Home Health

What is Home Health?

Home health care is a wide range of health care services that are given in the home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as a hospital or skilled nursing facility (SNF).

Learn more from AOTA: Home Health Fact Sheet
Learn more from Medicare: What is Home Health?
Learn more from Medicare: Medicare and Home Health Booklet

Admission Criteria

To be eligible for HH under Medicare, a physician must certify that a patient:

is confined to the home or homebound due to:
- an injury or illness and they need the aid of supportive devices
- a condition such that leaving home is medically contraindicated
needs intermittent skilled services
is under the care of a physician
receives services in a care plan established and reviewed by a physician
had a face-to-face encounter with a physician or allowed a non-physician practitioner

The patient must ALSO have a normal inability to leave home, AND leaving home must require a considerable taxing effort.

Billing

Services in home health are paid for by Medicare Part A under the Home Health Prospective Payment System (HH PPS), more commonly known as the Patient-Driven Groupings Model (PDGM).
PDGM was implemented on January 1, 2020 and removed the incentive to overproduce therapy under the old HH PPS (therapy thresholds)
PDGM functions similarly to a value-based bundled payment system but is technically an adjusted case-mix model.
Reimbursement under PDGM is based on 4 main categories (See image from CMS below):
- Admission source and timing
- Clinical group
- Functional Impairment Level
- Comorbidity
The case-mix adjusted payment is called the Home Health Resource Group (HHRG) – there are 432 case-mix adjusted payment groups
Reimbursement is grouped into 30-day payments, but the certification period is still 60-days.

Learn more from Amplify OT: What is the PDGM in HH?

Learn more from Amplify OT: PDGM in Home Health Podcast

Learn more from MedPAC: Payment Basics in Home Health Services

Learn more from CMS: Home Health Prospective Payment System

Learn more from MLN: PDGM Overview

Learn more from CMS: HH PDGM

Learn more from CMS: HHRG under PDGM

Learn more from MLN: Payments and Payment Adjustments Under PDGM

CMS Assessment: Outcome & Assessment Information Set (OASIS)

Must be completed within five days of the start of care date
Use the OASIS-E Guidance Manual (effective January 1, 2023) for item-specific guidance
Section M1800 primarily used to determine functional impairment level
Contains Section GG and the M1800/ADL items are now part of Section G in the OASIS-E

Learn more from CMS: OASIS-E Manual

Learn more from CMS: OASIS-E Instrument

Learn more from CMS: OASIS Training Videos

Occupational therapy and home health

OT is not a qualifying service for Medicare at the start of care
- Qualifying services at initial eval: PT, SLP, and skilled nursing
OT is a qualifying service recertification.
OT can continue with treatments after other disciplines are discharged.
OT can initiate the OASIS in therapy only cases.
- With COVID-19 Waiver, OT can initiate OASIS in all cases.

Learn more from Amplify OT: Is OT a Qualifying Service in Home Health?

Learn more from Amplify OT: Is OT a Qualifying Discipline in HH? Podcast

Learn more from Amplify OT: Can Occupational Therapists Initiate the OASIS?

Learn more from MLN: The Role of Therapy Under the PDGM

Learn more from CMS: Home Health Occupational Therapy