- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD or Thumb Drive
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Referring, Monitoring and Certifying Home Health Services
Table of Contents
- Referring, Monitoring and Certifying Home Health Services
- Homebound Status
- Need for Skilled Services
- Under the Care of a Physician or Allowed Practitioner
- Plan of Care
- Face-to-Face Encounter
- Certification and Recertification
Referring, Monitoring and Certifying Home Health Services
Services that the Medicare patient/beneficiary may receive at home include:
- Skilled nurse on an intermittent/part-time basis
- Home health aides on an intermittent/part-time basis
- Physical therapy
- Occupational therapy
- Speech language pathology
- Social work
In order to utilize these benefits, however, the patient must meet certain eligibility criteria. Therefore, upon referral of the patient to home health services, all of the following eligibility criteria must be documented within the patient’s medical record:
The patient/beneficiary must:
- Be confined to the home (homebound)
- Require “skilled” services
- Remain under the care of a physician or allowed practitioner
- Receive services under a plan of care established and reviewed by a physician or allowed practitioner
- Must have had a face-to-face encounter for their current diagnosis with a physician or allowed practitioner
Homebound Status
Federal Medicare regulations define homebound status/confined to the home using the two following criteria:
- Criteria One: The type of support and/or supportive device or assistance required to assist the patient in leaving home or the condition such that leaving his or her home is medically contraindicated, such as a mental or psychological illness
- Criteria Two: Explain the patient’s normal inability to leave home and define the taxing effort considering these (and other pertinent) areas:
-
- Prior level of function
- Current diagnosis
- Duration of condition
- Clinical course (worsening or improvement)
- Prognosis
- Nature and extent of functional limitations
- Therapeutic interventions and results
- Pain medications
- Rest periods
- Oxygen needs
- Continence issues
- Safety concerns
- Other necessary accommodations
A beneficiary/patient does not have to be “confined to the home” 24 hours per day to be considered homebound. If the patient does in fact leave the home, the patient may, nevertheless, be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.
- For medical appointments/treatments
- For religious services
- To attend adult daycare centers for medical care
- For other unique or infrequent events funeral, graduation, hair care
Documentation to support homebound status in the medical record should:
- Include information about the injury/illness and the type of support and/or supportive device/assistance required for illness/injury to assist the patient in leaving home.
- Explain in detail what about the patient’s current condition makes leaving home medically contraindicated. This must be documented if the patient did not meet the first criteria of requiring assistance. For example, in cases where the patient is immunocompromised or has a social anxiety disorder.
- Clarify the distinct difference in the patient’s normal ability versus their normal inability. For example, prior to the illness, accident or surgery this patient had a normal ability to leave home, and/or they were able to navigate stairs into and out of the house without the assistance of a walker and/or another person, and/or they were able to ambulate without rest.
- Describe exactly what effects are causing the considerable and taxing effort for this patient when leaving home. For example, the patient is now homebound and unable to ambulate without assistance of another person and/or medical equipment due to multiple traumas, total hip replacement, and/or routine narcotic pain medication due to high pain levels causing drowsiness. Patient only able to ambulate five to ten feet at a time without a rest period and significant pain.
Need for Skilled Services
Each patient must have a need for “skilled” services in their home in order to be eligible for their Medicare home health benefit and this must be documented within the patient’s medical record at the time a referral is made.
Documentation should:
- Distinguish exactly what services are going to be provided by the skilled professional in the patient’s home.
- Explain why a “skilled professional” is required to provide the home health care services requested.
- Disclose clinical information (beyond a list of recent diagnoses, injury, or procedure) that is individual and specific to the patient.
- Provide information regarding the face-to-face encounter. The provider referring the patient is meeting with the patient; thus, having a face-to-face visit with the patient in your office, hospital or skilled nursing facility. Therefore, the documentation regarding the face-to-face encounter must be included with the referral and support the primary reason for the skilled services being requested.
As per federal Medicare regulations, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge and skills of a registered nurse are necessary. Federal Medicare regulations also state that to be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.
Under the Care of a Physician or Allowed Practitioner
During the 2020 Public Health Emergency for COVID-19 (5/4/2020), federal Medicare regulations temporarily incorporated direction allowing Nurse Practitioners, certified Clinical Nurse Specialists, and Physician Assistants to order home health services, certify eligibility for home health benefits, as well as oversee/monitor the patient plan of care as they receive home health services. This direction later became a permanent change to federal regulation that will remain in effect indefinitely.
Remember, the patient may or may not be under the care of the physician or allowed practitioner who ordered/referred the patient for home health services, as the ordering/referring provider has the option of identifying a community provider that has agreed to monitor the home health services. However, there is only one certifying physician or allowed practitioner who attests that the beneficiary is eligible because all five eligibility requirements have been met.
When the referring/ordering provider is also the same provider that will be certifying and monitoring home health eligibility, they would be exclusively responsible for completing and signing a certification statement attesting to the fact that all of the eligibility criteria have been met. Upon certifying eligibility, the physician or allowed practitioner that will be certifying and/or monitoring home health services should ask themselves the following questions:
- Is the beneficiary eligible for home health services?
- Is the patient homebound as per federal regulation?
- Is there a need for skilled services in the home?
- Has a face-to-face encounter been completed?
- Is the certification statement complete, signed and dated?
- Was all of this documentation shared with the home health agency upon referral?
