Home Health Care Services Industry Terminology

ABN (Advance Beneficiary Notice of Noncoverage)

A written notice given to Original Medicare beneficiaries when a service is expected to be denied as not reasonable and necessary or not covered, informing them they may be financially responsible if they still choose to receive it.

Examples: - Before providing extra aide hours not covered by Medicare, the agency obtained an ABN so the patient could decide whether to proceed and pay out-of-pocket. - We issued an ABN when the physician’s order did not establish medical necessity for additional PT visits. - The clinician explained via ABN that telehealth-only follow-up would not count as a billable Medicare home health visit.

ADR (Additional Documentation Request)

A payer (often the Medicare Administrative Contractor) request for records supporting a claim. Agencies must respond by the deadline with clinical and billing documentation or risk denial.

Examples: - The MAC sent an ADR for the final claim; we uploaded the OASIS, plan of care, F2F, and visit notes. - Missing signature dates caused an ADR denial; we appealed with corrected documentation. - Our billing team tracks ADR response timeliness to prevent cash flow delays.

ADLs (Activities of Daily Living)

Basic self-care tasks such as bathing, dressing, toileting, transferring, continence, and eating. ADL status influences care planning, staffing, and outcomes reporting.

Examples: - OASIS ADL items indicated the patient needs partial assistance with bathing and dressing. - We set aide tasks to target impaired ADLs and documented progress. - PT focused on transfers to improve ADL independence.

BAA (Business Associate Agreement)

A HIPAA-required contract between a covered entity and a vendor that creates, receives, maintains, or transmits protected health information (PHI), delineating responsibilities to safeguard PHI.

Examples: - The agency executed a BAA with its EVV vendor to cover PHI handling. - Our cloud EHR won’t go live until the BAA is signed. - The BAA specifies breach notification timelines and security safeguards.

Bag Technique

A field infection-control method for clinicians who carry a supply bag into homes. It establishes clean/dirty zones and processes to minimize contamination and protect patients and staff.

Examples: - The nurse used bag technique at the doorway, designating clean and dirty areas to prevent cross-contamination. - We updated competencies on bag technique during infection-control training. - Surveyors observed proper bag placement off the floor and hand hygiene.

Care Coordination

Deliberate organization and sharing of patient information and activities among all participants in a patient’s care to achieve safer, more effective, and efficient care transitions and outcomes.

Examples: - The case manager coordinated with the cardiologist and DME supplier for a home oxygen upgrade. - Weekly IDT calls improved care coordination and reduced readmissions. - We documented coordination with the PCP about new anticoagulation orders.

Case Mix Weight

A relative value assigned to a patient’s classification that reflects expected resource use and determines payment. In home health, PDGM case mix weights are driven by clinical group, functional level, comorbidity, and admission source/timing.

Examples: - Under PDGM, this 30-day period’s case mix weight increased due to high functional impairment and comorbidity. - Finance monitors average case mix weight to forecast revenue. - Coding accuracy directly impacts case mix weight and payment.

Certification (Physician Certification and Recertification)

Provider attestation that a patient is homebound and requires skilled services, establishing eligibility for Medicare home health. Initial certification covers up to 60 days; recertification is required for continued care.

Examples: - The physician certified homebound status and skilled need for SOC. - We obtained recertification for the second 60-day episode. - Billing held the final claim pending signed certification.

Comorbidity Adjustment (PDGM)

A PDGM payment factor reflecting the impact of certain secondary diagnoses on resource use. Classified as none, low, or high based on ICD-10-CM codes.

Examples: - Accurate coding of diabetes and CKD yielded a high comorbidity adjustment. - Coding reviewed secondary diagnoses to avoid missing the comorbidity payment bump. - Payer audit questioned the comorbidity adjustment documentation.

CoPs (Conditions of Participation)

Federal requirements set by CMS that home health agencies must meet to participate in Medicare, covering patient rights, care planning, personnel, QAPI, infection control, emergency preparedness, and more.

Examples: - The survey focused on CoPs for patient rights, QAPI, and care planning. - We updated policies to align with CoP changes on aide supervision. - Noncompliance with CoPs can jeopardize Medicare certification.

DME (Durable Medical Equipment)

Reusable medical equipment such as walkers, wheelchairs, and oxygen systems. Typically provided by DME suppliers; home health agencies coordinate but usually do not bill DME under the home health benefit.

Examples: - The nurse coordinated with a DME supplier for a wheelchair. - The agency doesn’t bill Medicare for DME; we facilitate referrals instead. - Documentation justified home oxygen per coverage criteria.

Documentation Standards

Requirements for accurate, complete, timely clinical and administrative records that support medical necessity, compliance, quality reporting, and payment.

Examples: - The therapist linked each visit to skilled goals and medical necessity. - Late entries were signed and dated per policy. - Thorough SOC documentation supported the F2F narrative.

DON (Director of Nursing)

The senior clinical leader responsible for nursing operations, compliance with CoPs, staffing, quality initiatives, and patient care outcomes. Also called Director of Patient Care Services in some agencies.

Examples: - The DON reviews clinical policies and oversees competency evaluations. - The DON led the case conference on high-risk patients. - Surveyors interviewed the DON about supervision processes.

EHR/EMR (Electronic Health/Medical Record)

Digital systems that store and manage patient clinical and administrative data, enabling documentation, order management, interoperability, reporting, and billing workflows.

Examples: - We integrated OASIS-E with our EHR to reduce duplicate entry. - Clinicians use secure messaging in the EHR for care coordination. - EHR audit trails supported our ADR response.

Emergency Preparedness Rule

CMS CoP requirement for an all-hazards emergency program including risk assessment, policies and procedures, communication plan, and training/testing.

Examples: - The agency conducted an annual full-scale disaster exercise per the rule. - Patient-specific emergency plans were updated ahead of hurricane season. - The risk assessment informed our staffing contingency plans.

Episode/Period of Care

In home health, PDGM uses 30-day payment periods within a 60-day certification episode. Periods are categorized as early or late and drive claims and payment.

Examples: - Under PDGM, billing submits a final claim for each 30-day period of care. - Recertification still occurs every 60 days if care continues. - This is an early period; the next will be late if the patient remains on service.

EVV (Electronic Visit Verification)

Technology that electronically verifies home-based service delivery, capturing the date, time, location, caregiver, service type, and patient, as required by the 21st Century Cures Act for personal care and (in many states) home health services.

Examples: - Aides clock in/out with GPS-based EVV per state mandate. - EVV exceptions require supervisor approval and notes. - We integrated EVV with payroll and scheduling.

Face-to-Face (F2F) Encounter

A required encounter with an allowed practitioner documenting clinical findings that support home health eligibility. Must occur within 90 days before or 30 days after SOC; may be conducted via telehealth consistent with CMS and state rules.

Examples: - The F2F occurred two weeks before SOC via telehealth per CMS rules. - The physician’s F2F narrative linked the clinical findings to the skilled need. - Missing F2F caused claim denial on audit.

Functional Impairment Level (PDGM)

One of PDGM’s payment components, derived from selected OASIS items, categorizing patients as low, medium, or high functional impairment to reflect resource needs.

Examples: - OASIS functional items placed the patient at high impairment. - Functional level increased the case mix weight for this period. - Therapy goals targeted functional deficits impacting ADLs/IADLs.

FWA (Fraud, Waste, and Abuse)

Activities that result in improper use of healthcare resources or payments. Agencies implement compliance programs to prevent, detect, and correct FWA.

Examples: - Staff completed annual FWA training. - We monitor for upcoding and medically unnecessary visits. - The compliance hotline captures suspected FWA reports.

Geographic Wage Index

A CMS adjustment that reflects area labor cost differences; applied to the labor-related share of home health payments based on the agency’s Core-Based Statistical Area (CBSA).

Examples: - The period payment reflects our CBSA wage index. - Rural add-on and wage index both affected revenue projections. - Contracting accounts for wage index when modeling rates.

HHA (Home Health Aide)

Paraprofessional caregiver under RN or therapist supervision who assists patients with ADLs and other delegated tasks in the home, per the plan of care and competency standards.

Examples: - The RN performed the required 14-day aide supervisory visit. - Aide tasks included bathing and grooming per the POC. - Staffing shortages in HHAs drove schedule changes.

HHCAHPS (Home Health Consumer Assessment of Healthcare Providers and Systems)

The standardized patient experience survey for home health, administered by approved vendors. Results inform public reporting and performance programs.

Examples: - Our vendor administers HHCAHPS surveys each quarter. - Communication and timeliness scores improved this year. - HHCAHPS results feed into star ratings and HHVBP.

HHRG (Home Health Resource Group)

Legacy case-mix classification used under the Home Health Prospective Payment System (HHPPS) prior to PDGM; still referenced historically but replaced for payment.

Examples: - Historical reports still reference HHRGs from the PPS era. - We mapped legacy HHRGs to PDGM groupings for trend analysis. - Coding reviews explain why the HHRG methodology no longer applies.

