(Medicare Benefit Policy Manual)

Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided to home health patients under a home health plan of care. When a range of visits is ordered, the upper limit of the range is considered t he specific frequency.   EXAMPLE 2:   SN x 2 -4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical site.  Orders for services to be furnished "as needed" or "PRN" must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained.  30.2.4 - Who Signs the Plan of Care  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  The physician or allowed practitioner who signs the plan of care must be qualified to sign the certification as described in 42 CFR 424.22.  30.2.5 - Timeliness of Signature  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   A.  Initial Percentage Payment   If a physician or allowed practitioner signed plan of care is not available at the beginning of the 30-day period, the HHA may submit a RAP for the initial percentage payment based on physician or allowed practitioner verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician or allowed practitioner.  If the RAP submission is based on verbal orders, the verbal order must be recorded in the plan of care, include a description of the patient's condition and the services to be provided by the home health agency, include an attestation (relating to the physician's or allowed practitioners orders and the date received per 42 CFR 409.43), and the plan of care is copied and immediately submitted to the physician or allowed practitioner.  A billable visit must be rendered prior to the submission of a RAP. B.  Final Percentage Payment   The plan of care must be signed and dated by a physician or allowed practitioner as described who meets the certification and recertification requirements of 42 CFR 424.22 and before the claim for each 30 -day period for services is submitted for the final percentage payment.  Any changes in the plan of care must be signed and dated by a physician or allowed practitioner.  30.2.6 - Use of Oral (Verbal) Orders                                                       (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   When services are furnished based on a physician or allowed practitioners oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies.  The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services.  The orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as HHA personnel who receive the oral orders notify that nurse or therapist before the service is rendered.  Thus, the rendering of a service that is based on an oral order would not be delayed pending signature of the supervising nurse or therapist.  Oral orders must be countersigned and dated by the physician or allowed practitioner before the HHA bills for the care in the same way as the plan of care.   Services which are provided from the beginning of the 60-day certification period based on a request for anticipated payment and before the physician or allowed practitioner signs the plan of care are considered to be provided under a plan of care established and approved by the physician or allowed practitioner where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care.  Services that are provided in the subsequent 60-day certification period are considered provided under the plan of care of the subsequent 60- day episode where there is an oral order before the services provided in the subsequent period are furnished and the order is reflected in the medical record.  However, services that are provided after the expiration of the plan of care, but before the acquisition of an oral order or a signed plan of care are not considered provided under a plan of care.   EXAMPLE 1:   The HHA acquires an oral order for I.V. medication administration for a patient to be performed on August 1.  The HHA provides the I.V. medication administration August 1 and evaluates the patient's need for continued care.  The physician or allowed practi tioner signs the plan of care for the I.V. medication administration on August 15.  The visit is covered since it is considered provided under a plan of care established and approved by the physician or allowed practitioner, and the HHA had acquired an ora l order prior to the delivery of services.   EXAMPLE 2:   The patient is under a plan of care in which the physician or allowed practitioner orders I.V. medication administration every 2 weeks.  The last day covered by the initial plan of care is July 31.  The patient's next I.V. medication administration is sche duled for August 5 and the physician or allowed practitioner signs the plan of care for the new period on August 1.  The I.V. medication administration on August 5 was provided under a plan of care established and approved by the physician or allowed pract itioner.    EXAMPLE 3:   The patient is under a plan of care in which the physician or allowed practitioner orders I.V. medication administration every 2 weeks.  The last day covered by the plan of care is July 31.  The patient's next I.V. medication administration is scheduled for August 5 and the physician or allowed practitioner does not sign the plan of care until August 6.  The HHA acquires an oral order for the I.V. medication administration before the August 5 visit, and therefore the visit is considered to be provided under  a plan of care established and approved by the physician or allowed practitioner.    Any increase in the frequency of services or addition of new services during a 60- day certification must be authorized by a physician or allowed practitioner by way of a written or oral order prior to the provision of the increased or additional services.   30.2. 7 - Frequency of Review of the Plan of Care                                  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  The plan of care must be reviewed and signed by the physician or allowed practitioner who established the plan of care, in consultation with HHA professional personnel, at least every 60 days.  Each review of a patient's plan of care must contain the signa ture of the physician or allowed practitioner and the date of review.    30.2.  8 - Facsimile Signatures                                                                    (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  The plan of care or oral order may be transmitted by facsimile machine.  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.  30.2.9 - Alternative Signatures                                                                 (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  HHAs that maintain patient records by computer rather than hard copy may use electronic signatures.  However, all such entries must be appropriately authenticated and dated.  Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry.  The HHA must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records in the event of a system breakdown.  30.2. 10 - Termination of the Plan of Care - Qualifying Services          (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   The plan of care is considered to be terminated if the patient does not receive at least one covered skilled nursing, physical therapy, speech-language pathology service, or occupational therapy visit in a 60- day certification period since these are qualif ying services for the home health benefit.  An exception is if the physician or allowed practitioner documents that the interval without such care is appropriate to the treatment of the patient's illness or injury.  30.2.11 - Sequence of Qualifying Services and Other Medicare Covered Home Health Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   Once patient eligibility has been confirmed and the plan of care contains physician or allowed practitioner orders for the qualifying service as well as other Medicare covered home health services, the qualifying service does not have to be rendered prior to the other Medicare covered home health services ordered in the plan of care.  The sequence of visits performed by the disciplines must be dictated by the individual patient's plan of care.  For example, for an eligible patient in an initial 60 -day certi fication period that has both physical therapy and occupational therapy orders in the plan of care, the sequence of the delivery of the type of therapy is irrelevant as long as the need for the qualifying service is established prior to the delivery of other Medicare covered services and the qualifying discipline provides a billable visit prior to transfer or discharge in accordance with 42 CFR 409.43(f).  NOTE:   Dependent services provided after the final qualifying skilled service are not covered under the home health benefit, except when the dependent service was not followed by a qualifying skilled service due to unexpected inpatient admission, death of the p atient, or some other unanticipated event.  30.3 - Under the Care of a Physician or Allowed Practitioner                (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  The patient must be under the care of a physician or allowed practitioner who is qualified to sign the certification and plan of care in accordance with 42 CFR 424.22.  A patient is expected to be under the care of the physician or allowed practitioner who signs the plan of care.  It is expected that in most instances, the physician or allowed practitioner who certifies the patients eligibility for Medicare home health s ervices, in accordance with 30.5 below, will be the same physician or allowed practitioner who establishes and signs the plan of care.  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  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  The patient must need one of the following types of services:  1. Skilled nursing care that is   Reasonable and necessary as defined in 40.1;   Needed on an "intermittent" basis as defined in 40.1.3; and   Not solely needed for venipuncture for the purposes of obtaining blood sample as defined in 40.1.2.13;or  2. Physical therapy as defined in 40.2.2 ; or  3. Speech -language pathology services as defined in 40.2.3; or  4. Have a continuing need for occupational therapy as defined in 40.2.4.  The patient has a continued need for occupational therapy when:  1. The services which the patient requires meet the definition of "occupational therapy" services of 40.2.4, and  2. The patient's eligibility for home health services has been established by virtue of a prior need for skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample), speech -language pathology services, or physical therap y in the current or prior certification period.   EXAMPLE:  A patient who is recovering from a cerebrovascular accident (CVA) has an initial plan of care that called for physical therapy, speech -language pathology services, occupational therapy, and home health aide services.  In the next certification period, the physician or allowed practitioner orders only occupational therapy and home health aide services because the patient no longer needs the skills of a physical therapist or a speech -language pathologist, but needs the services provided by the occupational ther apist.  The patient's need for occupational therapy qualifies him for home health services, including home health aide services (presuming that all other qualifying criteria are met), because in the prior certification period the beneficiarys eligibility for home health services was established by virtue of prior needs for physical therapy and speech- language pathology, and occupational therapy was initiated while the patient still required physical therapy and/or speech language -pathology.