evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
 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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
The skilled nursing service must be reasonable and necessary to the diagnosis and treatment of the patient's illness or injury within the context of the patient's unique medical condition.  To be considered reasonable and necessary for the diagnosis or treatment of the patient's illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of medical and nursing practice.  The determination of whether the services are reasonable and necessary should be made in consideration that a physician or allowed practitioner has determined that the services ordered are reasonable and necessary.  The services must, therefore, be viewed from the perspective of the c ondition of the patient when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certification period.  A patient's overall medical condition, without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time, should be considered in deciding whether skilled services are needed.  A patient's diagnos is should never be the sole factor in deciding that a service the patient needs is either skilled or not skilled.  Skilled care may, depending on the unique condition of the patient, continue to be necessary for patients whose condition is stable. As is outlined in home health regulations, as part of the home health agency (HHA) Conditions of Participation (CoPs), the clinical record of the patient must contain progress and clinical notes.  Additionally, in Pub. 100- 04, Medicare Claims Processing Manual, Chapter 10; Home Health Agency Billing, instructions specify that for each claim, HHAs are required to report all services provided to the beneficiary during each 30-day period, which includes reporting each visit in line -item detail.  As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided.  These clinical notes are also expected to provide important communication among all members of the home care team regarding the developme nt, course and outcomes of the skilled observations, assessments, treatment and training performed.  Taken as a whole then, the clinical notes are expected to tell the story of the patients achievement towards his/her goals as outlined in the Plan of Care .  In this way, the notes will serve to demonstrate why a skilled service is needed.   Therefore  the home health clinical notes must document as appropriate:
(Medicare Benefit Policy Manual)
Therefore  the home health clinical notes must document as appropriate:    the history and physical exam pertinent to the days visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and   the patient/caregivers response to the skilled services provided, and    the plan for the next visit based on the rationale of prior results,    a detailed rationale that explains the need for the skilled service in light of the patients overall medical condition and experiences,   the complexity of the service to be performed, and    any other pertinent characteristics of the beneficiary or home   Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care.  Clinical notes should also provide a clear picture of the treatment, as well as next steps to be taken.  Vague or subjective description s of the patients care should not be used.  For example, terminology such as the following would not adequately describe the need for skilled care:    Patient tolerated treatment well  Caregiver instructed in medication management   Continue with POC   Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.   EXAMPLE 1:   The presence of a plaster cast on an extremity generally does not indicate a need for skilled nursing care.  However, the patient with a preexisting peripheral vascular or circulatory condition might need skilled nursing care to observe for complications, monitor medication administration for pain control, and teach proper skin care to preserve skin integrity and prevent breakdown.  The documentation must support the severity of the circulatory condition that requires skilled care.  The clinical notes for each home health visit should document the patients skin and circulatory examination a s well as the patient and/or caregiver application of the educational principles taught since the last visit.  The plan for the next visit should describe the skilled services continuing to be required.   EXAMPLE 2:
(Medicare Benefit Policy Manual)
EXAMPLE 2:   The condition of a patient, who has irritable bowel syndrome or is recovering from rectal surgery, may be such that he or she can be given an enema safely and effectively only by a nurse.  If the enema were necessary to treat the illness or injury, then the visit would be covered as a skilled nursing visit.  The documentation must support the skilled need for the enema, and the plan for future visits based on this information.  EXAMPLE 3:   Giving a bath does not ordinarily require the skills of a nurse and, therefore, would not be covered as a skilled nursing service unless the patient's condition is such that the bath could be given safely and effectively only by a nurse (as discussed in 30.1 above).  EXAMPLE 4:   A patient with a well-established colostomy absent complications may require assistance changing the colostomy bag because they cannot do it themselves and there is no one else to change the bag.  Notwithstanding the need for the routine colostomy care, changing the colostomy bag does not become a skilled nursing service when the nurse provides it.  EXAMPLE 5:   A patient was discharged from the hospital with an open draining wound that requires irrigation, packing, and dressing twice each day.  The HHA has taught the family to perform the dressing changes.  The HHA continues to see the patient for the wound care that is needed during the time that the family is not available and willing to provide the dressing changes.  The wound care continues to be skilled nursing care, notwithstanding that the family provides it part of the time, and may be covered as long as t he patient requires it.   EXAMPLE 6:   A physician has ordered skilled nursing visits for a patient with a hairline fracture of the hip.  The home health record must document the reason skilled services are required and why the nursing visits are reasonable and necessary for treatment of the patient's hip injury.  EXAMPLE 7:   A physician has ordered skilled nursing visits for teaching of self -administration and self -management of the medication regimen for a patient, newly diagnosed, with diabetes mellitus in the home health plan of care.  Each visits documentation must describe the patients progress in this activity.   EXAMPLE 8:
(Medicare Benefit Policy Manual)
EXAMPLE 8:   Following a cerebrovascular accident (CVA), a patient has an in -dwelling Foley catheter because of urinary incontinence, and is expected to require the catheter for a long and indefinite period.  The medical condition of the patient must be described and documented to support the need for nursing skilled services in the home health plan of care.  Periodic visits to change the catheter as needed, treat the symptoms of catheter malfunction, and teach proper catheter care would be covered as long as they are reasonable and necessary, although the patient is stable, even if there is an expectation that the care will be needed for a long and indefinite period.  However, at every home health visit, the patients current medical condition must be described and ther e must be documentation to support the need for continued skilled nursing services.  EXAMPLE 9:   A patient with advanced multiple sclerosis undergoing an exacerbation of the illness needs skilled teaching of medications, measures to overcome urinary retention, and the establishment of a program designed to minimize the adverse impact of the exacerbati on.  The clinical notes for each home health visit must describe why skilled nursing services were required.  The skilled nursing care received by the patient would be covered despite the chronic nature of the illness.  EXAMPLE 10:   A patient with malignant melanoma is terminally ill, and requires skilled observation, assessment, teaching, and treatment.  The patient has not elected coverage under Medicare's hospice benefit.  The documentation should describe the goal of the skilled nursing intervention, and at each visit the services provided should support that goal.  The skilled nursing care that the patient requires would be covered, notwithstanding that the condition is terminal, because the documentation and description must support that the needed services required the skills of a nurse.   40.1.2 - Application of the Principles to Skilled Nursing Services  (Rev. 1, 10- 01-03) A3-3118.1.B, HHA -205.1.B   The following discussion of skilled nursing services applies the foregoing principles to specific skilled nursing services about which questions are most frequently raised.
(Medicare Benefit Policy Manual)
The following discussion of skilled nursing services applies the foregoing principles to specific skilled nursing services about which questions are most frequently raised.   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  (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02- 11-20)  Observation and assessment of the patient's condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient's condition that requires skilled nursing personnel to identify and evaluate the pa tient's need for possible modification of treatment or initiation of additional medical procedures until the patient's clinical condition and/or treatment regimen has stabilized.  Where a patient was admitted to home health care for skilled observation bec ause there was a reasonable potential of a complication or further acute episode, but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential  for such a complication or further acute episode.   Information from the patient's home health record must document the rationale that demonstrates that there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3- week period.  Such signs and symptoms as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment.  Where these signs and symptoms are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient, then the services would be covered.  However, observation and assessment by a nurse is not reasonable and necessary for the treatment of the illness or injury where fluctuating signs and symptoms are part of a longstanding pattern of the patient's condition which has not previously required a change in the prescribed treatment.   EXAMPLE 1: