Georgia Medicare HH PPS PDGM 2026 Guide

When a Georgia Medicare beneficiary leaves an acute hospital after a hip fracture repair, when a beneficiary with congestive heart failure needs ongoing skilled nursing to manage her diuretic regimen and education to avoid readmission, when a beneficiary with new-onset diabetes needs nursing teaching on insulin administration, when a beneficiary recovering from a stroke needs physical therapy and occupational therapy in her home, or when a beneficiary with chronic wounds needs skilled wound care that cannot be safely managed in outpatient settings, the Medicare home health benefit is often the right care setting. Home health allows beneficiaries to recover, manage chronic conditions, and age in place in their own homes while receiving skilled care from licensed nurses, therapists, and home health aides.

Medicare pays home health agencies (HHAs) under the Home Health Prospective Payment System (HH PPS), established by Section 4603 of the Balanced Budget Act and codified at Section 1895 of the Social Security Act. The framework was substantially restructured by the Patient-Driven Groupings Model (PDGM), which CMS adopted under authority from the Bipartisan Budget Act. PDGM replaced the 60-day episode unit of payment with a 30-day period of care and replaced the prior Home Health Resource Groups with a case-mix classification system based on timing (early or late period), admission source (community or institutional), clinical grouping, functional impairment level, and comorbidity adjustment.

For Georgia, the home health landscape includes Medicare-certified Home Health Agencies ranging from large national chains to small local providers. National operators serving Georgia include AccentCare (which acquired Encompass Health's home health and hospice business), Amedisys, BAYADA Home Health Care, CenterWell Home Health (Humana-affiliated), Enhabit Home Health & Hospice (spun off from Encompass), and LHC Group (acquired by UnitedHealth/Optum). Hospital-affiliated home health agencies operate within major Georgia health systems including Emory, Wellstar, Piedmont, Northside, and Northeast Georgia.

The framework imposes specific coverage criteria. Medicare home health requires that the beneficiary be homebound under Section 1814(a)(2)(C) (for Part A) or Section 1835(a)(2)(A) (for Part B), that she need skilled care (intermittent skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy), that she be under a physician's care, that the physician certify the need for home health, and that a face-to-face encounter occur with the certifying practitioner within the timeframe specified in current CMS guidance. The coverage continues as long as eligibility criteria are met, with plan of care review every 60 days. Importantly, Medicare home health has no spell of illness limit and no day limit, and beneficiaries face no cost-sharing for home health services (except 20 percent coinsurance for durable medical equipment).

This guide is published by Brevy at brevy.com as part of our mission to be America's most trusted and comprehensive eldercare resource. It covers Section 4603 of the BBA and HH PPS, Section 1895 of the Social Security Act, the 42 CFR Part 484 regulations, the PDGM case-mix classification, the OASIS patient assessment, the homebound and skilled care coverage criteria, the face-to-face encounter requirement, the Jimmo v. Sebelius maintenance therapy standard, the Low Utilization Payment Adjustment (LUPA) and outlier provisions, the Home Health Quality Reporting Program, the national Home Health Value-Based Purchasing, the Conditions of Participation, the beneficiary cost-sharing, the major Georgia home health agencies, and the practical questions Georgia families face when home health is being considered for an older adult.

By Brevy Care Team · Last verified May 21, 2026

For Georgia Medicare beneficiaries and their families, the home health benefit is often the difference between aging in place at home and requiring institutional care, between recovering from a hospital stay at home and being readmitted, and between independent function and progressive decline. Georgia beneficiaries access this benefit through the Home Health Prospective Payment System (HH PPS) established by Section 4603 of the Balanced Budget Act, which sets case-mix-adjusted payment for the HHAs that deliver care. Home health bridges acute hospital, skilled nursing, inpatient rehabilitation, and outpatient settings, allowing beneficiaries to receive skilled care in the lowest-acuity setting consistent with safety and clinical needs.

Consider a Georgia Medicare beneficiary in her late 70s who has been hospitalized for community-acquired pneumonia. After 5 days in the hospital, she is medically stable and ready for discharge. She lives alone, has type 2 diabetes, has mild congestive heart failure, and has lost some functional capacity during the hospital stay. The hospital discharge planner identifies that she needs skilled nursing for medication management and CHF teaching, physical therapy for functional recovery, and a home health aide for personal care assistance during the recovery period.

The hospital discharge planner refers her to Wellstar Home Health, an HHA serving the metro Atlanta area. Wellstar Home Health conducts an OASIS-E start of care assessment within 5 days of discharge. The OASIS data drives PDGM classification: this is an early 30-day period (first period), institutional admission (from acute hospital), MMTA Cardiac and Circulatory clinical grouping (CHF as primary), with medium functional impairment and high comorbidity (CHF and diabetes both qualify). The case-mix-adjusted 30-day period payment supports skilled nursing twice weekly, physical therapy three times weekly, and home health aide three times weekly.

