Home Health Documentation

Home Health Referrals

Table of Contents

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Home Health Referrals

The certifying physician or allowed NPP and/or the acute/post-acute care facility referring the patient for home care must ensure that the medical record justifies the referral for Medicare home health services. The following information should be documented and shared with the home health agency chosen by the patient:

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Order for Home Health Services

The orders must indicate the type of services to be provided to the patient, with respect to the skilled professional who will provide them, as well as the nature and frequency of the services being ordered.

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Documentation to Support Homebound Status

Homebound status is one of five eligibility criteria that the patient must meet to utilize their home health benefit. The complete definition of “homebound” as defined by CMS can be found within Chapter 7, Section 30.1.1 of the Medicare Benefit Policy Manual (also see the Homebound Status job aid). The following two homebound status criteria must be addressed within the patient’s medical record documentation provided by the certifying physician or allowed NPP, and/or the acute/post-acute care facility when the patient is referred for home health services:

  • Criteria One:
    The type of support and/or supportive device or assistance required when the patient leaves their home, or the condition such that leaving the home is medically contraindicated (e.g., immunocompromised, or psychological illness).
  • Criteria Two:
    Explanation of the patient’s normal ability to leave home, as well as documentation regarding the patients taxing effort to leave the home.

Information from the medical record regarding the patient’s homebound status may include:

  • Patient’s diagnosis
  • Duration of the patient’s condition
  • Patient’s prior level of function (level of function before the current injury or illness)
  • Clinical course
  • Prognosis
  • Nature and extent of current functional limitations
  • Other therapeutic interventions and results
  • Pain medications and any related side effects
  • Required rest periods
  • Oxygen needs
  • Continence issues
  • Confusion, delirium, hallucinations
  • Safety concerns
  • Alternative accommodations

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Documentation to Support the Need for Skilled Services

The need for skilled services is one of five eligibility criteria that the patient must meet to utilize their home health benefit. For the purpose of the Medicare home health benefit, “skilled services” include that of a licensed professional within:

  • Nursing
  • Physical Therapy
  • Occupational Therapy
  • Speech Language Pathology
  • Medical Social Work

The need for skilled services must be addressed within the patient’s medical record documentation provided by the certifying physician or allowed NPP and/or the acute/post-acute care facility when the patient is referred for home health services. In an effort to ensure quality documentation that supports the need for skilled services, documentation should:

  1. Distinguish exactly what services are going to be rendered by the skilled professional in the patient's home
  2. Explain why a skilled professional is required to provide the home health care services
  3. Disclose clinical information (beyond a list of recent diagnoses, injury or procedure) that is individual and specific to the patient
  4. Include findings from the face-to-face encounter visit that support the primary reason for the skilled services that are going to be rendered by the skilled professional

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Documentation Regarding the Face-to-Face Encounter

The face-to-face encounter is also one of five eligibility criteria that the patient must meet to utilize their home health benefit. The 1:1 visit between the patient and the physician or allowed NPP regarding the patient’s current diagnosis as it relates to the referral for home health services must be documented within the patient’s medical record and shared with the home health agency at the time of referral. This documentation may consist of:

  • The progress note written at the time of the patient’s 1:1 visit with the physician or allowed NPP
  • A history and physical or discharge summary from the acute or post-acute care facility for the patient that is directly discharged to home health services.

Face-to-face encounter documentation must occur and be dated within 90 days prior to, or 30 days following, the home health start of care.

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Collaboration of Documentation

It is the responsibility of the referring and/or certifying physician and/or NPP to provide documentation regarding eligibility criteria to the home health agency chosen by the patient. Home health agencies require as much documentation from the referring and/or certifying physician, NPP, acute or post-acute care facility medical records as necessary to assure that eligibility criteria have been met. The record from the certifying physician/NPP medical office, acute or post-acute care facility is what is utilized to support patient eligibility prior to the home health start of care. The home health agency medical record documentation, by itself, is not sufficient in demonstrating the patient’s eligibility for Medicare home health services.

Documentation from the home health agency must be corroborated by other medical record entries and align with the time period in which services were rendered. Information from the home health agency can be incorporated into the certifying physician’s medical record for the patient. The certifying physician must review and sign any documentation used to support the certification of eligibility criteria. If documentation is to be used for verification of the eligibility criteria, it must be signed by the certifying physician and dated prior to submission of the claim.

Medicare certified providers are responsible for all claims submitted or cause to be submitted to the Medicare program. Medicare assumes that every claim you submit or cause to be submitted is for something determined to be medically necessary. Submitting false claims or causing false claim submission can subject providers to civil or criminal penalties and have consequences on provider licensure and ability to bill future Medicare claims; false claims include claims where the service is not supported by the patient’s medical record.

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Revised 8/13/2024