Home Health Eligibility Q & A

Home Health Eligibility Q & A

CR 9119 Transmittal 92 & 208 CR 9189 Transmittal 602

1. When must the Home Health Agency (HHA) obtain certification of patient eligibility?

CERTIFICATION

At the time the plan of care (POC) is established or as soon thereafter as possible. It is not acceptable for HHA's to wait until the end of a 60-day episode to care to obtain a completed certification/recertification. The physician must sign and date the POC and the certification prior to the claim being submitted. Certification is considered to be any time that a Start of Care OASIS is completed to initiate care.

2. What exactly is the physician certifying?

A physician who is Medicare enrolled and certifies (attests to the fact) that all elements of eligibility criteria have been met, including:

1. Homebound status; 2. Need for skilled services; 3. That a POC has been established and periodically

reviewed by a physician (him/herself or another physician); 4. That services were furnished under the care of a physician; and, 5. That a face-to-face encounter , related to the primary reason for home health care, occurred within the required time frame, and was performed by a physician or non-physician practitioner (NPP).

3. What forms should the HHA utilize for certification or recertification of patient eligibility, should they maintain the original signature on file?

4. Should the HHA medical record documentation include documentation from the referring physician or acute/post-acute care facility?

The physician must sign and date below the certification statement. There is no specific form or format for the certification/recertification of patient eligibility as long as all elements of the certification are included and attested to. The certification must be retained by the HHA.

The HHA is not required to have the original signature on file. However, the HHA is responsible for obtaining original signatures if an issue surfaces that would require verification of an original signature. HHAs must be able to provide, upon request, the supporting documentation that substantiates the eligibility for the Medicare home health benefit to review entities and/or CMS. HHAs should obtain as much documentation from 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) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria for certification and recertification have been met and must be able to provide it to CMS and its review entities upon request.

Home Health Eligibility Q & A

CR 9119 Transmittal 92 & 208 CR 9189 Transmittal 602

5. Can the certifying physician be different from the community physician who is monitoring the patients home health services?

It is expected that in most instances, the physician who certifies the patient's eligibility for Medicare home health services will be the same physician who establishes and signs the POC. If the patient is starting home health directly after discharge from an acute/post-acute care setting where the physician, with privileges, that cared for the patient in that setting is certifying the patient's eligibility for the home health benefit, but will not be following the patient after discharge, then the certifying physician must identify the community physician who will be following the patient after discharge.

6. If the initial HHA claim is denied for purposes of ineligibility, will subsequent episodes of care claims be denied as well?

If the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will be non-covered--even if the requirements for recertification are met.

HOMEBOUND STATUS

7. Is there a mandatory narrative documentation requirement regarding the patient's homebound status during a face-to-face encounter.

8. Does documentation regarding the patient's homebound status require a co-signature (counter signature) when completed by a NPP?

9. Can the HHA add information to the certifying physician's medical record to support the patient's homebound status?

There are no mandatory narrative requirements for a face-to-face encounter. However, the face-to-face encounter must be related to the primary reason the patient requires home health services.

The information regarding the patient's homebound status can be located anywhere in certifying physician's medical records or the acute/post-acute care medical record documentation (if the patient was directly admitted to home health), and that documentation should be shared with the HHA. The documentation should provide enough information to substantiate the patient's homebound status. There is no regulation stating that a physician must co- or counter sign information regarding the patient's homebound status when documented by a NPP.

However, the Medicare enrolled physician must sign the attestation, certifying that all five of the eligibility criteria (see FAQ #2) have been met, including the patient's homebound status. Information from the HHA, such as the initial and/or comprehensive assessment or the home health POC for the patient can be incorporated into the certifying physician's medical record for the patient and used to support the patient's homebound status.

However, this information must be corroborated by other medical record entries in the certifying physician's and/or the acute/postacute care facility's medical record for the patient.

Home Health Eligibility Q & A

CR 9119 Transmittal 92 & 208 CR 9189 Transmittal 602

As per CR 9189, documentation from the HHA that is used to

support the home health certification is considered to be incorporated timely when it is signed off prior to or at the time of

the certification/prior to claim submission and must corroborate with the rest of the patient's medical record.

10. Can a patient leave their home and still be

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the

considered homebound?

home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.

NEED FOR SKILLED SERVICES

11. Is there a mandatory narrative documentation

There are no mandatory narrative requirements for a face-to-face encounter. However, the face-to-face encounter must be related

requirement regarding the patient's need for skilled services during a face to

to the primary reason the patient requires home health services. The information regarding the patient's need for skilled services

face encounter?

can be located anywhere 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), and

that documentation should be shared with the HHA. The documentation should provide enough information to substantiate the need for skilled services.

12. Does documentation

There is no Medicare regulation stating that a physician must co-

regarding the patient's need or counter sign information regarding the patient's need for

for skilled services require a skilled services when completed by a NPP.

co-signature (counter signature) when completed by a NPP?