Over the first 30 days, she receives medication reconciliation, CHF teaching (low-sodium diet, weight monitoring, recognizing exacerbations), gait and balance training, strength building, and assistance with personal care. Her CHF stabilizes, her functional capacity improves, and she avoids readmission. After the first 30 days, a second 30-day period continues skilled care at lower frequency, with the patient now transitioning toward self-management. By day 60, she is discharged from home health with a clear plan for outpatient follow-up.

This scenario, multiplied across hundreds of thousands of Georgia Medicare beneficiaries each year, illustrates the central role of home health in the Medicare benefit structure. Hospital discharge to home with home health is the most common discharge pathway. Chronic disease management with home health prevents hospitalization. Therapy services through home health support functional recovery and aging in place.

For Georgia, several specific factors shape the home health landscape. The state has Medicare-certified HHAs ranging from large national chains operating across the state to small local agencies serving specific regions. The Atlanta metropolitan area has the highest concentration of HHAs. Rural Georgia faces home health workforce and access challenges. Some rural counties have only one or two HHAs serving them, with long travel distances limiting the frequency and intensity of services that can be provided.

Brevy publishes this guide and related guides at brevy.com to help Georgia families understand the home health benefit, what kinds of patients are appropriate, how PDGM affects payment, what coverage criteria apply, and how to choose an HHA. The right choice depends on the patient's clinical needs, the available agencies, and the family situation.

Section 4603 BBA and the HH PPS framework

Before HH PPS, home health agencies were paid under a cost-based reimbursement framework with substantial annual growth in Medicare home health spending throughout the 1990s. Cost-based reimbursement encouraged HHA expansion but produced weak incentives for efficiency and created concerns about excessive visit utilization. Section 4603 of the Balanced Budget Act directed CMS to develop and implement a prospective payment system for home health.

The original HH PPS used a 60-day episode as the unit of payment. Each episode was classified into a Home Health Resource Group based on clinical, functional, and service utilization information. The episode payment structure remained in place for many years, with refinements through annual rulemaking. By the late 2010s, however, MedPAC and CMS had identified concerns about therapy thresholds incentivizing extra therapy visits, about the 60-day episode encouraging long stays, and about the case-mix system not adequately reflecting patient characteristics.

The Bipartisan Budget Act directed CMS to implement the Patient-Driven Groupings Model (PDGM), with a 30-day unit of payment, case-mix groups based on patient characteristics rather than therapy use, and budget neutrality. PDGM was the largest structural change to HH PPS since its initial implementation.

The Patient-Driven Groupings Model (PDGM) under HH PPS

PDGM is the current HH PPS case-mix classification system. It replaced the previous Home Health Resource Groups and continues today with annual refinement through the HH PPS Final Rule.

30-day period of care

The fundamental change in PDGM is the unit of payment. The previous 60-day episode is replaced by the 30-day period of care. A continuous home health stay can include multiple 30-day periods, each separately classified and paid. The 30-day structure aligns payment more closely with the clinical realities of home health, where patient needs change over time.

Case-mix groups

Each 30-day period is classified into a case-mix group derived from five dimensions:

Timing

• Early period: The first 30-day period in a home health continuum (where "continuum" is defined by specific rules about gaps between periods)
• Late period: Subsequent 30-day periods within the continuum

Early periods are typically more resource-intensive (initial assessment, plan of care development, early visits) than late periods.

Admission source

• Community admission: The patient was admitted to home health from the community (not from an inpatient facility within the prior 14 days)
• Institutional admission: The patient was admitted to home health from an inpatient facility (acute hospital, IRF, LTCH, SNF, or IPF) within the prior 14 days

Institutional admissions typically reflect higher acuity post-acute patients with greater resource needs.

Clinical grouping (12 categories)

Each period is assigned to one of 12 clinical groupings based on the principal diagnosis and other clinical factors:

1. Musculoskeletal Rehabilitation
2. Neuro/Stroke Rehabilitation
3. Wounds (skin care)
4. Complex Nursing Interventions
5. Behavioral Health
6. Medication Management, Teaching, and Assessment (MMTA): Surgical Aftercare
7. MMTA: Cardiac and Circulatory
8. MMTA: Endocrine
9. MMTA: Gastrointestinal and Genitourinary
10. MMTA: Infectious Disease, Neoplasms, and Blood Disorders
11. MMTA: Respiratory
12. MMTA: Other

The clinical grouping reflects the primary reason for home health services.

Functional impairment level

Based on OASIS functional items, each period is classified as:

• Low functional impairment
• Medium functional impairment
• High functional impairment

The functional level reflects the patient's need for assistance with activities of daily living and mobility.

Comorbidity adjustment

Based on secondary diagnoses, each period receives one of three comorbidity adjustments:

• None: No qualifying comorbidities
• Low: A single qualifying comorbidity
• High: Specific comorbidity interaction (combinations that elevate resource needs)

The comorbidity adjustment recognizes that patients with complex comorbidity profiles require more resources.

