CMS Clarifies Home Health Documentation

The Centers for Medicare & Medicaid Services (CMS) recently clarified documentation rules for home health care provided following an acute or post-acute stay after CMS contractors denied payment in the following situations:

  • The home health care agency (HHA) uses a single form (i.e., 485) for the plan of care and the certification with a single signature by the community physician who assumes oversight of the patient’s home health care.
  • The physician who cared for the patient in the acute or post-acute setting is the certifying physician and has provided and signed attached documentation of the face-to-face encounter.

CMS contractors have been instructed to accept the CMS-485 form signed by the community physician who assumes oversight of the patient’s care. If the HHA requests reopening of the claim, CMS contractors have been instructed to reopen and determine if face-to-face requirements have been met, due to their meeting the criteria described in the instruction described above. However, a determination that face-to-face requirements have been met would not result in automatic payment of the claim. Contractors must subsequently perform a complete and full review to determine if payment should be made.

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CMS says it doesn’t require a specific form to be used for certification or plan of care. Many providers choose to file the no-longer-required CMS 485 form to satisfy both the plan of care and the certification, attaching documentation of the face-to-face encounter and providing a single signature.

In the case of patients admitted to home health following an acute or post-acute stay, the Benefit Policy Manual (BPM) language allows one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care. If the face-to-face encounter documentation and the CMS-485 form collectively satisfy all of the certification and plan of care content requirements, as defined in chapter 7, section 30 of the BPM, Medicare contractors shall accept a CMS-485 form. However, it must be signed by the community physician who assumes oversight of the patient’s home health care and include an addendum containing the face-to-face encounter documentation requirements signed by the physician who cared for the patient in an acute or post-acute setting. Only this will satisfy the certification, face-to-face encounter, and plan of care requirements. In this scenario, the certifying physician is the acute or post-acute physician who has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation. The physician who signs the CMS-485 assumes care for the patient’s home health care.

CMS also wants providers and payers to know that no protocol exists for identifying the community physicians to whom care is being passed.

In the 2011 Health Home Prospective Payment System (HH PPS) final rule and in chapter 7, section 30.5.1.1 of the BPM, CMS allows for the following when the patient is admitted to a HHA following an acute or post-acute stay:

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  • The physician who cared for the patient during the acute or post-acute stay may certify the patient’s eligibility for the Medicare home health benefit, document the encounter based on his or her experience with the patient in the acute or post-acute setting, and initiate and sign the patient’s plan of care. The community physician who assumes care for the patient after admission to the HHA would then oversee and update the plan of care as needed.
  • A physician who cared for the patient during the acute or post-acute stay may certify the patient’s eligibility for the Medicare home health benefit, document the encounter based on his or her experience with the patient in the acute or post-acute setting, and initiate the patient’s plan of care. CMS allows the physician who assumes responsibility for the patient’s home health care to update the plan of care as needed, and sign the plan of care. This flexibility is allowed because often the acute or post-acute physician is hesitant to sign the home health plan of care since he or she does not follow the patient after acute discharge.

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One Response to “CMS Clarifies Home Health Documentation”

  1. Diana Sheets says:

    However, it must be signed by the community physician who assumes oversight of the patient’s home health care and include an addendum containing the face-to-face encounter documentation requirements signed by the physician who cared for the patient in an acute or post-acute setting.

    Where does this addendum need to go? Are there instructions for entering the date last seen and NPI # for the physician who cared for the patient in in block 19 or anything for the claim for the community physician to be paid?

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