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Home health - Patient Eligibility criteria - Part 2 - Re-certification requirements -
Certification Requirements: Who Can Perform a Face-to-Face Encounter
According to 42 CFR 424.22(a)(1)(v)(A), the face-to-face encounter can be performed by:
** The certifying physician;
** The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health);
** A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician; or
** A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician.
According to 42 CFR 424.22(d)(2), the face-to-face encounter cannot be performed by any physician or allowed NPP (listed above) who has a financial relationship with the HHA.
Certification Requirements: Management and Evaluation Narrative
According to 42 CFR 424.22(a)(1)(i) if a patient's underlying condition or complication requires a Registered Nurse (RN) to ensure that essential non-skilled care is achieving its purpose and a RN needs to be involved in the development, management and evaluation of a patient's care plan, the physician will include a brief narrative describing the clinical justification of this need.
If the narrative is part of the certification form then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification form in addition to the physician's signature on the certification form, the physician must sign immediately following the narrative in the addendum.
For skilled nursing care to be reasonable and necessary for management and evaluation of the patient's plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of a registered nurse to promote the patient's recovery and medical safety in view of the patient's overall condition.
For more information about SN for management and evaluation refer to Section 22.214.171.124, Chapter 7 of the “Medicare Benefit Policy Manual” at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf on the CMS website.
Certification Requirements: Supporting Documentation
** Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. 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.
** According to the regulations at 42 CFR 424.22(c), Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the home health agency, review entities, and/or CMS. Certifying physicians who show patterns of non-compliance with this requirement, including those physicians whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as provider-specific probe reviews.
** Information from the HHA, such as the patient’s comprehensive assessment, can be incorporated into the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.
** Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.
** The certifying physician must review and sign off on anything incorporated into the patient’s medical record that is used to support the certification of patient eligibility (that is, agree with the material by signing and dating the entry).
** The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s:
1. Need for the skilled services; and
2. Homebound status.
** The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:
1. Occurred within the required timeframe;
2. Was related to the primary reason the patient requires home health services; and
3. Was performed by an allowed provider type.
This information can be found most often in, but is not limited to, clinical and progress notes and discharge summaries.
Please review the following examples included at the end of this article:
1. Discharge Summary;
2. Progress Note;
3. Progress Note and Problem List; or
4. Discharge Summary and Comprehensive Assessment.
At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient for a subsequent 60-day episode. According to the regulations at 424.22(b)(1) recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode and unless there is a:
** Patient-elected transfer; or
** Discharge with goals met and/or no expectation of a return to home health care.
(These situations trigger a new certification, rather than a recertification)
Medicare does not limit the number of continuous episodes of recertification for patients who continue to be eligible for the home health benefit.
1. Must be signed and dated by the physician who reviews the plan of care;
2. Indicate the continuing need for skilled services (the need for OT may be the basis for continuing services that were initiated because the individual needed SN, PT or SLP services); and
3. Estimate how much longer the skilled services will be required.
Physician Billing for /Certification/Recertification
Certifying/recertifying patient eligibility can include contacting the home health agency and reviewing of reports of patient status required by physicians to affirm the implementation of the plan of care that meets patient’s needs.
1. Healthcare Common Procedure Coding System (HCPCS) code G0180 - Physician certification home health patient for Medicare-covered home health service under a home health plan of care (patient not present).
2. HCPCS code G0179 -Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)
Physician claims for certification/recertification of eligibility for home health services (G0180 and G0179 respectively) are not considered to be for “Medicare-covered” home health services 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.
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