HHVBP (Home Health Value-Based Purchasing)

A national CMS program that adjusts Medicare payments up or down based on quality and patient experience performance relative to peers. Payment adjustments can be significant as the program matures.

Examples: - The agency’s TPS improved, increasing our payment adjustment. - We targeted measures like acute care hospitalization and HHCAHPS. - HHVBP performance reports guided our QAPI priorities.

HIPAA (Health Insurance Portability and Accountability Act)

Federal law establishing standards for privacy, security, and breach notification for protected health information and for electronic data interchange.

Examples: - Staff use encrypted devices to comply with HIPAA. - A privacy breach triggered HIPAA-required notifications. - The BAA with our billing vendor outlines HIPAA responsibilities.

IADLs (Instrumental Activities of Daily Living)

Complex life tasks such as meal preparation, shopping, housekeeping, medication management, and transportation that enable independent living but are not basic self-care.

Examples: - The patient needs help with shopping and meal prep (IADLs). - OT addressed IADL safety in the kitchen. - IADL limitations inform aide care plans and caregiver education.

ICD-10-CM Coding

International classification used to code diagnoses. Code selection and sequencing drive PDGM clinical grouping and comorbidity adjustments and must reflect documentation.

Examples: - Primary diagnosis selection placed the patient in the PDGM Wounds clinical group. - We avoided unacceptable primary codes that fail PDGM grouping. - Secondary codes secured a high comorbidity adjustment.

IDT (Interdisciplinary Team)

Collaborative care team across disciplines (e.g., RN, PT, OT, SLP, MSW, aide) that plans and coordinates patient-centered home health care.

Examples: - Weekly IDT conferences sync nursing, therapy, and aide services. - The IDT updated the POC after a medication change. - IDT reviews high-risk cases to prevent readmissions.

Intake and Referral

The front-end process of receiving referrals, verifying payer benefits and eligibility, gathering documentation, obtaining orders, and preparing for start of care.

Examples: - Intake verified homebound status and payer eligibility before scheduling SOC. - Referral packets now include the F2F and recent H&P. - Intake checks MA authorizations to avoid denials.

Joint Commission (TJC) Accreditation

Voluntary accreditation by The Joint Commission; can confer deemed status for Medicare participation and reflects adherence to quality and safety standards.

Examples: - Achieving deemed status through TJC survey demonstrated CoP compliance. - We closed survey findings with a corrective action plan. - TJC standards guided our infection-control program updates.

KPI (Key Performance Indicator)

Quantifiable metrics used to monitor clinical, operational, and financial performance, guiding management decisions and improvement efforts.

Examples: - We track LUPA rate and 30-day readmissions as core KPIs. - NOA timeliness and days in A/R are RCM KPIs. - Clinician productivity and turnover are HR KPIs.

Late NOA Penalty

A reduction in Medicare payment when the Notice of Admission is submitted after the 5-calendar-day window from SOC. Each day late generally reduces the period payment proportionally.

Examples: - A late NOA reduced payment for days prior to submission. - We implemented alerts to prevent NOA submission after the 5-day window. - Billing reconciles census daily to catch missing NOAs.

LPN/LVN (Licensed Practical/Vocational Nurse)

A nurse licensed at the practical/vocational level who provides care within a defined scope under RN or physician direction; roles vary by state and payer requirements.

Examples: - The LPN made a medication administration visit under RN supervision. - Scope of practice for LVNs varies by state. - Staffing models balance RN and LPN visits for efficiency.

LUPA (Low-Utilization Payment Adjustment)

A payment adjustment when visits in a 30-day period do not meet the PDGM-specific LUPA visit threshold, resulting in per-visit reimbursement instead of the full case-mix amount.

Examples: - We fell below the LUPA threshold, so payment was per-visit rather than case-mix. - Scheduling safeguards help avoid unintended LUPAs. - Different PDGM groupings have different LUPA thresholds.

Medical Necessity

Clinical justification that services are reasonable and necessary for diagnosis or treatment and require the skills of a qualified clinician, supported by documentation and orders.

Examples: - Documentation tied wound-care skills to clinical complexity and risk. - Therapy notes supported skilled interventions beyond maintenance. - The physician’s POC established medical necessity for SN visits.

Medicare Advantage (MA)

Private health plans that administer Medicare benefits. For home health, MA plans can have different authorization, network, documentation, and payment policies than Original Medicare.