Case-mix calculation

A 30-day period in PDGM is classified using the combination of those five dimensions: timing × admission source × clinical grouping × functional impairment × comorbidity adjustment.

Each case-mix group has a specific relative weight derived from analyses of resource use. The relative weight is applied to the national standardized payment amount, adjusted by the wage index, to compute the period payment.

The OASIS-E patient assessment

The Outcome and Assessment Information Set (OASIS) is the comprehensive patient assessment instrument for Medicare home health. OASIS has evolved through multiple versions (OASIS-A through OASIS-D). The current version is OASIS-E.

Assessment timing

OASIS assessments occur at:

• Start of care (SOC): Within 5 days of the start of care
• Resumption of care (ROC): Following an inpatient stay
• Recertification: At or near the end of every 60 days
• Discharge: At discharge from home health

Data captured

OASIS captures a comprehensive picture of the patient including:

• Clinical and demographic information
• Sensory status (vision, hearing)
• Integumentary status (skin condition, pressure injuries)
• Respiratory status (dyspnea, oxygen use)
• Cardiac status (heart conditions)
• Elimination status (bladder, bowel)
• Neuro/emotional/behavioral status
• ADL and IADL functional status
• Medications
• Care management needs
• Therapy needs
• Emergent care use

Section GG (added with OASIS-E)

OASIS-E added Section GG (Functional Abilities and Goals), which aligns with other post-acute care settings (IRF-PAI, MDS, LTCH CARE Data Set). Section GG captures:

• Self-care abilities (eating, oral hygiene, toileting hygiene, bathing, etc.)
• Mobility abilities (rolling, sit to stand, transfers, walking, stairs, etc.)
• Performance scores from 06 (independent) to 01 (dependent), with codes for activities not attempted

OASIS data uses

OASIS data have multiple uses:

• PDGM case-mix: The functional impairment level for PDGM is derived from OASIS functional items
• HH QRP quality measures: Outcome measures (improvement in ambulation, bathing, etc.) come from OASIS
• HHVBP performance: Many HHVBP measures come from OASIS
• Care planning: OASIS findings inform the plan of care
• Outcome tracking: Comparing admission to discharge OASIS shows patient progress

OASIS coding accuracy

Accurate OASIS coding is essential. Coding errors can result in payment under- or over-statement, quality measure misclassification, and audit findings. HHAs invest substantial training resources in OASIS coding accuracy.

The homebound requirement

Medicare home health requires that the beneficiary be "confined to the home." The homebound requirement at Section 1814(a)(2)(C) (Part A) or Section 1835(a)(2)(A) (Part B) involves two criteria:

Criterion 1

The patient must:

• Need the assistance of a supportive device (such as crutches, walker, wheelchair), the assistance of another person, OR special transportation, in order to leave home, OR
• Have a medical condition such that leaving home is contraindicated

Criterion 2

The patient must:

• Be normally unable to leave home
• If she does leave home, the absence must require considerable and taxing effort
• Absences from home must be infrequent or of short duration

Allowed absences

Despite the homebound requirement, the following absences are permitted without disqualifying the patient from homebound status:

• Medical treatment (PT, OT, ST, doctor visits, dialysis, infusion therapy, lab tests, etc.)
• Religious services
• Attending licensed adult day programs (such as those providing therapeutic services)
• Funerals
• Unique family events (limited)
• Other short, infrequent absences

Common misunderstandings

• "Homebound" does not mean bed-bound or unable to walk
• A patient using a walker, cane, or wheelchair who has difficulty leaving home can be homebound
• A patient who occasionally attends doctor appointments or short events can still be homebound
• A patient who works full-time or attends school regularly is generally not homebound

Documentation

The homebound determination must be documented by the physician and supported by clinical findings. Inadequate documentation is a common audit finding.

The skilled care requirement

Medicare home health covers skilled care: care that requires the expertise of a licensed professional. Qualifying skilled services include:

• Intermittent skilled nursing: Not more than 8 hours per day or 28 hours per week (combined skilled nursing and home health aide). Examples: wound care, IV therapy, catheter management, diabetic teaching, CHF management.
• Physical therapy: For functional recovery, gait training, strength, balance, pain management.
• Speech-language pathology: For swallowing disorders, communication impairment after stroke or other neurological conditions.
• Continued occupational therapy: After an initial qualifying skilled need (RN, PT, or ST), OT can continue independently.