However, the Medicare enrolled physician must sign the attestation, certifying that all five of the eligibility criteria (see FAQ #2) have been met, including the patient's need for skilled

services.

13. Can the HHA add

Information from the HHA, such as the initial and/or

information to the certifying comprehensive assessment of the patient, or the home health

physician's medical record POC, can be incorporated into the certifying physician's medical

to support the patients need record for the patient and used to support the patient's need for

for skilled services?

skilled care.

However, this information must be corroborated by other medical record entries in the certifying physician's and/or the acute/postacute care facility's medical record for the patient.

As per CR 9189, documentation from the HHA that is used to support the home health certification is considered to be incorporated timely when it is signed off prior to or at the time of the certification/prior to claim submission and must corroborate with the rest of the patient's medical record.

Home Health Eligibility Q & A

CR 9119 Transmittal 92 & 208 CR 9189 Transmittal 602

UNDER THE CARE OF A PHYSICIAN/PHYSICIAN OVERSIGHT

14. When does the referring

If the patient is starting home health directly after discharge from

physician, who certifies the an acute/post-acute care setting where the physician, with

patient for home health

privileges, that cared for the patient in that setting is certifying

services, have to identify the the patient's eligibility for the home health benefit, but will not be

community physician who following the patient after discharge, then the certifying physician

will be following the patient must identify, as part of the home health certification, the

after discharge?

community physician who will be following the patient after

discharge.

PLAN OF CARE

15. What information should be There is no specific form or format for the POC. The POC must

included in the POC?

contain all pertinent diagnoses, including:

? The patient's mental status;

? The types of services, supplies, and equipment required;

? The frequency of the 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.

16. When should the POC be signed?

If the POC includes a course of treatment for therapy services: ? The course of therapy treatment must be established by the physician after any needed consultation with the qualified therapist; ? The plan must include measurable therapy treatment goals which pertain directly to the patient's illness or injury, and the patient's resultant impairments; ? The plan must include the expected duration of therapy services; and ? The plan must describe a course of treatment which is consistent with the qualified therapist's assessment of the patient's function. The physician must sign and date the POC prior to the claim being submitted. Additionally, any changes in the POC must be signed and dated by a physician.

FACE TO FACE ENCOUNTER

17. Can a NPP complete a face- NPPs who are allowed to perform the encounter are:

to-face encounter?

? A nurse practitioner or a clinical nurse specialist working in

Home Health Eligibility Q & A

CR 9119 Transmittal 92 & 208 CR 9189 Transmittal 602

accordance with State law and in collaboration with the certifying

physician or in collaboration with an acute or post-acute care

physician, with privileges, who cared for the patient in the acute

or post-acute care facility from which the patient was directly

admitted to home health;

? A certified nurse midwife, as authorized by State law, under the

supervision of the certifying physician or under the supervision of

an acute or post-acute care physician with privileges who cared

for the patient in the acute or post-acute care facility from which

the patient was directly admitted to home health;

? A physician assistant under the supervision of the certifying

physician or under the supervision of an acute or post-acute care

physician with privileges who cared for the patient in the acute or

post-acute care facility from which the patient was directly

admitted to home health.

18. Does documentation

There is no Medicare regulation stating that a physician must co-

regarding the face-to-face or counter sign information regarding the face to face encounter

encounter require a co-

when completed by a NPP.

signature (counter

signature) when completed However, the Medicare enrolled physician must sign an

by a NPP?

attestation statement certifying that all five of the eligibility

criteria (see FAQ #2) have been met including the date of the

face-to-face encounter.

19. What are the time frame The encounter must occur no more than 90 days prior to the

requirements for the face- home health start of care date or within 30 days after the start of

to-face encounter?

care.

20. In the situation where the This question highlights a scenario where the certification

face-to-face encounter is statement is signed prior to the completion of the face-to-face

not scheduled or performed encounter.

until the 30-day post-

admission timeframe and The certification statement is an attestation that the beneficiary is

plan of care has been signed eligible to utilize their Medicare home health benefit, and as part

and returned, what

of that eligibility, the beneficiary must have had a face-to-face

documentation is expected encounter within 30 days of the start of care. If a HHA receives a

to connect the dots

certification statement on the POC or anywhere in the medical

between the face-to-face record, and it does not include an attestation of the face-to-face

(once completed) and the having been performed, you must ensure that the face-to-face is

certification/POC?

attested to separately by the same certifying physician that

attested to the other elements. In this instance, you would have

a certification statement attesting to four of the five eligibility

criteria (see FAQ #2), and another certification statement

attesting that a face-to-face encounter occurred within the

required timeframe by an allowed provider along with the date of

the encounter. Both statements must be signed by the same

physician, as there is only one certifying physician.

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