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Medicare Benefit Policy Manual

Chapter 7 - Home Health Services

Table of Contents (Rev. 10738, 05-07-21)

Transmittals for Chapter 7

10 - Home Health Prospective Payment System (HH PPS) 10.1 - National 30-Day Period Payment Rate 10.2 - Adjustments to the 30-Day Episode Rates 10.3 - Continuous 60-Day Episode Recertifications 10.4 - Split Percentage Payment Approach to the 30-Day Period Unit of Payment 10.5 ? Requirements for Submission of "No-Pay" RAPs 10.6 - Low Utilization Payment Adjustment (LUPA) 10.7 - Partial Payment Adjustment 10.8 - Outlier Payments 10.9 - Discharge Issues 10.10 - Consolidated Billing 10.11 - Change of Ownership Relationship to Periods Under the HH PPS 10.12 - Change of Ownership Relationship to Episodes Under PPS

20 - Conditions To Be Met for Coverage of Home Health Services 20.1 - Reasonable and Necessary Services 20.1.1 - Background 20.1.2 - Determination of Coverage 20.2 - Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services 20.3 - Use of Utilization Screens and "Rules of Thumb"

30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services 30.1 - Confined to the Home 30.1.1 - Patient Confined to the Home 30.1.2 - Patient's Place of Residence 30.2 - Services Are Provided Under a Plan of Care Established and Approved by a Physician or Allowed Practitioner

30.2.1 - Definition of Allowed Practitioner

30.2. 2 - Content of the Plan of Care 30.2.3 - Specificity of Orders 30.2.4 - Who Signs the Plan of Care 30.2.5 - Timeliness of Signature 30.2. 6 - Use of Oral (Verbal) Orders 30.2.7 - Frequency of Review of the Plan of Care 30.2.8 - Facsimile Signatures 30.2. 9 - Alternative Signatures 30.2.10 - Termination of the Plan of Care - Qualifying Services 30.2.11 - Sequence of Qualifying Services and Other Medicare Covered Home Health Services 30.3 - Under the Care of a Physician or Allowed Practitioner 30.4 - Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech-Language Pathology Services, or Has Continued Need for Occupational Therapy 30.5 - Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services 30.5.1 - Physician or Allowed Practitioner Certification

30.5.1.1 - Face-to-Face Encounter 30.5.1.2 - Supporting Documentation Requirements 30.5.2 - Physician or Allowed Practitioner Recertification 30.5.3 - Who May Sign the Certification or Recertification

30.5.4 - Physician or Allowed Practitioner Billing for Certification and Recertification

40 - Covered Services Under a Qualifying Home Health Plan of Care 40.1 - Skilled Nursing Care 40.1.1 - General Principles Governing Reasonable and Necessary Skilled Nursing Care 40.1.2 - Application of the Principles to Skilled Nursing Services 40.1.2.1 - Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status 40.1.2.2 - Management and Evaluation of a Patient Care Plan

40.1.2.3 - Teaching and Training Activities 40.1.2.4 - Administration of Medications 40.1.2.5 - Tube Feedings 40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration 40.1.2.7 - Catheters 40.1.2.8 - Wound Care 40.1.2.9 - Ostomy Care 40.1.2.10 - Heat Treatments 40.1.2.11 - Medical Gases 40.1.2.12 - Rehabilitation Nursing 40.1.2.13 - Venipuncture 40.1.2.14 - Student Nurse Visits 40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching 40.1.3 - Intermittent Skilled Nursing Care 40.2 - Skilled Therapy Services 40.2.1 - General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy 40.2.2 - Application of the Principles to Physical Therapy Services 40.2.3 - Application of the General Principles to Speech-Language Pathology Services 40.2.4 - Application of the General Principles to Occupational Therapy 40.2.4.1 - Assessment 40.2.4.2 - Planning, Implementing, and Supervision of Therapeutic

Programs 40.2.4.3 - Illustration of Covered Services 50 - Coverage of Other Home Health Services 50.1 - Skilled Nursing, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy 50.2 - Home Health Aide Services 50.3 - Medical Social Services 50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs), the Use of Durable Medical Equipment and Furnishing Negative Pressure Wound Therapy Using a Disposable Device 50.4.1 - Medical Supplies

50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and the Patient's Plan of Care

50.4.1.2 - Routine Supplies (Nonreportable) 50.4.1.3 - Nonroutine Supplies (Reportable) 50.4.2 - Durable Medical Equipment 50.4.3 ? Covered Osteoporosis Drugs 50.4.4 - Negative Pressure Wound Therapy Using a Disposable Device 50.5 - Services of Interns and Residents 50.6 - Outpatient Services 50.7 - Part-Time or Intermittent Home Health Aide and Skilled Nursing Services 50.7.1 - Impact on Care Provided in Excess of "Intermittent" or "PartTime" Care 50.7.2 - Application of this Policy Revision 60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) 60.1 - Post-Institutional Home Health Services Furnished During A Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part B 60.2 - Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet Threshold for Post-Institutional Home Health Services 60.3 - Beneficiaries Who Are Part A Only or Part B Only 60.4 - Coinsurance, Copayments, and Deductibles 70 - Duration of Home Health Services 70.1 - Number of Home Health Visits Under Supplementary Medical Insurance (Part B) 70.2 - Counting Visits Under the Hospital and Medical Plans 80 - Specific Exclusions From Coverage as Home Health Services 80.1 - Drugs and Biologicals 80.2 - Transportation 80.3 - Services That Would Not Be Covered as Inpatient Services 80.4 - Housekeeping Services 80.5 - Services Covered Under the End Stage Renal Disease (ESRD) Program 80.6 - Prosthetic Devices 80.7 - Medical Social Services Furnished to Family Members 80.8 - Respiratory Care Services 80.9 - Dietary and Nutrition Personnel

80.10- Telecommunications Technology

90 - Medical and Other Health Services Furnished by Home Health Agencies 100 - Physicianor or Allowed Practitioner Certification for Medical and Other Health

Services Furnished by Home Health Agency (HHA) 110 - Use of Telehealth in Delivery of Home Health Services

10 - Home Health Prospective Payment System (HH PPS)

(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)

The unit of payment under the HH PPS is a national 30-day period rate with applicable adjustments. The periods, rate, and adjustments to the rates are detailed in the following sections.

