
https://www.cms.gov/files/document/r12477cp.pdf

NOA must be submitted:

• Within 5 calendar days of the SOC

• To avoid daily penalties

Final Claim (RAP no longer required)

Final billing cannot occur until:

• OASIS is completed

• POC is signed

• All visits are documented

• All orders are signed

• Homebound criteria validated

• LUPA thresholds evaluated

Documentation must support payment grouping.

5. Items Surveyors Examine During Billing Audits

Surveyors evaluate whether billed services were:

• Ordered

• Provided

• Documented

• Reasonable

• Necessary

• Homebound-qualifying

• Skilled

They look for:

Inconsistencies

(Example: POC frequency 3x weekly, but notes show only 1 visit.)

Missing signatures

Every clinical visit must be signed with:

• Name

• Credentials

• Date

• Time (best practice)

Unsigned or missing orders

Billing cannot occur until orders are signed:
https://www.ecfr.gov/current/title-42/section-484.60

Documentation not matching HIPPS code

If functional level documentation does not justify OASIS scoring, claims may be recoded or denied.

Late NOA

CMS applies penalties automatically.

6. Internal Billing Checklist for Agencies

Below is a complete internal billing checklist for compliance.

Before Billing

• F2F valid and compliant

• Certification statement complete

• OASIS locked

• Physician-signed POC

• All orders signed and filed

• Documentation supports homebound status

• Documentation supports skilled need

• No visit gaps requiring explanation

• HIPPS matches OASIS

• ICD-10 codes reviewed

• Comorbidity codes validated

• Supervisory visits completed (required every 14 days for HHAs under 42 CFR 484.80)
  https://www.ecfr.gov/current/title-42/section-484.80

Before Claim Submission

• NOA submitted on time

• Visit logs complete

• All disciplines signed documentation

• All missed visits documented

• Medication reconciliation completed

• Discharge or transfer OASIS completed if applicable

• Clinician signatures meet CMS standards

7. Tools and Documentation Surveyors Expect to See

Surveyors expect agencies to maintain:

• Billing policies and procedures

• Coding policies

• Documentation guidelines

• Face-to-face process map

• NOA submission logs

• Internal billing audits

• ADR/TPE response logs

• Billing compliance monitoring tools

CMS requires ongoing monitoring under the QAPI Condition at 42 CFR 484.65
https://www.ecfr.gov/current/title-42/section-484.65

8. Avoiding Common Causes of Claim Denials

Top denial reasons include:

• Invalid or missing F2F

• Missing POC signatures

• Incomplete or conflicting documentation

• Diagnoses that do not support skilled need

• Missing orders

• Visit notes lacking measurable documentation

• LUPA thresholds not met

• Late NOA

Surveyors link these issues to noncompliance with 42 CFR 424.22, 484.60, and 409.42.

Conclusion

Billing for home health under Medicare requires complete and accurate documentation, valid orders, compliant OASIS assessments, proper coding, timely NOA submissions, and strict adherence to CMS regulations. Errors in any part of the process can lead to denials, audits, penalties, and survey deficiencies.

For home health agencies needing expert guidance on billing compliance, documentation audits, policy development, or ADR/TPE support, SummitRidge Consulting provides complete operational and regulatory solutions to ensure accurate billing and sustained compliance.