Remember, the referring provider, may or may not be the same provider that will be monitoring home health services in the community. As stated above, the ordering/referring physician or allowed practitioner may certify the patient’s eligibility, but if they are not going to monitor home health services, they must identify, in writing, the community provider that has agreed to oversee the home health services. This means that if a hospitalist, a SNF provider, or a specialist refers the patient to home health services, they must communicate with the community provider to ensure he/she agrees to monitor the home health services being ordered and this must be documented in the patient’s medical record.
When the ordering/referring physician or allowed practitioner is referring a patient, but not certifying or monitoring home health services:
- Is the beneficiary eligible for home health services?
- Is the patient homebound as per federal regulation?
- Is there a need for skilled services in the home?
- Has a community provider agreed to certify and monitor home health services?
- Has the community provider been identified within the medical record documentation?
- Has a face-to-face encounter been completed?
- Was all of this documentation shared with the home health agency upon referral?
Plan of Care
As per federal Medicare regulations, it is expected that in most instances that the provider who certifies the patient’s eligibility for Medicare home health services, will be the same provider who establishes and signs the plan of care.
As in the past, the home health agency staff will further develop and evolve the plan of care in collaboration with the community physician. There are no mandatory forms for the plan of care, but obviously there must be “a plan” if the patient is being referred for home health. That plan should be identified within the patient’s medical record and subsequently shared with the home health agency in which the patient is being referred.
Face-to-Face Encounter
A face-to-face encounter with the patient must be performed by the certifying physician/allowed practitioner, or the provider that cared for the patient in the acute or post-acute care facility who is now referring the patient for home health services. For episodes with starts of care beginning 1/1/2011 and later, a face-to-face encounter must occur no more than 90 days prior to or within 30 days after the start of the home health care, must be related to the primary reason the patient requires home health services, and be performed by an allowed provider type.
As of 1/1/2015, the face-to-face encounter is a clinical note, such as a discharge summary from an acute or post-acute care facility or a progress note from the physician’s office, documenting that the patient has had a one-on-one visit for the primary reason they are now being referred for home care. Information regarding homebound status and the need for skilled service must be documented within the medical record, as well as information regarding the physician or allowed practitioner that has agreed to monitor/oversee home health services and the clinical plan for the patient as it relates to their primary diagnosis and face-to-face encounter.
When home health services are ordered, the patient is seen in the physician’s office, or an acute/post acute care facility. Therefore, when that specific provider refers the patient for home health services, documentation to support that this one-on-one face-to-face encounter occurred should be provided to the home health agency. Again, an office note, summary of the visit, discharge summary, or history and physical from the acute or post-acute care facility must be included within the documentation provided to the home health agency with the referral for requested services.
Certification and Recertification
When the physician or allowed practitioner certifies or recertifies, he or she is attesting and signing to the fact that the patient meets all of the eligibility criteria, including:
- The patient is homebound
- The patient requires skilled care in their home
- A plan of care has been established
- The patient is and will remain under the care of a physician or allowed practitioner; and
- A face-to-face encounter occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by a physician or allowed practitioner
It is important to remember that:
- A certifying physician must be enrolled in the Medicare Program and be a Doctor of Medicine, a Doctor of Osteopathy; or a Doctor of Podiatric Medicine
- A certifying allowed practitioner must be a nurse practitioner, clinical nurse specialist, or a physician assistant who is working in accordance with state law
- A certifying physician or allowed practitioner must be enrolled in the PECOS
- A certifying physician or allowed practitioner cannot have financial relationship with the home health agency unless it meets one of exceptions within the Code of Federal Regulations: 42 CFR 411.355-42 and CFR 411.357
- The certification statement can be signed at the point of referral by the ordering/referring physician or allowed practitioner that has agreed to oversee home health services
The following is an example of a certification statement when the certifying physician allowed practitioner is ordering/referring the patient, but will not be following the patient’s home care services in the community:
- I certify this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy, or continues to need occupational therapy. I have authorized the services on the initial plan of care which will be further developed by Dr. XXX who has agreed to monitor home health services. I further certify this patient had a face-to-face encounter that was performed on (include date) by a physician/NPP that was related to the primary reason the patient requires home health services.
The following is an example of a certification statement when the ordering/referring physician or allowed practitioner is certifying eligibility and will be monitoring the home health care services:
- I certify this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy, or continues to need occupational therapy. This patient is under my care, and I have authorized the services on this plan of care, and will periodically review the plan. I further certify this patient had a face-to-face encounter that was performed on (include date of face-to-face encounter) by a Medicare enrolled physician or non-physician practitioner that was related to the primary reason the patient requires home health services.
Recertification is required at least every 60 days. The physician recertifying the patient’s eligibility is the physician that has been monitoring the plan of care and providing oversight of home health services in the community. Federal Medicare regulations do not limit the number of continuous episode re-certifications for patients who continue to be eligible for the home health benefit.
The following is an example of a recertification statement that includes all required elements:
- I recertify this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy, or continues to need occupational therapy. This patient remains under my care, I have authorized the services on the plan of care, and will continue to periodically review the plan.
Reminder: There are no mandatory forms for the home health certification, recertification plan of care, or the face-to-face encounter. It is not required that your certification or recertification statements read exactly like those provided within this job aid; these are provided as examples only.
Reviewed 8/28/2024