Skilled care examples

• Wound care requiring nursing assessment (debridement, advanced dressings, infection monitoring)
• IV therapy (antibiotics, hydration, chemotherapy)
• Foley catheter care
• Tracheostomy care
• Ostomy management
• Diabetic management with insulin teaching and titration
• Cardiac rehabilitation
• Stroke rehabilitation (PT/OT/ST)
• Joint replacement recovery (PT/OT)
• Tube feeding management

Non-skilled care

Custodial care alone is not covered:

• Personal care (bathing, dressing, grooming) without skilled need
• Meal preparation
• Light housekeeping
• Companionship
• Standby supervision

Skilled vs custodial distinction

The dividing line is whether the care requires the expertise of a licensed professional. A patient who needs only personal care assistance does not qualify for Medicare home health. A patient who needs skilled care AND personal care can receive both (HHA visits are covered when ordered as part of the plan of care).

Jimmo v. Sebelius

Before Jimmo, Medicare contractors often denied coverage for maintenance therapy or care that did not produce improvement. The Jimmo settlement clarified that Medicare covers skilled care needed to maintain function or slow deterioration, not only care that produces improvement.

This is significant for chronic and progressive conditions:

• Parkinson's disease (maintenance PT to maintain mobility)
• Multiple sclerosis (maintenance therapy for function)
• ALS (skilled care to manage progressive symptoms)
• CHF (skilled nursing for management to prevent exacerbations)
• COPD (skilled nursing for management to prevent exacerbations)

The standard is that the care must require skilled professional expertise, not that it must produce improvement.

Face-to-face encounter

Medicare requires a face-to-face encounter between the patient and a physician (or allowed non-physician practitioner) related to the primary reason for home health care. The encounter must occur within the timeframe specified in current CMS guidance, either shortly before or shortly after the start of care. The HHA and certifying practitioner should consult the current Medicare Benefit Policy Manual for the specific window in effect.

Allowed practitioners

The face-to-face encounter can be conducted by:

• The certifying physician
• A nurse practitioner working in collaboration with the certifying physician
• A physician assistant under physician supervision
• A clinical nurse specialist working in collaboration with the certifying physician
• Certain other allowed non-physician practitioners

Documentation

The encounter documentation must:

• Be a separate, dated, and signed document
• Document clinical findings supporting home health eligibility
• Include homebound rationale
• Include skilled care rationale
• Be included in the patient's home health record

Telehealth flexibility

Limited telehealth options exist for the face-to-face encounter, including the PHE-era flexibilities (now sunset) and certain ongoing telehealth provisions. The specifics evolve through rulemaking.

Common audit findings

Face-to-face encounter documentation gaps are among the most common Medicare home health audit findings. Inadequate documentation can result in denial of payment for the entire home health stay.

Plan of care

The home health plan of care is the central clinical document. It must include:

• Diagnoses
• Medications
• Treatments
• Goals
• Frequency and duration of services (specific visits per discipline per week)
• Functional limitations
• Activities permitted
• Equipment needed
• Discharge plans

Plan of care development

The plan of care is developed at the start of care based on the OASIS assessment, the physician's orders, and the patient's needs. It is signed by the physician and updated as needed.

60-day review

The plan of care must be reviewed by the physician at least every 60 days. The physician confirms continued eligibility, reviews progress, and modifies the plan as needed. Recertification involves a new physician signature.

Plan of care updates

Significant changes in the patient's condition (such as a change in functional status, new diagnosis, or hospitalization) trigger plan of care updates and may trigger a new OASIS assessment.

HH PPS payment methodology under Section 1895

National standardized payment amount

The national standardized payment amount for a 30-day period is set in the annual HH PPS Final Rule. The amount is updated for market basket changes and productivity adjustments.

Wage index

The wage index adjusts the labor-related portion of the national standardized amount for geographic differences in labor costs. HHAs use the wage index for their service area. The wage index is updated annually.

Case-mix adjustment

Each 30-day period is assigned to a PDGM case-mix group with a specific relative weight. The relative weight is applied to the wage-adjusted national standardized amount to compute the case-mix-adjusted period payment.

LUPA (Low Utilization Payment Adjustment)

LUPA applies when the visits in a 30-day period fall below the case-mix-specific threshold. Under LUPA, Medicare pays per-visit instead of per-period. The thresholds vary by case-mix group and are published in the annual HH PPS Final Rule.

LUPA exists to prevent payment of full period payment for periods with very low visit utilization. It aligns payment with actual care delivery.

Outlier payment

High-cost cases can qualify for outlier payment, providing additional payment beyond the standard period payment. The fixed loss threshold and marginal cost factor are defined in the annual final rule. Outliers protect HHAs from substantial financial losses on cases with extraordinary cost.

Partial Episode Payment (PEP)

When a patient is transferred to a different HHA or has a significant change in condition triggering a new case-mix calculation, the original period payment may be prorated. PEP ensures appropriate payment allocation.

Home Health Quality Reporting Program (HH QRP)

The HH QRP under Section 1895(b)(3)(B) requires HHAs to report specific quality measures. HHAs that fail to report face an annual payment reduction; the current percentage is set in statute and applied through the HH PPS Final Rule.