10.1 - National 30-Day Period Payment Rate

(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

A. Services Included

The law requires the 30-day period to include all covered home health services, including medical supplies, paid on a reasonable cost basis. That means the 30-day period payment rate includes costs for the six home health disciplines and the costs for routine and nonroutine medical supplies. The six home health disciplines included in the 30-day period payment rate are:

1. Skilled nursing services;

2. Home health aide services;

3. Physical therapy;

4. Speech-language pathology services;

5. Occupational therapy services; and

6. Medical social services.

The 30-day period payment rate also includes amounts for nonroutine medical supplies and therapies that could have been unbundled to Part B prior to HH PPS. (See ?10.11.C for those services.)

B. Excluded Services

The law specifically excludes durable medical equipment (DME) from the 30-day period payment rate and consolidated billing requirements. DME continues to be paid the fee schedule amounts or through the DME competitive bidding program outside of the HH PPS rate.

Certain injectable osteoporosis drugs which are covered where a woman is postmenopausal and has a bone fracture are also excluded from the 30-day period payment rate, but must be billed by the home health agency (HHA) while a patient is under a home health plan of care since the law requires consolidated billing of these osteoporosis drugs. These osteoporosis drugs continue to be paid on a reasonable cost basis.

Negative pressure wound therapy (NPWT) using a disposable device that is an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy (in lieu of a conventional NPWT DME system), is also excluded from the 30-day period payment rate, but must be billed by the home health agency (HHA) while a patient is under a home health plan of care since the law requires consolidated billing of NPWT using a disposable device.

Furnishing NPWT using a disposable device means the application of a new applicable disposable device, as that term is defined in ?1834 of the Social Security Act (the Act), which includes the professional services (specified by the assigned CPT code) that are provided.

10.2 - Adjustments to the 30-Day Period Payment Rate

(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)

A. Case-Mix Adjustment

A case-mix methodology adjusts the 30-day payment rate based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into their case-mix groups.

The following case-mix variables are obtained from home health or other Medicare claims:

? Admission Source-Institutional (i.e., acute hospital, inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, inpatient psychiatric facility) or Community;

? Timing-Early (the first 30-day period of care) or Late (all subsequent 30-day periods of care, unless there is a gap of more than 60-days between the end of one period of care and the start of another),

? Clinical Group-As determined by the principal diagnosis reported on home health claims; 30-day periods are assigned to one of 12 clinical groups describing the primary reason for the home health encounter:

Clinical Groups Musculoskeletal Rehabilitation

Neuro/Stroke Rehabilitation

Wounds ? Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care

The Primary Reason for the Home Health Encounter is to Provide:

Therapy (physical, occupational or speech) for a musculoskeletal condition Therapy (physical, occupational or speech) for a neurological condition or stroke Assessment, treatment & evaluation of a surgical wound(s); assessment, treatment & evaluation of non-surgical wounds, ulcers, burns, and other lesions

Clinical Groups Behavioral Health Care

Complex Nursing Interventions Medication Management, Teaching and Assessment (MMTA)

MMTA ?Surgical Aftercare

MMTA ? Cardiac/Circulatory MMTA ? Endocrine MMTA ? GI/GU

MMTA ? Infectious Disease/Neoplasms/Blood-forming Diseases

MMTA ?Respiratory

MMTA ? Other

The Primary Reason for the Home Health Encounter is to Provide:

Assessment, treatment & evaluation of psychiatric and substance abuse conditions Assessment, treatment & evaluation of complex medical & surgical conditions including IV, TPN, enteral nutrition, ventilator, and ostomies

Assessment, evaluation, teaching, and medication management for surgical aftercare Assessment, evaluation, teaching, and medication management for cardiac or other circulatory related conditions Assessment, evaluation, teaching, and medication management for endocrine related conditions Assessment, evaluation, teaching, and medication management for gastrointestinal or genitourinary related conditions Assessment, evaluation, teaching, and medication management for conditions related to infectious diseases, neoplasms, and bloodforming diseases Assessment, evaluation, teaching, and medication management for respiratory related conditions Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in one of the previously listed groups

? Comorbidity Adjustment-As determined by certain secondary diagnoses reported on home health claims; a 30-day period of care can receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment.

The following case mix variable is determined from responses to certain items on the OASIS assessment:

? Functional Impairment Level-As determined by responses to certain OASIS items. A 30-day period of care can be assigned a low, medium, or high functional impairment level.

Each 30-day period is assigned into one of 432 case-mix groups based on the variables described above. Each group's case-mix weight reflects the predicted mean cost of the group relative to the overall average across all groups.

B. Labor Adjustments

The labor portion of the 30-day period payment rate is adjusted to reflect the wage index based on the site of service of the beneficiary. The beneficiary's location is the determining factor for the labor adjustment. The HH PPS rates are adjusted by the prefloor and pre-reclassified hospital wage index. The hospital wage index is adjusted to account for the geographic reclassification of hospitals in accordance with

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