PENDING 2026 HOME HEALTH FINAL RULE AFFECTS 2026 CLAIMS

Article by Michael Tidd, COS-C, HCS-D

We have reached the time of year that episodes are starting to cross over the 2025-2026 calendar years. This results in a $0 (zero dollar) amount on the claim that ends on or after January 1, 2026. Typically, CMS has released the Home Health Payment Final Rule between October 27-Noveber 4. This final rule provides the payment update rates that EMR systems require to calculate a claim amount for all claims ending in the new calendar year. Unfortunately, the US Government Shutdown has prevented non-essential government staff from working since October 1, 2025. These non-essential staff include the individuals that would be diligently working on the Home Health Payment Final Rule. Since this final rule has not been published in the Federal Register, no EMR vendor or agency knows how the Home Health Payment Proposed Rule will be altered and finalized. As such HealthCare Synergy SEMR cannot calculate a rate for claims that end in 2026.

Once the US Government Shutdown has been resolved by Congress, these non-essential staff will return to work. At this time, CMS will resume finalizing the Home Health Payment Final Rule. Once this Final Rule is published in the Federal Register, HealthCare Synergy staff will quickly make the adjustments in SEMR to allow all the claims with a $0 amount to be recalculated to show the actual value of the claim. This calculation will happen automatically with no user action required. Please keep in mind that under PDGM the claim amount is an estimate of what CMS will pay agencies on claims. PDGM requires CMS to calculate the HIPPS code and claim amount at the MAC (Medicare Administrative Contractor) level and provide payment to the agencies. Thus, the absence of a claim dollar amount does not mean you cannot bill the claim, it just means that you don’t have any dollar amount to use for budget purposes.

The other factor that agencies should be aware of is that the PDGM HIPPS calculation is modified every year and the proposed changes for 2026 have yet to be finalized. Which diagnosis codes are valid as Primary, which diagnosis qualify for a Low or High comorbidity, the points and thresholds for the Functional Limitations and the LUPA threshold for each of the 432 HIPPS codes to be used in 2026 have yet to be finalized. These will all appear in the Final Rule when it is published.

You can monitor the Home Health Agency Center as this will be updated when the Home Health Payment Final Rule for 2026 is released: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/home-health-agency-center

Please consider registering for this free webinar to understand what is included in the Final Rule:
https://www.healthcaresynergy.com/events/2026-home-health-final-rule-dec11/

Questions?
CLICK HERE to schedule a Zoom Call with Michael Tidd.