TL;DR
Chapter 7 of the Medicare Benefit Policy Manual sets the conditions for Medicare home health coverage. It explains the home health prospective payment system's 30-day periods, the requirement that the patient be confined to the home, the plan of care and the physician or allowed practitioner's certification with its face-to-face encounter, the need for intermittent skilled nursing or therapy, and which services and supplies are covered.
Chapter 7 at a glance
- Current revision
- Rev. 12425
- Issued December 21, 2023
- Effective
- January 1, 2024
- Implemented January 2, 2024
- Sections
- 108
- 11 top-level sections
- Transmittals in history
- 16
- Listed at the end of the chapter
- Monthly searches
- 210
- Google Ads, US, October 2026
What chapter 7 governs for billing
Section 10 describes the home health prospective payment system. Medicare pays a national rate for each 30-day period of care, adjusted for case mix and wages, with a low utilization payment adjustment when a period has few visits, partial payments, outliers and the notice of admission each agency files at the start of care. Home health is a consolidated benefit: the 30-day payment covers the six home health disciplines and medical supplies, so other providers cannot bill for most of these services during an open period.
Section 30 lists the conditions the patient must meet. The patient must be confined to the home under a two-part test: either needing supportive devices, special transportation or another person's help to leave home, or having a condition that makes leaving home medically contraindicated, and in addition having a normal inability to leave home that requires a considerable and taxing effort (30.1.1). Care must follow a plan of care established and periodically reviewed by a physician or allowed practitioner (30.2), and that practitioner must certify eligibility (30.5), including a face-to-face encounter related to the primary reason for home care that occurred no more than 90 days before or within 30 days after the start of care (30.5.1.1).
Section 40 defines the covered services. Skilled nursing must be reasonable and necessary and intermittent, which for daily care means less than 8 hours a day and 28 or fewer hours a week, with case-by-case review up to 35 hours (40.1.3). Skilled therapy, home health aide services, medical social services and supplies are covered under the conditions in 40.1 to 50. The chapter then covers the split between Part A and Part B home health (60), duration and exclusions (70 and 80), physician certification billing and the use of telehealth in home health (100 and 110).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 7 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 10.1 | National 30-Day Period Payment Rate | The national 30-day period payment rate and what it includes. |
| 10.6 | Low Utilization Payment Adjustment (LUPA) | The low utilization payment adjustment for periods with few visits. |
| 30.1.1 | Patient Confined to the Home | The two criteria that define a patient confined to the home. |
| 30.2 | Services Are Provided Under a Plan of Care Established and Approved by a Physician or Allowed Practitioner | The plan of care established and reviewed by a physician or allowed practitioner. |
| 30.5.1.1 | Face-to-Face Encounter | The face-to-face encounter: who performs it, its timing and its content. |
| 40.1.3 | Intermittent Skilled Nursing Care | What counts as intermittent skilled nursing care. |
How chapter 7 shows up on claims and denials
Home health denials almost always come from documentation review rather than claim edits. When the certification lacks a valid face-to-face encounter, the record does not support homebound status, or the plan of care was not signed before the claim, the period is denied with reason code 50 or a program-guideline denial such as reason code 272. Missing elements on the claim, such as the certifying practitioner, return reason code 16.
Other providers meet chapter 7 through consolidated billing: supplies and therapy furnished during an open home health period are paid to the agency, so an outside claim for them is rejected. Physicians bill their certification and recertification of the plan of care separately under Part B, as section 30.5.4 describes.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 50 | Claim adjustment reason code | Home health services not reasonable and necessary or not supported by the record. |
| 272 | Claim adjustment reason code | Coverage or program guidelines were not met, for example homebound status. |
| 16 | Claim adjustment reason code | Claim missing required information such as the certifying practitioner. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 12425, issued December 21, 2023, effective January 1, 2024, implemented January 2, 2024 (change request 13496). That revision changed section 40.1.2.15 (Psychiatric Evaluation, Therapy, and Teaching). Its subject line reads: “Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update”.