Quality measure domains

OASIS-derived outcome measures

• Improvement in ambulation
• Improvement in bathing
• Improvement in bed transferring
• Improvement in dyspnea
• Improvement in pain interfering with activity
• Improvement in management of oral medications

These measures compare admission to discharge OASIS data, capturing functional and clinical improvement during the home health stay.

Process measures

• Influenza immunization
• Pneumonia immunization
• Timely initiation of care
• Drug regimen review with follow-up
• Transfer of health information

Patient experience (HHCAHPS)

The Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey captures:

• Care from home health agency providers
• Communication between providers and patient
• Specific care issues (pain, falls, mental health)
• Overall rating of agency
• Recommendation of agency to others

Claims-based outcome measures

• Acute care hospitalization during the home health stay
• Emergency department use without hospitalization
• Discharge to community

Public reporting

HH QRP measures are publicly reported on Medicare Care Compare at medicare.gov/care-compare. Families can compare HHAs based on the reported quality measures.

Home Health Value-Based Purchasing (HHVBP)

The original HHVBP operated as a multi-state pilot demonstrating the feasibility and impact of value-based payment in home health. Section 1895(b)(8) of the Social Security Act authorized national expansion.

National expansion

HHVBP now operates nationally under expanded authority. All Medicare-certified HHAs participate in the expanded program.

Total Performance Score

Each HHA receives a Total Performance Score based on:

• Achievement: HHA's performance relative to national benchmarks
• Improvement: HHA's improvement from baseline

The higher of achievement or improvement points is used for each measure.

Payment adjustment

The Total Performance Score determines the HHVBP payment adjustment. The maximum adjustment percentage is set through CMS rulemaking and reflected in the annual HH PPS Final Rule. The adjustment is applied to the year following the performance year.

Measures

HHVBP measures include:

• OASIS-based outcome measures
• HHCAHPS patient experience
• Claims-based hospital use measures
• Other measures as added through rulemaking

Strategic implications

HHVBP has reshaped HHA operations. Strong outcome measures, low hospitalization rates, and good patient experience translate to financial rewards. Poor performance results in payment reductions.

Section 4603 BBA, HH PPS, and the Conditions of Participation

The Home Health Conditions of Participation at 42 CFR Part 484 establish the federal regulatory standards that Medicare-certified HHAs must meet. The current CoPs include:

• Patient rights (notice, confidentiality, decision-making, grievance)
• Comprehensive assessment (initial within 5 days, OASIS)
• Care planning, coordination, and quality of care
• Quality assessment and performance improvement (QAPI)
• Infection prevention and control
• Skilled professional services (RN, LPN, PT, OT, SLP, MSW)
• Home health aide services (training, competency evaluation, RN supervision)
• Clinical records
• Personnel qualifications
• Compliance with state and federal laws

Patient rights

Patients have rights to:

• Receive notice of rights at start of care
• Confidentiality of clinical records
• Be informed of plan of care and treatment
• Participate in decisions about care
• Voice grievances without retaliation
• Refuse treatment

Skilled professional services

The HHA must provide or arrange skilled professional services as ordered in the plan of care. Services include:

• Registered nurses (RNs)
• Licensed practical nurses (LPNs)
• Physical therapists (PTs)
• Occupational therapists (OTs)
• Speech-language pathologists (SLPs)
• Medical social workers (MSWs)

Home health aide services

Home health aides provide personal care under the supervision of an RN. Requirements established at 42 CFR Part 484 include:

• Federally specified training hours, including classroom and supervised practical training
• Competency evaluation
• RN supervision visits
• Activities documented in plan of care
• Annual in-service education

Consult 42 CFR Part 484 for the current specific hour requirements and supervision intervals.

Beneficiary cost-sharing

Medicare home health services have no beneficiary cost-sharing under the standard benefit:

• No Part A or Part B deductible for home health services
• No coinsurance for skilled nursing, therapy, home health aide, MSW services
• No day limit
• No spell of illness limit

Coverage continues as long as the beneficiary meets eligibility criteria (homebound, skilled care need, physician certification, face-to-face encounter).

DME (Durable Medical Equipment)

DME ordered as part of home health (wheelchair, walker, hospital bed, oxygen, etc.) is paid under Part B with 20 percent coinsurance after the Part B deductible. Most Medigap plans cover the DME coinsurance.

No three-day stay requirement

Unlike SNF, Medicare home health does not require a prior three-day qualifying hospital stay. Patients can start home health from:

• Hospital discharge
• SNF, IRF, LTCH, or IPF discharge
• Community (with physician order)

Audit and oversight

OIG home health audits

OIG conducts audits of Medicare home health, focusing on:

• Homebound documentation
• Skilled care need documentation
• Face-to-face encounter compliance
• Plan of care compliance
• OASIS coding accuracy
• Billing accuracy

Targeted Probe and Educate (TPE)

TPE is a CMS contractor pre-payment review process. The MAC selects providers based on data analysis, reviews claims, and provides education for compliance. Three rounds of TPE precede potential further action.

Review Choice Demonstration (RCD)

RCD is a more intensive review program operating in select states designated by CMS. Under RCD, HHAs choose between pre-claim review, postpayment review, or other options. Georgia is not currently part of RCD; consult the current CMS RCD page for the active state list.

Palmetto GBA audit activity

Palmetto GBA, as Georgia's MAC, conducts TPE reviews and educational outreach for Georgia HHAs. Provider education resources address common documentation and billing issues.

PRRB appeals

Home health agencies can appeal payment determinations through the Provider Reimbursement Review Board (PRRB) for unresolved cost report issues.

Worked example 1: GA HH post-hospital discharge scenario

Consider a 78-year-old Georgia Medicare beneficiary discharged from Northside Hospital after a 4-day stay for community-acquired pneumonia. She has a history of CHF (NYHA Class II), type 2 diabetes, and hypertension. Her hospital admission was complicated by mild dehydration and one episode of CHF exacerbation requiring diuretic adjustment. She lives alone with daughter nearby. Discharge planning identifies need for skilled home health.

Home health admission

• Hospital discharge planner refers to a home health agency
• HHA conducts OASIS-E start of care assessment within 5 days
• Face-to-face encounter confirmed (physician encounter during hospital stay within 90 days before)
• Physician signs initial certification and plan of care

OASIS-E findings

• Functional status: moderate impairment in mobility, mild in self-care
• Clinical status: stable but with chronic conditions requiring monitoring
• CHF and diabetes as primary clinical concerns
• Comorbidities of hypertension, mild diabetic neuropathy

PDGM classification

• Timing: Early (first 30-day period)
• Admission source: Institutional (from acute hospital)
• Clinical grouping: MMTA Cardiac and Circulatory (CHF primary)
• Functional impairment: Medium
• Comorbidity adjustment: High (CHF and diabetes together qualify)

Case-mix group derived from these dimensions, with associated relative weight.

Plan of care

• Skilled nursing 3 times per week (CHF management, medication reconciliation, diabetic management, patient teaching)
• Physical therapy 3 times per week (gait, balance, strengthening)
• Home health aide 3 times per week (bathing assistance, personal care)
• Frequency reassessed weekly

30-day period 1 (Days 1-30)

• Total visits: SN 13 visits + PT 12 visits + HHA 13 visits = 38 visits
• Well above the LUPA threshold for this case-mix group
• Period payment: full PDGM case-mix-adjusted amount, wage-adjusted for Atlanta

30-day period 2 (Days 31-60)

• Patient stabilized, decreased frequency
• Skilled nursing 2 times per week, PT 2 times per week, HHA 2 times per week
• Total visits: 18 visits
• Above LUPA threshold
• Classification: Late period, MMTA Cardiac and Circulatory, medium functional, high comorbidity
• Period payment: lower than period 1 due to "late" timing weight

Discharge (Day 65)

• Patient reaches functional baseline, CHF stable, diabetes controlled
• Discharge OASIS completed
• Patient transitions to outpatient management

Beneficiary cost-sharing

• No cost-sharing for home health services
• DME (cane provided): 20% Part B coinsurance, covered by Medigap

Outcome

Patient avoids readmission, maintains functional independence, continues outpatient management. Home health bridged the gap from acute hospital to stable chronic care management.

Worked example 2: PDGM case-mix classification

Consider a 72-year-old Georgia Medicare beneficiary starting home health from the community for chronic wound management. She has a non-healing diabetic foot ulcer, type 2 diabetes, and peripheral artery disease.

PDGM classification

• Timing: Early (first 30-day period)
• Admission source: Community (no inpatient stay in prior 14 days)
• Clinical grouping: Wounds (Skin Care)
• Functional impairment: Low (ambulates independently, ADLs preserved)
• Comorbidity adjustment: High (diabetes and PAD together qualify as comorbidity interaction)

Resource implications

• Wound clinical grouping reflects higher resource needs for wound care
• Community admission has different relative weight than institutional admission
• High comorbidity adjustment increases payment

Plan of care

• Skilled nursing 3 times per week for wound care
• Wound vac changes, advanced dressings
• Diabetes management teaching
• Care coordination with wound care clinic

Resource use vs payment

The PDGM classification produces a case-mix-adjusted payment that supports the resource intensity of wound care. Without the wound clinical grouping classification, the case would be under-paid for the resource use.

Lesson

PDGM classification matters significantly for HHA payment. Accurate OASIS coding and ICD-10 diagnosis sequencing affect the classification.

Worked example 3: LUPA threshold scenario

Consider a 75-year-old Georgia Medicare beneficiary on home health for routine post-hip-replacement physical therapy. She lives with her husband who provides good support.

