In 2014, Medicare says it had identified overpayments for home health claims, most of them due to insufficient documentation of the face-to-face encounter required prior to certifying a Medicare patient's eligibility for the home health benefit.*
Typically
in those cases, the required brief
narrative portion of the documentation did not sufficiently describe how
the clinical findings from the encounter supported the patient's homebound
status and the need for skilled services. For example, some of the records
Medicare reviewed contained very little clinical information beyond simple
lists of diagnoses, recent injuries, or procedures. The physician also needed
to title, sign, and date the face-to-face encounter narrative.
The Centers
for Medicare & Medicaid Services (CMS) later announced a policy change whereby for home health
service episodes of care beginning on or
after Jan. 1, 2015, the narrative requirement of the documentation was
eliminated. However, the physician still must provide adequate justification
for the home health services referral in
the medical record.
For
Medicare to accept a home health services claim, as well as the physician’s
claim for certifying/recertifying a patient, the physician must substantiate the
following:
Confined to the home — Describe why the patient is homebound. An individual is considered "confined to the home" if both of the following two criteria are met:
- The patient must either:
- Because of illness or injury, need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or another person's help to leave his or her residence, OR
- Have a condition such that leaving his or her home is medically contraindicated.
- There must exist:
- A normal inability to leave home; AND
- Exertion of a considerable and taxing effort needed to leave the home.
Need for skilled services — To qualify for home health services, the patient must need intermittent skilled nursing services, physical therapy, or speech language pathology services. Describe the purpose of these and other services in the home. (For example, "skilled nursing required to assess and manage new COPD regimen.") The skilled services must be reasonable and necessary for treating the patient's illness or injury, or restoring or maintaining affected function within the context of the patient's medical condition.
- Examples of skilled nursing services are teaching/training; observation/assessment; complex care plan management; administration of certain medications; tube feedings; wound care, catheters, and ostomy care; NG and tracheostomy aspiration/care; psychiatric evaluation and therapy; and rehabilitation nursing.
- Assuming all other eligibility and coverage requirements are met, the patient must need the skills of a qualified therapist:
- To restore patient function,
- To design or establish a maintenance program, or
- To perform maintenance therapy (not to be performed by an assistant).
For details and do-and-don't examples of home health documentation, see the Centers for Medicare & Medicaid Services' (CMS') MLN Matters No. SE1405 (PDF). A
Remember also to check TMA's Medicare Resource Center for Medicare help, news, and information.
*Prior to certifying a Medicare patient's eligibility for the home health benefit, the certifying physician must document that he or she or an allowed nonphysician practitioner had a face-to-face encounter with the patient within 90 days prior to the start of care or up to 30 days after the start of care.
Revised April 21, 2015
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