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health care includes a wide range of health and social services delivered in your home to treat illness or injury. Services covered by Medicare’s home health benefit include intermittent skilled nursing care, therapy, and care provided by a
home health aide. Depending on the circumstances, home health care will be covered by either Part A or Part B. Medicare covers your home health care if: Note: You cannot qualify for Medicare home health coverage if you only need occupational therapy. However, if you qualify for home health care on another basis, you can also get occupational therapy. When your other home health needs end, you can continue receiving Medicare-covered occupational therapy under the home health benefit
if you need it. If you meet all the requirements, Medicare should pay for skilled care in your home and/or home health aide services. If you have questions or experience billing issues, call 1-800-MEDICARE. Print | Bookmark | Email | Font Size: + | – Medicare Benefit Policy Manual, (CMS Publication 100-02, Ch. 7) Medicare pays for care in a beneficiary's home, when qualifying criteria are met, and documented. It is essential for home health agencies to have a complete understanding of these criteria, as you have the right and responsibility, in collaboration with the physician, to decide if the beneficiary qualifies for your services. The agency then must understand what services are covered, and how to document these services. Refer to the following topics for more information:
Medicare-Covered Home Health Services
Additional ResourcesHome Health Payment RatesUpdated: 11.30.21 Change Request (CR) 9189 was released July 10, 2015 was an implementation date of August 11, 2015. This CR was issued to update the Medicare Program Integrity Manual, Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services. The CR specifically updates the review protocol for documentation to be included in certifying and recertifying home health patients. Certification Requirements: When conducting a medical necessity review, the review contractor shall determine whether the supporting documentation addresses each of the following criteria for which a physician certified (attested to):
Per 42CFR 424.22 (a) and (c), the patient’s medical record must support the certification of eligibility. Documentation in the patient’s medical record shall be used as a basis for certification of home health eligibility. Therefore, reviewers will consider HHA documentation if it is incorporated into the patient’s medical record held by the certifying physician and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) and signed off by the certifying physician. The documentation does not need to be on a special form. Recertification Requirements: The contractor shall review for the certifying physician statement which must indicate the continuing need for services and estimate how much longer the services will be required. As mentioned earlier in this section, the reviewer will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid. Certification affects all subsequent episodes: A physician certification/recertification of patient eligibility for the Medicare home health benefit is a condition for Medicare payment per sections 1814(a) and 1835(a) of the Social Security Act (the “Act”). The regulations at 42 CFR 424.22 list the requirements for eligibility certification and recertification. The requirements differ for eligibility certification and recertification; however, if the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will be non-covered—even if the requirements for recertification are met. Key things to remember…. Recertification includes that the physician must include in his/her recertification statement of the patient an estimated amount of time that services will continue to be required! This is new and can be as simple as: “I certify that in my estimation continued services will be required for _______.” A statement for the estimation of services is even if the original estimation extends beyond a 60-day recert episode. Also, when sending charts to be medically reviewed you will need to send the certification documentation as well. If the certification requirements are not met all subsequent episodes are non-covered. Lastly, there has been grave concern over when this is all required to be documented in the chart! CMS made an announcementthat states: Probe and Educate Reviews – CMS will conduct pre-payment reviews of home health claims for episodes beginning on or after August 1, 2015. CMS contractors will conduct these reviews using a Probe and Educate strategy through an end date to be determined. The purpose of this Probe and Educate process is to ensure that HHAs understand the new patient certification requirements. Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about October 1, 2015. So, any new portions of the certification and recertification requirements will be reviewed starting with episodes beginning on or after August 1, 2015! Which is generally covered by Medicare for the homebound patient?Medicare considers you homebound if: You need the help of another person or medical equipment such as crutches, a walker, or a wheelchair to leave your home, or your doctor believes that your health or illness could get worse if you leave your home.
What does Bill G0180 require?To bill for CPO, the physician must document time spent on Medicare reimbursable activities for that patient in a calendar month. Cert and Recert – If a physician reviews and signs initial certification for Medicare-covered Home Health services, the physician can bill under code G0180.
What is the primary purpose of quality documentation in home healthcare?Overall, the primary goal of proper clinical documentation is to ensure the quality and continuity of care to the patient by allowing the next care provider to know what you did, why you did it, and the benefit to the patient.
How do you write a visit frequency for home health?Nurses provided visit pattern information in the form of 1 or more visits for a set of weeks. For example, 1-2W1 2W2-3 1-2W4 means 1 to 2 visits for the first week, 2 visits per week for the next 2 to 3 weeks, and 1 to 2 visits for the following 4 weeks.
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