Plan of care

• Physical therapy 3 times per week initially
• No skilled nursing needed (no medication management or wound care)
• Home health aide for personal care

30-day period 1 visit count

• PT: 12 visits
• HHA: 12 visits (typically does not count toward LUPA for some periods)
• Total visit count for LUPA purposes: 12

Classification

• Timing: Early
• Admission source: Institutional (from acute hospital after surgery)
• Clinical: MMTA Surgical Aftercare
• Functional: Medium
• Comorbidity: Low

LUPA threshold

• LUPA threshold for this case-mix group is set in the annual HH PPS Final Rule
• Actual visits: 12 (well above the threshold for this case-mix group)
• No LUPA applies
• Full period payment

Alternative scenario: Faster recovery

• Patient recovers faster than expected, reduces frequency
• PT: 4 visits in the 30-day period
• HHA: 4 visits
• Total LUPA-counted visits: 4 (below the threshold for this case-mix group)
• LUPA applies
• Per-visit payment instead of period payment

Lesson

LUPA significantly affects payment for short periods or low-frequency care. HHAs and patients should understand the LUPA threshold for their case-mix group when planning care.

Worked example 4: OASIS-E start of care assessment

Consider a 70-year-old Georgia Medicare beneficiary starting home health after hospital discharge for stroke with right-sided weakness.

OASIS-E assessment within 5 days of start

Domains assessed

• Sensory status: Vision and hearing
• Integumentary: Skin condition, pressure injuries (none noted at present)
• Respiratory: Mild dyspnea on exertion
• Cardiac: Hypertension, history of CHF
• Elimination: Continence preserved
• Neuro/emotional/behavioral: Mild aphasia, cognitive status preserved, mood within normal limits
• Section GG (functional abilities and goals):
  • Eating: independent (06)
  • Oral hygiene: partial/moderate assistance (03)
  • Toilet hygiene: supervision (05)
  • Bathing: substantial/maximal assistance (02)
  • Dressing upper body: partial/moderate assistance (03)
  • Dressing lower body: substantial/maximal assistance (02)
  • Rolling: independent (06)
  • Sit to stand: partial/moderate assistance (03)
  • Walking: walks with walker, partial/moderate assistance (03)

PDGM functional impairment level derivation

• OASIS functional items combined into PDGM functional score
• Score corresponds to Medium functional impairment level

Plan of care development

• Based on OASIS findings
• Physical therapy 4 times per week (gait, balance, strengthening)
• Occupational therapy 3 times per week (ADLs, self-care, adaptive equipment)
• Speech therapy 2 times per week (aphasia, communication)
• Skilled nursing 2 times per week (medication management, BP monitoring)
• Home health aide 3 times per week (bathing, personal care)

Goals

• Improve mobility from medium to low functional impairment (improvement in ambulation)
• Improve self-care abilities
• Improve communication
• Stabilize medical conditions

Lesson

OASIS-E start of care assessment is the foundation for PDGM classification, plan of care, and HH QRP quality measurement. Accurate and complete assessment is essential.

Worked example 5: Homebound determination

Consider a 76-year-old Georgia Medicare beneficiary with CHF and arthritis. Her family is considering home health for medication management and physical therapy.

Functional status

• Walks with cane, slow pace, limited endurance
• Becomes short of breath after walking one block
• Lives alone, daughter visits frequently
• Attends doctor appointments twice per month (transportation provided)
• Goes to church on Sunday mornings (transportation provided)
• Does not work, does not attend regular outside activities

Homebound analysis

Criterion 1: Need for assistance or contraindication

• Walks with cane (supportive device required)
• Becomes short of breath (medical condition affects ability to leave home)
• Meets Criterion 1

Criterion 2: Normally unable to leave, considerable effort, infrequent absences

• Normally home (does not regularly leave)
• Leaving home requires considerable effort (slow pace, fatigue, shortness of breath)
• Absences are infrequent and short:
  • Doctor appointments: medical treatment (allowed)
  • Church attendance: religious services (allowed)
• Meets Criterion 2

Conclusion: Homebound

The patient meets the homebound requirement. Home health is appropriate if she meets the other eligibility criteria (skilled care need, physician certification, face-to-face encounter).

Alternative scenario: Not homebound

If the same patient were also going to a part-time job, attending weekly senior center programs, and driving herself to multiple non-medical activities, she might not meet the homebound requirement. The "normally unable to leave home" standard would not be met.

Lesson

Homebound determination requires careful clinical and lifestyle assessment. Documentation of homebound status with specific clinical findings is essential.

Worked example 6: Face-to-face encounter compliance

Consider a 73-year-old Georgia Medicare beneficiary starting home health from the community for skilled nursing related to wound care.

Timeline

• May 1: Patient sees primary care physician for routine visit, primary care physician identifies non-healing wound
• May 15: Patient seen by wound care clinic, wound care plan developed
• May 20: HHA initial referral and admission, start of care
• May 22: OASIS start of care assessment

Face-to-face encounter analysis

• Encounter on May 1 (PCP visit, 19 days before start of care)
• Encounter on May 15 (wound care clinic, 5 days before start of care)
• Both within 90 days before start of care
• Either encounter can serve as the face-to-face encounter

Documentation requirements

• Encounter documentation must be a separate, dated, signed document
• Must document clinical findings supporting home health eligibility
• Must address homebound status
• Must address skilled care need

Allowed practitioners

• Primary care physician: physician (allowed)
• Wound care physician: physician (allowed)
• Both eligible as the face-to-face encounter source

Alternative scenario: Encounter not documented

• If the May 1 PCP visit was a brief follow-up without specific home health-related findings, and the May 15 wound care visit documentation does not address home health eligibility, the face-to-face encounter requirement might not be satisfied
• HHA would need to coordinate with the certifying physician to ensure proper face-to-face encounter documentation

Lesson

Face-to-face encounter compliance is a frequent audit issue. Coordination between the HHA and the certifying physician at the start of care prevents documentation gaps.

14 best practices for Georgia home health

1. Conduct thorough OASIS-E assessments: Accurate OASIS coding drives PDGM classification, HH QRP measures, HHVBP performance, and care planning.

2. Document homebound status with specific findings: Generic statements ("patient is homebound") are inadequate. Document the specific clinical findings supporting homebound status.

3. Verify face-to-face encounter documentation at start of care: Confirm that a qualifying encounter occurred within the time window and that documentation supports home health eligibility.

4. Develop individualized plans of care: Plan of care should reflect patient-specific needs, goals, frequency, and duration of services. Generic plans are not adequate.

5. Coordinate with hospital discharge planners: Effective hospital-to-home transitions reduce readmissions and support outcomes.

6. Track LUPA risk: For each 30-day period, monitor visit count relative to LUPA threshold. Adjust care planning if LUPA risk emerges without compromising clinical care.

7. Engage families in care planning: Family understanding of care plan, goals, and discharge planning improves outcomes.

8. Apply Jimmo standard for chronic conditions: Maintenance therapy and skilled care for chronic conditions (Parkinson's, MS, ALS, CHF, COPD) are covered when skilled care is needed.

9. Participate fully in HH QRP and HHVBP: Quality reporting is required, and value-based purchasing affects payment. Strong performance is both clinically and financially important.

10. Reduce hospital readmissions: Hospital readmission is an HHVBP measure and a clinical priority. Robust discharge planning, medication reconciliation, and 24/7 access reduce readmissions.

11. Coordinate with Acentra Health QIO: 1-844-455-8708 for utilization review and discharge appeals.

12. Maintain rigorous documentation: Audit findings frequently identify documentation gaps. Daily visit notes, plan of care updates, and OASIS data must be complete and accurate.

13. Participate in TPE compliance: Address Targeted Probe and Educate findings constructively. Use educational opportunities to improve compliance.

14. Communicate with Palmetto GBA for payment and policy questions: Provider Customer Service at 1-866-238-9650 addresses payment, billing, and policy questions.

14 common issues and how to address them

1. Homebound documentation gaps: Generic homebound statements without specific findings. Address through training on documentation standards, specific clinical findings.

2. Face-to-face encounter compliance: Encounter not within time window, inadequate documentation. Address through coordination with certifying physician, encounter scheduling at start of care.

3. OASIS coding errors: Incorrect functional or comorbidity coding affecting PDGM classification. Address through OASIS coding training, audits, peer review.

4. LUPA exposure: Visit count falls below LUPA threshold. Address through care planning that meets clinical needs while maintaining viable visit count.

5. Hospital readmissions: Affecting HHVBP score and clinical outcomes. Address through robust discharge planning, medication reconciliation, 24/7 access.

6. Coverage denials for maintenance therapy: Despite Jimmo, some contractors deny maintenance care. Address through documentation of skilled care requirement, Jimmo citation when needed, appeals.

7. Plan of care 60-day review delays: Recertification not completed timely. Address through physician communication, electronic systems, calendar tracking.

8. Discharge planning to inadequate community resources: Patient discharged without adequate community support. Address through extended care planning, family engagement, community resource coordination.

9. OIG audit findings: Targeting documentation, face-to-face, OASIS coding. Address through internal compliance reviews, audit-ready documentation, education.

10. TPE prepayment review impact: Cash flow effects of TPE. Address through compliance improvements, education uptake, internal review.

11. HHCAHPS scores below target: Patient experience affecting HHVBP. Address through communication training, complaint handling, family engagement.

12. Workforce shortages and turnover: RN, therapist, and aide availability. Address through workforce strategies, training pipelines, partnership with schools.

13. Rural access challenges: Long travel distances, limited workforce. Address through telehealth where allowed, partnerships, careful caseload management.

14. Coordination between HH and other settings: Hospital, SNF, IRF, hospice. Address through transition protocols, communication, family engagement.