5 Ways to Reduce Denials and Maximize Medicaid Reimbursements for Senior Home Care Providers

Actionable strategies to boost revenue and streamline compliance

Master ADLs Documentation & Coding

Why it matters: Medicaid reimbursements for senior care often hinge on accurately documenting Activities of Daily Living (ADLs). Missing or vague documentation leads to underpayments or denials.

Action Steps:

Use GG codes (e.g., GG0130 for eating, GG0170 for mobility) to quantify ADL performance.
Train caregivers to document specifics: Example: “Patient requires moderate assistance (50% support) for toileting due to arthritis (M19.90).”
Link ADL documentation to ICD-10 codes justifying medical necessity (e.g., dementia F03.90, Parkinson’s G20).
Result: Reduce denials for “lack of medical necessity” and secure accurate reimbursement tiers.

Optimize Chronic Care Management (CCM) Billing

Why it matters: Medicaid reimburses for CCM (CPT 99490), but claims are often denied due to incomplete time logs or missing consent forms.

Action Steps:

Track 20+ minutes/month of non-face-to-face care coordination (e.g., medication management, caregiver communication).
Obtain written patient consent annually and document it in EHR.
Use templates for care plans to include:
o Patient goals (e.g., “Reduce fall risk”).
o Interdisciplinary team roles.

Result: Unlock $62+ per patient/month in reimbursements for CCM.

Avoid Telehealth Coding Pitfalls

Why it matters: Medicaid telehealth rules vary by state, and mismatched codes trigger denials.

Action Steps:

Use CPT 99453 (setup) + 99454 (monthly data transmission) for remote monitoring.
For virtual check-ins, bill HCPCS G2012 with documentation of verbal consent.
Include place-of-service code 02 and modifier -95 for telehealth.
Example:
Denial Risk: Billing G2012 without documenting “5-10 minutes of medical discussion.”
Fix: Add a telehealth note template to EHR.
Result: Ensure 100%

Fix Prior Authorization Gaps

Why it matters: Medicaid often requires prior authorizations for home health services (e.g., PT, wound care). Missed deadlines = automatic denials.
Action Steps:

Create a prior authorization calendar for recurring services (e.g., weekly wound care).
Train staff to verify auth requirements using Medicaid’s online portal.
Use AI tools to flag services needing auths (e.g., CPT 97535 for therapeutic activities).
Pro Tip: For retroactive auths, submit a Medicaid reconsideration form with clinical notes proving urgency (e.g., pressure ulcer L89.90).
Result: Slash denials for “no prior authorization” by 70%.

Audit-Proof OASIS Documentation

Why it matters: Medicaid uses OASIS data to determine reimbursement levels. Inconsistent documentation risks underpayments and audits.
Action Steps:

Standardize OASIS assessments for:
o Cognitive status (BIMS score).
o Pain management (e.g., “Patient reports pain level 6/10 during transfers”).
Conduct monthly OASIS audits to catch errors like:
o Missing signatures.
o Inconsistent responses between M1033 and M1800.
Example of Compliance:
Mismatch Risk: OASIS states “patient bedbound” (M1850) but caregiver notes say “uses wheelchair.”
Fix: Update OASIS and add a progress note explaining the change.
Result: Maximize reimbursement tiers (e.g., HIPPS codes) and pass CMS audits with zero penalties.