(Medicare Benefit Policy Manual)

This information can be found most often in clinical and progress notes and discharge summaries.  While the face- to-face encounter must be related to the primary reason for home health services, the patients skilled need and homebound status can be substa ntiated through an examination of all submitted medical record documentation from the certifying physician or allowed practitioner, acute/post -acute care facility, and/or HHA (see below).  The synthesis of progress notes, diagnostic findings, medications, nursing notes, etc., help to create a longitudinal clinical picture of the patients health status.    Information from the HHA, such as the plan of care required per 42 CFR 409.43 and the initial and/or comprehensive assessment of the patient required per 42 CFR 484.55, can be incorporated into the certifying physician or allowed practitioners medical r ecord for the patient and used to support the patients homebound status and need for skilled care.  However, this information must be corroborated by other medical record entries in the certifying physician or allowed practitioners and/or the acute/post -acute care facilitys medical record for the patient.  This means that the appropriately incorporated HHA information, along with the certifying physician or allowed practitioners and/or the acute/post -acute care facilitys medical record, creates a clinically consistent picture that the patient is eligible for Medicare home health services.    The certifying physician or allowed practitioner demonstrates the incorporation of the HHA information into his/her medical record for the patient by signing and dating the material.  Once incorporated, the documentation from the HHA, in conjunction with t he certifying physician or allowed practitioner and/or acute/post -acute care facility documentation, must substantiate the patients eligibility for home health services.   30.5.2 - Physician or Allowed Practitioner Recertification                       (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  At the end of the 60- day certification, a decision must be made whether or not to recertify the patient for a subsequent 60- days.  An eligible beneficiary who qualifies for a subsequent 60- day certification would start the subsequent 60- day certification o n day 61.  Under HH PPS, the plan of care must be reviewed and signed by the physician or allowed practitioner every 60 days unless one of the following occurs:    A beneficiary transfers to another HHA; or    A discharge and return to home health during the 60- day certification.   For recertification of home health services, the physician or allowed practitioner must certify (attest) that:  1.  The home health services are or were needed because the patient is or was confined to the home as defined in 30.1;   2.  The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech -language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech- language pathology services ceased.  Where a patients sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defin ed in 40.1.2.2), the physician or allowed practitioner must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification;   3.  A plan of care has been established and is periodically reviewed by a physician or allowed practitioner; and   4.  The services are or were furnished while the patient is or was under the care of a physician or allowed practitioner.  Medicare does not limit the number of continuous 60- day recertifications for beneficiaries who continue to be eligible for the home health benefit.  The certification may cover a period less than but not greater than 60 days. Because the updated home healt h plan of care must include the frequency and duration of visits to be made, the physician or allowed practitioner does not have to estimate how much longer skilled services will be needed for the recertification.    30.5.3 - Who May Sign the Certification or Recertification  (Rev. 10738, Issued: 05- 07-21, Effective: 01 -01-21, Implementation: 08- 09-21)  The physician or allowed practitioner who signs the certification or recertification must be permitted to do so by 42 CFR 424.22.  A physician or other allowed non -physician practitioner, other than the certifying physician or certifying allowed practitioner who established the home health plan of care, may sign the plan of care or the recertification statement in the absence of the certifying physician or certifying allowed practitioner. This is only permitted when such physician or allowed non- physician p ractitioner has been authorized to care for the certifying physicians or allowed practitioners patients in his/her absence.  The HHA is responsible for ensuring that the physician or allowed non-physician practitioner who signs the plan of care and recer tification statement was authorized by the physician or allowed practitioner who established the plan of care and completed the certification for his/her patient in his/her absence.  The physician or allowed practitioner that performed the required face- to-face encounter must sign the certification of eligibility, unless the patient is directly admitted to home health care from an acute or post -acute care facility and the encounter was performed by a physician or allowed practitioner in such setting.  30.5.4  Physician or Allowed Practitioner Billing for Certification and Recertification                                                                                           (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21) Certification and recertification claims are Part B claims paid for under the Physician Fee Schedule.  These claims are billed using HCPCS codes G0180 (certification) or G0179 (re-certification).  The descriptions of these two codes indicate that they are used to bill for certification or recertification of patient eligibility for Medicare -covered home health services under a home health plan of care (p atient not present), including contacts with the HHA and review of reports of patient status required by physicians or allowed practitioners to affirm the initial implementation of the plan of care that meets patient's needs, per certification period.  As  noted above, these codes are for certification or recertification for Medicare- covered home health services.  If there are no Medicare-covered home health services, these codes should not be billed or paid.  As such, claims for certification/recertification of eligibility for home health services (G0180 and G0179, respectively) will not be covered if the HHA claim itself was non -covered 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.  40 - Covered Services Under a Qualifying Home Health Plan of Care  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  Section 1861(m)of the Act governs the Medicare home health services that may be provided to eligible beneficiaries by or under arrangements made by a participating home health agency (HHA).  Section 1861(m) describes home health services as    Part-time or intermittent skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample);   Part-time or intermittent home health aide services;   Physical therapy;   Speech -language pathology;   Occupational therapy;   Medical social services;    Medical supplies (including catheters, catheter supplies, ostomy bags, supplies related to ostomy care, and a covered osteoporosis drug (as defined in 1861(kk of the Act), but excluding other drugs and biologicals);   Durable medical equipment while under the plan of care established by physician or allowed practitioner;   Medical services provided by an intern or resident- in-training under an approved teaching program of the hospital in the case of an HHA which is affiliated or under common control with a hospital; and    Services at hospitals, skilled nursing facilities, or rehabilitation centers when they involve equipment too cumbersome to bring to the home.  The term "part -time or intermittent" for purposes of coverage under 1861(m) of the Act means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case- by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week).  See 50.7.  For any home health services to be covered by Medicare, the patient must meet the qualifying criteria as specified in 30, including having a need for skilled nursing care on an intermittent basis, physical therapy, speech-language pathology services, or a continuing need for occupational therapy as defined in this section.  40.1 - Skilled Nursing Care  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3118.1, HHA-205.1  To be covered as skilled nursing services, the services must require the skills of a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, must be reasonable and necessary to the treatment of the patient's illness or injury as discussed in 40.1.1, below, and must be intermittent as discussed in 40.1.3.  Cover age of skilled nursing care does not turn on the presence or absence of a patients potential for improvement from the nursing care, but rather on the patients need for skilled care.   40.1.1 - General Principles Governing Reasonable and Necessary Skilled Nursing Care  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  If all other eligibility and coverage requirements under the home health benefit are met, skilled nursing services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse (skilled care) are necessary.  Skilled nursing services are covered where such skilled nursing services are necessary to maintain the patients current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.  When, however, the individualized assessment does not demonstrate such a necessity for skilled care , including when the services needed do not require skilled nursing care because they could safely and effectively be performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit.   Skilled nursing care is necessary only when (a) the particular patients special medical complications require the skills of a registered nurse or, when provided by regulation, a licensed practical nurse to perform a type of service that would otherwise be  considered non-skilled; or (b) the needed services are of such complexity that the skills of a registered nurse or, when provided by regulation, a licensed practical nurse are required to furnish the services.  To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel as provided by regulation, including 42 C.F.R. 409.32.  Some services may be classified as a skilled nursing service on the basis of complexity alone (e.g., intravenous and intramuscular injections or insertion of catheters) and, if reasonable and necessary to the treatment of the patient's illness or injury, w ould be covered on that basis.  If a service can be safely and effectively performed (or self -administered) by an unskilled person, without the direct supervision of a nurse, the service cannot be regarded as a skilled nursing service although a nurse actually provides the service.  However, in some cases, the condition of the patient may cause a service that would ordinarily be considered unskilled to be considered a skilled nursing service.  This would occur when the patient's condition is such that the s ervice can be safely and effectively provided only by a nurse.  A service is not considered a skilled nursing service merely because it is performed by or under the supervision of a nurse.  The unavailability of a competent person to provide a non- skilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a nurse provides the service.   A service that, by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, the patient's family, or other caregivers.