Examples: - MA plans often require prior authorization for therapy. - Rates and visit limits differ from Traditional Medicare. - Contracting with key MA plans boosted census.

Medication Reconciliation

The process of creating the most accurate medication list by comparing all current medications with orders at each transition of care, resolving discrepancies to enhance safety.

Examples: - At SOC, the RN reconciled hospital discharge meds with the home list. - Discrepancies were escalated to the prescriber for clarification. - Reconciliation reduced ADE-related readmissions.

NOA (Notice of Admission)

A Medicare claim transaction that establishes a beneficiary’s home health admission for billing under PDGM. Must be submitted timely to avoid payment reductions.

Examples: - We submitted the NOA within 5 days of SOC to avoid penalties. - Only one NOA is required per admission until discharge. - Late NOA errors delayed our cash flow.

NPI (National Provider Identifier)

A unique 10-digit identification number for covered healthcare providers used in administrative and financial transactions.

Examples: - Claims rejected due to a mismatch in the agency’s NPI and PTAN. - Referral orders listed the ordering physician’s NPI. - Our new branch was linked to the parent NPI in PECOS.

OASIS (Outcome and Assessment Information Set)

The standardized patient assessment required for Medicare home health, used for care planning, quality measurement, and PDGM payment classification.

Examples: - We completed OASIS-E at SOC, ROC, transfer, and discharge. - OASIS responses drive PDGM functional scoring and quality measures. - Coding collaborated with clinicians to ensure OASIS accuracy.

Outcome Measures

Quality indicators reflecting patient status changes or events, often derived from OASIS and claims, used for public reporting and value-based payment.

Examples: - We monitor improvement in self-care and mobility. - Acute care hospitalization within 30 days is a key outcome. - Outcome trends inform QAPI priorities and HHVBP strategy.

Outlier Payment

Additional payment for unusually high-cost periods that exceed a fixed-dollar loss threshold. Subject to limits to maintain overall budget neutrality.

Examples: - Extensive wound care and multiple RN visits triggered an outlier. - Finance modeled outliers within CMS budget-neutral limits. - Documentation substantiated the high resource use for audit.

PDGM (Patient-Driven Groupings Model)

CMS’s current home health payment system that bases reimbursement for 30-day periods on patient characteristics rather than therapy visit counts.

Examples: - PDGM classifies 30-day periods by admission source, clinical group, functional level, and comorbidity. - Therapy thresholds were removed under PDGM. - Accurate coding and OASIS scoring optimize PDGM payment and compliance.

PEP (Partial Episode Payment) Adjustment

A proportional reduction in payment when a 30-day period is shortened due to transfer, discharge, or other qualifying events, paying only for the portion of services provided.

Examples: - A mid-period transfer to another HHA resulted in a PEP adjustment. - Discharge and readmission within the same period triggered PEP. - Billing confirmed visit counts for accurate PEP calculation.

Plan of Care (POC)

The comprehensive, physician-approved care plan outlining diagnoses, goals, visit frequencies, disciplines, and orders that guide all home health services.

Examples: - The physician-signed POC specified visit frequencies and goals. - We updated the POC after a medication change and fall risk reassessment. - Auditors verified services matched the POC.

Prior Authorization

Payer approval required before rendering specific services or beyond a set quantity, common with Medicare Advantage and Medicaid managed care.

Examples: - The MA plan required prior auth for OT visits beyond the initial 6. - Denial occurred because prior auth expired before the visit date. - Intake obtains authorization before scheduling SOC for MA patients.

QAPI (Quality Assessment and Performance Improvement)

A CoP-mandated, data-driven program for monitoring, assessing, and systematically improving care processes and outcomes through ongoing projects and governance oversight.

Examples: - We launched a PIP to reduce 30-day readmissions. - QAPI tracked improvement in HHCAHPS communication scores. - The QAPI plan and data were reviewed during survey.

Quality of Patient Care Star Ratings

CMS publicly reported 1–5 star summary of an agency’s quality performance based on OASIS and claims-based measures, separate from HHCAHPS star ratings.

Examples: - Our Quality Star Rating rose from 3.5 to 4.0 this year. - Marketing highlights our star ratings on the agency website. - Star measure trends inform clinical training focuses.

RCM (Revenue Cycle Management)

End-to-end financial processes from intake and eligibility through coding, billing, collections, and denial management that convert services rendered into cash.

Examples: - RCM metrics include NOA timeliness, clean-claim rate, and days in A/R. - We streamlined RCM by automating eligibility checks and claim edits. - Strong RCM reduced write-offs from ADR denials.