The newest rows of the transmittal history printed at the end of the chapter (16 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R12425BP | December 21, 2023 | Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update | 13496 |
| R12382BP | November 28, 2023 | Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims | 13244 |
| R11447BP | June 6, 2022 | Update to Chapter 7, "Home Health Services," of the Medicare Benefit Policy Manual (Pub 100-02) | 12615 |
| R10738BP | May 7, 2021 | Home Health Manual Update to Implement Calendar Year 2021 Request for Anticipated Payment Policies and Corrections to Certification and Recertification for Home Health Beneficiaries | 12218 |
| R10438BP | November 6, 2020 | Home Health Manual Update to Incorporate Allowed Practitioners into Home Health Policy | 12023 |
| R265BP | January 10, 2020 | Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring | 11577 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 40.1.2.15 | Psychiatric Evaluation, Therapy, and Teaching | Rev. 12425, December 21, 2023; effective January 1, 2024 |
| 10.1 | National 30-Day Period Payment Rate | Rev. 12382, November 28, 2023; effective January 1, 2024 |
| 10.9 | Discharge Issues | Rev. 12382, November 28, 2023; effective January 1, 2024 |
| 10.10 | Consolidated Billing | Rev. 12382, November 28, 2023; effective January 1, 2024 |
| 50.4.4 | Negative Pressure Wound Therapy Using a Disposable Device | Rev. 12382, November 28, 2023; effective January 1, 2024 |
| 10.4 | Submission of the Notice of Admission (NOA) | Rev. 11447, June 6, 2022; effective January 1, 2022 |
| 10.5 | Requirements for Submission of NOA | Rev. 11447, June 6, 2022; effective January 1, 2022 |
| 30.2.1 | Definition of Allowed Practitioner 30.2. 2 - Content of the Plan of Care | Rev. 11386, April 27, 2022; effective January 1, 2022 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 Home Health Prospective Payment System (HH PPS) · p. 6 · 12 subsections
- Open section 10 in the PDF
- 10.1 National 30-Day Period Payment Rate · p. 6
- 10.2 Adjustments to the 30-Day Episode Rates · p. 7
- 10.3 Continuous 60-Day Episode Recertifications · p. 9
- 10.4 Submission of the Notice of Admission (NOA) · p. 9
- 10.5 Requirements for Submission of NOA · p. 10
- 10.6 Low Utilization Payment Adjustment (LUPA) · p. 11
- 10.7 Partial Payment Adjustment · p. 11
- 10.8 Outlier Payments · p. 13
- 10.9 Discharge Issues · p. 14
- 10.10 Consolidated Billing · p. 16
- 10.11 Change of Ownership Relationship to Periods Under the HH PPS · p. 19
- 10.12 Change of Ownership Relationship to Episodes Under PPS · p. 20
20 Conditions To Be Met for Coverage of Home Health Services · p. 20 · 5 subsections
- Open section 20 in the PDF
- 20.1 Reasonable and Necessary Services · p. 21
- 20.1.1 Background · p. 21
- 20.1.2 Determination of Coverage · p. 21
- 20.2 Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services · p. 22
- 20.3 Use of Utilization Screens and "Rules of Thumb" · p. 23
30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services · p. 23 · 21 subsections
- Open section 30 in the PDF
- 30.1 Confined to the Home · p. 23
- 30.1.1 Patient Confined to the Home · p. 24
- 30.1.2 Patient's Place of Residence · p. 26
- 30.2 Services Are Provided Under a Plan of Care Established and Approved by a Physician or Allowed Practitioner · p. 28
- 30.2.1 Definition of Allowed Practitioner 30.2. 2 - Content of the Plan of Care · p. 29
- 30.2.3 Specificity of Orders · p. 30
- 30.2.4 Who Signs the Plan of Care · p. 30
- 30.2.5 Timeliness of Signature 30.2. 6 - Use of Oral (Verbal) Orders · p. 30
- 30.2.7 Frequency of Review of the Plan of Care · p. 32
- 30.2.8 Facsimile Signatures 30.2. 9 - Alternative Signatures
- 30.2.10 Termination of the Plan of Care - Qualifying Services · p. 33
- 30.2.11 Sequence of Qualifying Services and Other Medicare Covered Home Health Services · p. 33
- 30.3 Under the Care of a Physician or Allowed Practitioner · p. 34
- 30.4 Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech-Language Pathology Services, or Has Continued Need for Occupational Therapy · p. 34
- 30.5 Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services · p. 35
- 30.5.1 Physician or Allowed Practitioner Certification · p. 35
- 30.5.1.1 Face-to-Face Encounter · p. 37
- 30.5.1.2 Supporting Documentation Requirements · p. 38
- 30.5.2 Physician or Allowed Practitioner Recertification · p. 40
- 30.5.3 Who May Sign the Certification or Recertification · p. 41
- 30.5.4 Physician or Allowed Practitioner Billing for Certification and Recertification · p. 41
40 Covered Services Under a Qualifying Home Health Plan of Care · 27 subsections
- Open section 40 in the PDF
- 40.1 Skilled Nursing Care · p. 42
- 40.1.1 General Principles Governing Reasonable and Necessary Skilled Nursing Care · p. 43
- 40.1.2 Application of the Principles to Skilled Nursing Services · p. 47
- 40.1.2.1 Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status · p. 47
- 40.1.2.2 Management and Evaluation of a Patient Care Plan · p. 49
- 40.1.2.3 Teaching and Training Activities · p. 51
- 40.1.2.4 Administration of Medications · p. 54
- 40.1.2.5 Tube Feedings · p. 56
- 40.1.2.6 Nasopharyngeal and Tracheostomy Aspiration · p. 56
- 40.1.2.7 Catheters · p. 56
- 40.1.2.8 Wound Care · p. 57
- 40.1.2.9 Ostomy Care · p. 59
