(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 7 - Home Health Services   Table of Contents  (Rev. 12382; Issued: 11-28-23) (Rev. 1 2425 Issued: 12- 21-23)   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 Recertification s 10.4 -  Submission of the Notice of Admission (NOA)   10.5  Requirements for Submission of NOA  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 "Part -Time" 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 -  Physician or or Allowed Practitioner Certification f or 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. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  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 using a disposable device (d NPWT) 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 only the device paid separately (specified by the assigned HCPCS code) and does not include payment for the professional services.  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 t heir 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: