Home Healthcare Billing For Medicare

Medicare Billing is complicated than it might seem when it comes to home healthcare treatment. It is very important that every visit is perfectly documented and meets requirements to ensure the payment process goes smoothly.

In this blog, tehre are some of the basics you need to know about medicare requirements for home health billing.

Medicare Requirements for Home Health Billing

Medicare pay for home health services if specific criteria met in relation to the patient’s needs. In short, not everyone is eligible for in-home medical care.

Medicare mandates specific guideline for what to pay for and what to deny when a physician or certified nurse practitioner treat/ see a person at their residence or another residential location.

Said guidelines are used to ensure only those with a specific medical treatment receive with additional care and associated cost of home health treatment. By knowing the guidelines, one can easily determine if a Medicare patient is eligible for this type of service.

Patient must meet three key criteria.

Home Confinement

First criteria for home healthcare qualification is that the patient is confined to his or her home. It means in terms of Medicare is that the individual has a condition that makes it very difficult to leave their residence. This may be due to need for special medical equipment like a wheelchair, oxygen tank, crutches, or other similar requirements.

Similarly, patients who has certain medical conditions, such as a terminal illness, serious disability, or other situation when the health condition makes travel contraindicated. Infrequent trips like the need to travel to specific one-time events like family funerals, religious services, and other common errands are not considered disqualifiers for the home confinement guidelines.

Need for Skilled Services

The patient must also be in need of skilled services. As per Medicare guidelines, there must be a documented requirement for either intermittent skilled nursing care for under eight hours per day or a special service, such as a physical therapist, occupational therapist, speech-language pathologist, or other similar providers. The requested services must be reasonable and follow guidelines for the recommended number of visits appropriate for the patient’s needs.

Physician Involvement

Patients must be under the care of a physician and advised for home health by a physician. The patient must have a face-to-face meeting with the recommending physician somewhere between sixty days before or thirty days after the start of home health care. IThe treating home health physician and the recommending physician cannot be the same and must have no financial link between them. This is very important for home health billing and should always be complied accordingly.

Required Documentation

Proper documentation is essential for billing Medicare for home health services. For claim to be paid, there must be perfect evidence in the patient’s medical file corroborating their homebound status, and the reason for the physician’s recommendation for services.

Detailed chart notes with the reasoning for the request and any additional information that would back up the need for home health care to prove medical necessity.

Medicare Cover for Home Health Care - Hours

Once a patient is qualified using the criteria mentioned here in above, there is a limit to the number of hours in which Medicare will pay for home health care. Patients cannot receive more than twenty-eight hours per week with a maximum of no more than eight hours per day. If utmost necessary, Medicare provide an additional thirty-five hours a week of care, determined on a case-by-case basis.

The patient’s plan of care must be recertified by the physician once every sixty days. Even if you’re using the maximum number of hours for care, it should be documented medical necessity every two months to continue at the same level.

Maximum Number of Visits Medicare Cover

There is no specific set number of maximum visits. It is marked by hours, which is detailed here in above.

Medicare guideline mandate that (i) the maximum number of hours cannot be exceeded and (ii) treatment plan certification must be renewed every sixty days to stay in compliance.


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