- 40.1.2.10 Heat Treatments · p. 59
- 40.1.2.11 Medical Gases · p. 59
- 40.1.2.12 Rehabilitation Nursing · p. 60
- 40.1.2.13 Venipuncture · p. 60
- 40.1.2.14 Student Nurse Visits · p. 62
- 40.1.2.15 Psychiatric Evaluation, Therapy, and Teaching · p. 62
- 40.1.3 Intermittent Skilled Nursing Care · p. 63
- 40.2 Skilled Therapy Services · p. 65
- 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy · p. 65
- 40.2.2 Application of the Principles to Physical Therapy Services · p. 70
- 40.2.3 Application of the General Principles to Speech-Language Pathology Services · p. 74
- 40.2.4 Application of the General Principles to Occupational Therapy · p. 75
- 40.2.4.1 Assessment · p. 76
- 40.2.4.2 Planning, Implementing, and Supervision of Therapeutic Programs · p. 76
- 40.2.4.3 Illustration of Covered Services · p. 77
50 Coverage of Other Home Health Services · p. 78 · 16 subsections
- Open section 50 in the PDF
- 50.1 Skilled Nursing, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy · p. 78
- 50.2 Home Health Aide Services · p. 79
- 50.3 Medical Social Services · p. 82
- 50.4 Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs), the Use of Durable Medical Equipment and Furnishing Negative Pressure Wound Therapy Using a Disposable Device · p. 85
- 50.4.1 Medical Supplies · p. 85
- 50.4.1.1 The Law, Routine and Nonroutine Medical Supplies, and the Patient's Plan of Care · p. 86
- 50.4.1.2 Routine Supplies (Nonreportable) · p. 87
- 50.4.1.3 Nonroutine Supplies (Reportable) · p. 89
- 50.4.2 Durable Medical Equipment · p. 90
- 50.4.3 Covered Osteoporosis Drugs · p. 90
- 50.4.4 Negative Pressure Wound Therapy Using a Disposable Device · p. 91
- 50.5 Services of Interns and Residents · p. 93
- 50.6 Outpatient Services · p. 94
- 50.7 Part-Time or Intermittent Home Health Aide and Skilled Nursing Services · p. 94
- 50.7.1 Impact on Care Provided in Excess of "Intermittent" or "Part-Time" Care · p. 95
- 50.7.2 Application of this Policy Revision · p. 95
60 Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) · p. 95 · 4 subsections
- Open section 60 in the PDF
- 60.1 Post-Institutional Home Health Services Furnished During A Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part B · p. 96
- 60.2 Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet Threshold for Post-Institutional Home Health Services · p. 97
- 60.3 Beneficiaries Who Are Part A Only or Part B Only · p. 97
- 60.4 Coinsurance, Copayments, and Deductibles · p. 98
70 Duration of Home Health Services · p. 98 · 2 subsections
- Open section 70 in the PDF
- 70.1 Number of Home Health Visits Under Supplementary Medical Insurance (Part B) · p. 98
- 70.2 Counting Visits Under the Hospital and Medical Plans · p. 98
80 Specific Exclusions From Coverage as Home Health Services · p. 100 · 10 subsections
- Open section 80 in the PDF
- 80.1 Drugs and Biologicals · p. 100
- 80.2 Transportation · p. 101
- 80.3 Services That Would Not Be Covered as Inpatient Services · p. 101
- 80.4 Housekeeping Services · p. 101
- 80.5 Services Covered Under the End Stage Renal Disease (ESRD) Program · p. 101
- 80.6 Prosthetic Devices · p. 101
- 80.7 Medical Social Services Furnished to Family Members · p. 102
- 80.8 Respiratory Care Services · p. 102
- 80.9 Dietary and Nutrition Personnel · p. 102
- 80.10 Telecommunications Technology · p. 102
90 Medical and Other Health Services Furnished by Home Health Agencies · p. 103
100 Physicianor or Allowed Practitioner Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA) · p. 104
110 Use of Telehealth in Delivery of Home Health Services · p. 105
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Benefit Policy Manual chapter 7
QuickAuth coordinates requirement checks, documentation, submission and status tracking with human review, so the coverage conditions in this chapter are looked at before the service. QuickRCM handles claim readiness and the coverage denials that follow.
Frequently asked questions: chapter 7
What is the timing rule for the home health face-to-face encounter?
Chapter 7 section 30.5.1.1 requires the encounter to occur no more than 90 days before the start of home health care or within 30 days after it, and it must relate to the primary reason the patient needs home health services.
How does Medicare define homebound?
Section 30.1.1 uses two criteria. The patient must need help, devices or special transportation to leave home, or leaving home must be medically contraindicated; and the patient must also have a normal inability to leave home that takes a considerable and taxing effort.
How long is a home health payment period?
Under the home health prospective payment system described in chapter 7 section 10, Medicare pays per 30-day period of care, while the plan of care is recertified every 60 days.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Benefit Policy Manual, Chapter 7: Home Health ServicesVersion Rev. 12425, issued 2023-12-21 · effective 2024-01-01 · file bp102c07.pdfSHA-256 a0777bd2428a9a11…
- Medicare Benefit Policy Manual (Pub. 100-02)Version 17 chapter PDFs; newest revision Rev. 13889 (chapter 15), issued 2026-07-30 · effective 2026-09-27 · file 100-02-benefit-policy-manual/*.pdf (17 chapters; SHA-256 of their sha256sum listing)SHA-256 be35772e4f9f80b4…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.