5F023: No Plan of Care or Certification

The services billed were not covered because the home health agency (HHA) did not have the plan of care (POC) established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.  

To Prevent This Denial

• Ensure that the appropriate POC is included and that it is legibly signed and dated by the physician prior to billing
• A POC refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. It contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include.
• Ensure that the signed certification or recertification is submitted when responding to an Additional Documentation Request (ADR)
• The physician must certify that:
  • The home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
  • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
  • The services were furnished while the individual was under the care of a physician
• Since the certification is closely associated with the POC, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
• The physician must recertify at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the POC is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary.

Resources

• Code of Federal Regulations, 42 (CFR), Sections 424.22 and 409.43
• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit  Policy Manual, Chapter 7, Section 30 (PDF)
• Code of Federal Regulations, 42 (CFR), Sections 409.41, 409.42, 409.43 and 424.22
• CMS Internet-Only Manuals (IOMs), Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30 (PDF)