Provider Compliance Tips for Home Health Services
While there has been more than a $5.3 billion decrease in estimated improper payments for home health services over the past three years, the projected improper payment amount for home health services during the 2018 report period was $3.2 billion. This translates to a Medicare Fee-For-Service (FFS) improper payment rate of 17.6 percent, accounting for 9.8 percent of the overall Medicare FFS improper payment rate in 2018, according to the Centers for Medicare & Medicaid Services.
Home health agencies (HHA) and providers who refer patients to home health, order home health services, and/or certify eligibility for the Medicare home health benefit must work to minimize insufficient documentation, which accounted for a large proportion of improper payments for home health services. The primary reason for these errors was that the documentation to support the certification of home health eligibility requirements was missing or inadequate.
Medicare coverage of home health services requires physician certification of the patient’s eligibility for the home health benefit. Let’s review some provider compliance tips for preventing denials and, in turn, improper payments through proper documentation and demonstration of medical necessity.
Prevent Denials for Home Health Services
Address inadequate documentation for certification/re-certification of eligibility by ensuring that physicians or Medicare allowed non-physician practitioners (NPPs) certify that the patient is:
- Confined to the home
- Under the care of a physician and receiving services under a plan of care established and periodically reviewed by the physician
- In need of home health services
- Has had a face-to-face encounter with a physician or an allowed NPP related to the primary reason the patient requires home health services that:
- Occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of home health care
- Was related to the primary reason the patient requires home health services
Let’s take a closer look at each certification requirement.
The following two criteria must be met for an individual to be considered “confined to the home” (homebound):
- Criterion One: The patient must either:
- Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence
- Have a condition such that leaving their home is medically contraindicated
If the patient meets one of these conditions, they must ALSO meet two additional requirements defined in criterion two below.
- Criterion Two:
- The patient must exhibit a normal inability to leave home
- Leaving home must require a considerable and taxing effort
The physician must take into account the illness or injury for which the patient met the first criterion and consider that illness or injury in the context of the patient’s overall condition. Longitudinal clinical information about the patient’s overall health status is usually needed to sufficiently demonstrate these two requirements. Such clinical information may include the patient’s diagnosis, duration of the condition, clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions, results, etc.
Services Provided Under a Plan of Care Established and Approved by a Physician
The medical records provided on behalf of the patient must contain information that justifies the referral for home health services. This includes documentation that substantiates the patient’s need for skilled services and homebound status. The HHA must be acting upon a physician’s plan of care that meets the requirements of this section for coverage of HHA services. Per the Medicare Benefit Policy Manual,
For HHA services to be covered, the individualized plan of care must specify the services necessary to meet the patient-specific needs identified in the comprehensive assessment. In addition, the plan of care must include the identification of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 CFR 484.60(a) that establish the need for such services. All care provided must be in accordance with the plan of care.
If the care plan includes a course of treatment for therapy services:
- The physician must establish the course of therapy after any needed consultation with a qualified therapist. The plan must include:
- Measurable therapy treatment goals which pertain directly to the patient’s illness or injury and resulting impairments,
- Expected duration of therapy services, and
- A description of the course of treatment that is consistent with the qualified therapist’s assessment of the patient’s function.
Medical Necessity of Home Health Services
Documentation must show the patient needs one of the following:
- Skilled nursing care that is
- Reasonable and necessary;
- Needed on an “intermittent” basis; and
- Not solely needed for venipuncture to obtain a blood sample.
- Physical therapy
- Speech-language pathology services or
- A continuing need for occupational therapy
Provider documentation must state that their face-to-face encounter with the patient was no more than 90 days prior to the start date of home health services or within 30 days of the initiation of home health care. The certifying physician or allowed NPP must also document the date of the encounter.
The patient’s medical record must contain the actual clinical note for the face-to-face visit that demonstrates that the encounter:
- Occurred within the required time frame
- Was related to the primary reason the patient requires home health services, and
- Was performed by an allowed provider type
- NPPs allowed to perform the encounter:
- Nurse practitioner or clinical nurse specialist
- Certified midwife
- Physician assistant
- NPPs allowed to perform the encounter: