(Medicare Benefit Policy Manual)

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.  30.5 - Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services                    (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  The HHA must be acting upon a plan of care as described in 30.2, and a physician or allowed practitioner certification or recertification that meets the requirements of the following sections in order for HHA services to be covered.   30.5.1 - Physician or Allowed Practitioner Certification  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  A certification (versus recertification) is considered to be anytime that a Start of Care OASIS is completed to initiate care.  In such instances, a 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 30.1.1;   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.  Where a patients sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined 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 th e certification, or as a signed addendum to the certification;   3. A plan of care has been established and is periodically reviewed by a physician or allowed practitioner;  4. The services are or were furnished while the patient is or was under the care of a physician or allowed practitioner;  5. For episodes/periods with starts of care beginning January 1, 2011 and later, in accordance with 30.5.1.1 below, a face- to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to t he primary reason the patient requires home health services, and was performed by a physician or non-physician practitioner.  The certifying physician or allowed practitioner must also document the date of the encounter.  Example Certification Statement:   I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy.  The patient is under my care, and I have authorized services on this plan of care and will periodically review the plan.  The patient had a face -to-face encounter with a physician or an allowed non-physician practitioner on 11/01/2020 and the encounter was related to the primary reason for home health care.   Physician or allowed practitioners Signature and Date Signed:   John Doe, MD   11/05/2020  Physician or Allowed Practitioners Name and Address  John Doe, MD  2121 Washington Pkwy Suite 220 Washington, DC 20000  NOTE : This represents one example of a valid certification statement. Certification statements can be included in varying forms or formats as long as the content requirements (#1- 5 above) for the certification are met.   If the patient is starting home health directly after discharge from an acute/post- acute care setting where the physician or allowed practitioner, with privileges, that cared for the patient in that setting is certifying the patients eligibility for the h ome health benefit, but will not be following the patient after discharge, then the certifying physician or allowed practitioner must identify the community physician or allowed practitioner who will be following the patient after discharge.  One of the cr iteria that must be met for a patient to be considered eligible for the home health benefit is that the patient must be under the care of a physician or allowed practitioner (number 4 listed above).  Otherwise, the certification is not valid.   The certification must be complete prior to when an HHA bills Medicare for reimbursement; however, physicians and allowed practitioners should complete the certification when the plan of care is established, or as soon as possible thereafter.  This is longstanding CMS policy as referenced in Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 4, section 30.1.  It is not acceptable for HHAs to wait until the end of a 60-day certification period to obtain a completed certifi cation/recertification.   30.5.1.1  Face -to-Face Encounter  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  1.  Allowed Provider Types  As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitione r that cared for the patient in the acute or post- acute care facility (with privileges who cared for the patient in an acute or post- acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner ( NPP).   NPPs who are allowed to perform the encounter are:   A nurse practitioner or a clinical nurse specialist working in 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.   NPPs performing the encounter are subject to the same financial restrictions with the HHA as the certifying physician, as described in 42 CFR 424.22(d).  2.  Timeframe Requirements    The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.    In situations when a physician or allowed practitioner orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the physician or an allowed NPP must see the patient agai n within 30 days after admission.  Specifically, if a patient saw the physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patients condition had changed to the extent that standards of practice would indica te that the physician or a non- physician practitioner should examine the patient in order to establish an effective treatment plan.  3.  Exceptional Circumstances   When a home health patient dies shortly after admission, before the face -to-face encounter occurs, if the contractor determines a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification require ments are met, the certification is deemed to be complete.   4.  Telehealth   The face- to-face encounter can be performed via a telehealth service, in an approved originating site.  An originating site is considered to be the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunication s system occurs.  Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area.  Entities that participate in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the Department of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location.   The originating sites authorized by law are:    The office of a physician or practitioner;   Hospitals;  Critical Access Hospitals (CAH);   Rural Health Clinics (RHC);  Federally Qualified Health Centers (FQHC);   Hospital -based or CAH -based Renal Dialysis Centers (including satellites);  Skilled Nursing Facilities (SNF); and   Community Mental Health Centers (CMHC).   30.5.1.2  Supporting Documentation Requirements  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  As of January 1, 2015, documentation in the certifying physician or allowed practitioners medical records and/or the acute /post -acute care facilitys medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.  Documentation from the certifying physician or allowed practitioners medical records and/or the acute /post -acute care facilitys medical records (if the patient was directly admitted to home health) used to support the certification of home health eligibility must be provided, upon request, to the home health agency, review entities, and/or the Centers for Medicare and Medicaid Services (CMS).  In turn, an HHA 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.  If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.   The certifying physician or allowed practitioner and/or the acute/post -acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health se rvices.  This includes documentation that substantiates the patients:    Need for the skilled services; and   Homebound status;   The certifying physician or allowed practitioner and/or the acute/post -acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain the actual clinical note for the face -to-face encounter visit that demonstrates that the encounter:    Occurred within the required timeframe,   Was related to the primary reason the patient requires home health services; and   Was performed by an allowed provider type.   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.