Nationwide Medicare Compliance Audit of Home Health Claims Billed With an Institutional Admission Source

OBJECTIVE

For home health services beginning on or after January 1, 2020, Centers for Medicare & Medicaid Services (CMS) implemented a revised case-mix adjustment methodology, the Patient-Driven Groupings Model (PDGM). The PDGM assigns 30-day periods of care into one of 432 case-mix groups based upon five variables, one of which is admission source (i.e., from the community or from an acute or post-acute care facility, also known as an institutional admission source). CMS created two new occurrence codes, 61 and 62, to allow home health agencies (HHAs) to indicate that an institutional stay occurred within 14 days of the home health admission. HHA institutional admissions result in higher reimbursement than community admissions, and HHAs may report institutional admissions using these codes even when no corresponding Medicare inpatient claim exists. Prior OIG audits found HHAs incorrectly billed institutional admissions using occurrence codes, sometimes based on emergency room visits or observation stays that do not qualify as inpatient stays. We will determine whether home health claims billed with occurrence codes 61 or 62 were submitted in accordance with Medicare source of admission billing and coding requirements. Our review will assess documentation supporting admission source and identify vulnerabilities that allow improper payments.

TIMELINE

• April 23, 2026
  Announced
• Today
  Office of Audit Services In-Progress
• Est FY2028
  Estimated Fiscal Year for Project Completion

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