Home Health Eligibility and Medical Necessity: Resources for Plan of Care, Certification and Face-to-Face Visits

Medicare covers home care for beneficiaries who meet specific qualifying criteria, which must be thoroughly documented. Home health agencies (HHAs) need to fully understand these criteria, as they have the right and responsibility, in collaboration with the physician, to determine if the beneficiary qualifies for their services. Additionally, the agency must be aware of the covered services and how to properly document them.

To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act) and:

• Be confined to the home;
• Need skilled services;
• Be under the care of a physician;
• Receive services under a plan of care (POC) established and reviewed by a physician; and
• Have had a face-to-face encounter with a physician or allowed nonphysician practitioner (NPP)

Home Health POC and Certification

For HHA services to be covered, the agency must follow a POC outlined in Section 30.2 of the Medicare Benefit Policy Manual, Chapter 7. Additionally, a physician or authorized practitioner must certify that the plan meets the necessary requirements.

Reminders

• 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
• The POC 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
• The physician or allowed practitioner 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
  • 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 POC 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 or allowed practitioner must recertify at intervals of at least once every 60 days that there is a continuing need for services The recertification should be obtained at the time the POC is reviewed and must be signed by the same physician who signs the POC. 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

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

Home Health Face-to-Face Encounter

The initial (start of care) certification must include documentation that an allowed physician or NPP had an face-to-face encounter with the patient. The encounter must be related to the primary reason for the home care admission. This requirement is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes. Claims may be denied if the face-to-face documentation is not complete.

Reminders

• An face-to-face encounter must occur 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
• Encounter was related to the primary reason the patient requires home health services
• Encounter was performed by a physician or allowed NPP
• The certifying physician or NPP must also document the date of the face-to-face encounter
• Support the need for skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or have a continuing need for occupational therapy
• The face-to-face encounter can be performed by:
  • The certifying physician;
  • A physician or qualified NPP who cared for the patient in an acute or post-acute facility directly prior to being admitted to home health, and who had privileges at the facility; or
  • A qualified NPP working in conjunction with the certifying physician

The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:

• Occurred within the required timeframe
• Was related to the primary reason the patient requires home health services
• Was performed by an allowed provider type

This information can be found most often in, but is not limited to, the following examples:

• Discharge summary
• Progress notes
• Progress notes and problem list
• Discharge summary and comprehensive assessment

Resources

• 42 CFR, 424.22(a)(1)(v)(A)
• 42 CFR, 424.22(d)(2)
• Medicare Learning Network (MLN) Matters Number SE1436 (PDF)
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual Chapter 7, Section 30.5.1.1 (PDF)