The role of home health agencies (HHAs) in the continuum of care for Medicare patients with chronic wounds is expanding for many reasons. These include the growing number of Medicare beneficiaries who are living longer and receiving care in their homes, wound care professionals' incentives to provide excellent outcomes-at the total lowest cost of care-and with excellent patient satisfaction, and so on. In the past few months, this author has received many questions from wound care professionals who want to understand the home health eligibility requirements and the certification/recertification requirements of covered Medicare home health services. The following are the most frequently asked questions and answers.
Q: What are the home health eligibility requirements?
A: The patient must
* have Medicare Part A and/or Part B
* be confined to the home
* need skilled services
* be under the care of a physician
* receive services under a plan of care established and reviewed by a physician
* have had a face-to-face encounter with a physician or allowed nonphysician practitioner (NPP).
The care must be furnished by or under arrangements made by a Medicare-participating HHA.
Q: What does "confined to the home" mean?
A: An individual is considered "confined to the home" (homebound) if the following 2 criteria are met:
1. First criteria: One of the following must be met:
* Because of illness or injury, the individual needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence.
* Have a condition such that leaving his/her home is medically contraindicated.
2. Second criteria: Both of the following must be met:
* There must exist a normal inability to leave home.
* Leaving home must require a considerable and taxing effort.
The patient may be considered homebound if absences from the home are
[white circle] infrequent
[white circle] for periods of relatively short duration
[white circle] to receive healthcare treatment
[white circle] for religious services
[white circle] to attend adult day-care programs
[white circle] for other unique or infrequent events (eg, funeral, graduation, trip to the barber).
Q: What does "need skilled services" mean?
A: The patient must be in need of one of the following services:
* skilled nursing care on an intermittent basis (furnished or needed on fewer than 7 days each week or less than 8 hours each day for periods of 21 days or less, with extensions in exceptional circumstances when the need for additional care is finite and predictable
* physical therapy (PT)
* speech-language pathology (SLP) services
* continuing occupational therapy (OT).
Q: What does "under the care of a physician and receiving services under a plan of care" mean?
A: The patient must be under the care of a Medicare-enrolled physician:
* doctor of medicine
* doctor of osteopathy
* doctor of podiatric medicine (may perform only plan of treatment functions that are consistent with the functions he/she is authorized to perform under state law).
The patient must receive home health services under a plan of care established and periodically reviewed by a physician. The plan of care may not be established and reviewed by any physician who has a financial relationship with the HHA.
Q: How does a physician certify patient eligibility for home health services?
A: As a condition for Medicare payment,
* a physician must certify that a patient is eligible for Medicare home health services.
* the physician who establishes the plan of care must sign and date the certification.
The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as a physician certifies that the following 5 requirements are met:
1. The patient needs intermittent skilled nursing care, PT, and/or SLP services.
2. The patient is confined to the home (ie, homebound).
3. A plan of care has been established and will be periodically reviewed by a physician.
4. Services will be furnished while the individual was or is under the care of physician.
5. A face-to-face encounter
[white circle] 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 healthcare.
[white circle] was related to the primary reason the patient requires home health services.
[white circle] was performed by a physician or allowed NPP.
Note: The certifying physician must also document the date of the face-to-face encounter.
Physicians should complete the certification when the plan of care is established or as soon as possible thereafter. The certification must be complete prior to when an HHA bills Medicare for reimbursement.
Q: Who can perform a face-to-face encounter?
A: The face-to-face encounter can be performed by:
* the certifying physician.
* the physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health).
* a nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician.
* a certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician.
The face-to-face encounter cannot be performed by any physician or allowed NPP who has a financial relationship with the HHA.
Q: What must be included in the physician's clinical justification for a registered nurse (RN) to manage and evaluate "nonskilled" care?
A: If a patient's underlying condition or complication requires an RN to ensure that essential nonskilled care is achieving its purpose and an RN needs to be involved in the development, management, and evaluation of a patient's care plan, the physician will include a brief narrative describing the clinical justification of this need.
If the narrative is part of the certification form, the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification form, in addition to the physician's signature on the certification form, the physician must sign immediately following the narrative in the addendum.
For skilled nursing care to be reasonable and necessary for management and evaluation of the patient's plan of care, the complexity of the unskilled services that are a necessary part of the medical treatment must require the involvement of an RN to promote the patient's recovery and medical safety in view of the patient's overall condition.
Q: What supporting documentation can be used to certify home health services?
A: Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.
Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the HHA, review entities, and/or the CMS. Certifying physicians who show patterns of noncompliance with this requirement, including those physicians whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as provider-specific probe reviews.
Information from the HHA, such as the patient's comprehensive assessment, can be incorporated into the certifying physician's and/or the acute/post-acute care facility's medical record for the patient.
* Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.
* The certifying physician must review and sign off on anything incorporated into the patient's medical record that is used to support the certification of patient eligibility (ie, agree with the material by signing and dating the entry).
The certifying physician's and/or the acute/post-acute care facility's medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient's:
* need for the skilled services and
* homebound status.
The certifying physician's and/or the acute/post-acute care facilities' 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, discharge summaries, clinical and progress notes, problem lists, and comprehensive assessments.
Q: How often must home health services be recertified?
A: At the end of the initial 60-day home health episode, a decision must be made as to whether to recertify the patient for a subsequent 60-day episode. Recertification is required at least every 60 days when there is a need for continuous home healthcare after an initial 60-day episode and unless there is a
* patient-elected transfer or
* discharge with goals met and/or no expectation of a return to home healthcare.
Note: These situations trigger a new certification, rather than a recertification.
Medicare does not limit the number of continuous episodes of recertification for patients who continue to be eligible for the home health benefit.
Q: What are the recertification requirements?
A: Recertifications must
* be signed and dated by the physician who reviews the plan of care,
* indicate the continuing need for skilled services (the need for OT may be the basis for continuing services that were initiated because the individual needed skilled nursing, PT, or SLP services), and
* estimate how much longer the skilled services will be required.
Q: What are the requirements for a physician to bill for home health certification/recertification?
A: Certifying/recertifying patient eligibility can include contacting the HHA and reviewing of reports of patient status required by physicians to affirm the implementation of the plan of care that meets patient's needs:
* HCPCS (Healthcare Common Procedure Coding System) code G0180 Physician certification home health patient for Medicare-covered home health service under a home health plan of care (patient not present).
* HCPCS code G0179 Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present).
Physician claims for certification/recertification of eligibility for home health services (G0180 and G0179, respectively) are not considered to be for "Medicare-covered" home health services if the HHA claim itself was noncovered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit.