Home Health Referrals
As of January 1, 2015, the certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. The following should be documented and shared with the home health agency:
- Order for Home Health Services -The orders must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.
- Documentation to Support Homebound Status - 2 Criteria
- Criteria 1
- The type of support and/or supportive device or assistance required to assist the patient in leaving home OR the condition such that leaving his or her home is medically contraindicated, such as a mental or psychological illness.
- Criteria 2
- Explain the patient's normal inability to leave home and define the taxing effort considering these areas:
- Patient's diagnosis
- Duration of the patient's condition
- Clinical course (worsening or improvement)
- Nature and extent of functional limitations
- Other therapeutic interventions and results, etc.
- Pain meds
- Rest Periods
- Oxygen needs
- Continence Issues
- Safety concerns
- Other accommodation necessary
- Criteria 1
- Documentation to Support the Need for Intermittent Skilled Services
- Disclose clinical information (beyond a list of recent diagnoses, injury, procedure or codes) that is individual and specific to the patient that describes the services to be provided in the home.
- Explain why a skilled professional is necessary. If the care could safely and effectively be performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit.
- Face-to-Face Encounter Documentation
- Progress note written at the time of the patient one on one visit with the physician, Nurse Practitioner, Physician's Assistant, Certified Nurse Specialist or Certified Midwife, or a Discharge Summary from the acute/post-acute facility for the patient directly discharged with Home Health Services.
- Must occur 90 days prior or 30 days after the Start of Care and be related to the same reason the beneficiary needs home health services.
You are responsible for all claims that you submit or cause to be submitted to the Medicare Program. Medicare assumes that every claim you submit or cause to be submitted is for something that you determined to be medically necessary. Submitting false claims or causing false claims to be submitted can subject you to civil or criminal penalties and can have consequences on your medical license and ability to bill Medicare. False claims include claims where the service is not supported by the patient's medical record.
This document was developed through the A/B Medicare Administrative Contractor Provider Outreach & Education Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 - Home Health Services
- CMS Medicare Learning Network (MLN) Matters Special Edition (SE)1436 - Certifying Patients for the Medicare Home Health Benefit - Revised November 5, 2018
- False Claims Act, OIG HHS YouTube Video
- Referral, Certification and Oversight of Home Health Services (Part 1) NGS
- Referral, Certification and Oversight of Home Health Services (Part 2) NGS
- Referral, Certification and Oversight of Home Health Services (Part 3) NGS
Last Updated Aug 09, 2019