CMS Guidelines for Home Health
It feels like one cannot learn everything in home health. There seems to be never ending rabbit holes and links for additional information. There are questions about billing, OASIS visits, who can perform OASIS, how to qualify, what the rules are, Conditions of Participation, Guidance on Conditions of Participation, PDGM, LUPA, the list is exhaustive, and sometimes exhausting.
We try to give people information they can handle in a format that is manageable. The adage of "How do you eat an elephant? One bite at a time?" What about eating or digesting things that don't seem to be very pleasant, but necessary? Conditions of Participation? PDGM guidelines? Updated Public Health Emergency Guidance? One's head seems to spin at the thought. Throw in caring for actual patients, hiring and retaining staff, accepting referrals with staff shortages, training, QAPI, management expectations, and you have a list that makes it ripe for frustration or worse, burnout. There are a lot of people and agencies that are hiring as fast as possible, which makes nursing visits and training difficult.
Luckily, we try to give information to you in ways you can handle- from the sources themselves. We have a lot of knowledge- because we've been doing this for a long time and have sat in the very same seats you sit in in prior positions and what seems like prior work lives. But the best source is CMS. There is so much information out there in the universe (or Google-verse) that finding it can be overwhelming.
is a fantastic short brochure on the basics of home health. It answers the following questions:
- How does a patient qualify for home health with Medicare?
- Patient is enrolled in Medicare Part A, Part B or both parts of Medicare Program
- Patient is eligble for home health services
- The Home Health Agency (HHA) has a valid agreement to participate in Medicare Home Health
- A claim is submitted for covered services
- The services aren't excluded from payment.
- Be confined to the home (homebound)
- To be considered homebound, patients must meet two criteria:
- Criterion 1
- The patient needs the aid of supportive devices (such as crutches, canes, wheelchairs, or walkers)
because of an illness or injury; uses special transportation; or requires someone’s help to leave their
place of residence
- Leaving home is medically contraindicated for the patient
- Criterion 2
- The patient is unable to leave home
- Leaving home requires a considerable and taxing effort for the patient
- A patient can still be considered homebound if they leave the home infrequently, for a short time, or for health
care services. For example, homebound patients can leave to attend:
- Religious services
- Adult daycare programs
- Unique or infrequent events (such as a funeral, a graduation, a walk around the block, or a trip to the
- Need intermittent skilled nursing care, physical therapy, or speech-language pathology
- Have a continuing need for occupational therapy
- Be under the care of a physician or allowed practitioner
- Get services under a home health plan of care (POC) that a physician or allowed practitioner establishes
and periodically reviews
- Who can perform a Face to Face Encounter?
- As part of the certification process, a face-to-face encounter with the patient must be conducted by:
● The certifying physician or allowed practitioner
● A physician or allowed practitioner that cared for the patient in the acute or post-acute care facility that
sent the patient to home health
● An allowed non-physician practitioner
The following non-physician practitioners are allowed to perform the encounter under the supervision of the
certifying physician or the physician who cared for the patient in the acute or post-acute care facility:
● A nurse practitioner or a clinical nurse specialist
● A certified nurse midwife
● A physician assistant
Providers that have a financial relationship with the HHA can’t perform the face-to-face encount
- NOTE: Telehealth Face to Face Encounters are valid under the Public Health Emergency.
- The face-to-face encounter can be performed via a telehealth service, in an approved originating
site. An originating site is the location of an eligible Medicare patient at the time the service is furnished via
a telecommunications system. The patient’s home isn’t considered an originating site. However, the March
2020 COVID-19 Interim Final Rule amended the regulations to allow physicians and allowed non-physician
practitioners (NPPs) to conduct the required face-to-face encounter via telehealth when the patient is at home
for the duration of the Public Health Emergency (PHE) for the COVID-19 pandemic. Telehealth refers to 2-way
audio-video telecommunications technology that allows for real-time interaction between the physician or
allowed practitioner and the patient.
- CMS Recertification Guidelines
- How long can a patient receive home health care?
- The initial certification period lasts 60 days. Near the end of this initial period, the physician or allowed
practitioner must decide whether to recertify the patient for a subsequent 60-day certification period.
Recertification is required at least every 60 days unless the patient elects to transfer services to another HHA.
There’s no need to recertify if discharge goals are met or if there’s no expectation that the patient will return to
home health care. Medicare doesn’t limit the number of continuous 60-day recertification periods for patients
who continue to be eligible for the home health benefit.
- If a patient is discharged and then requires a new episode, the physician must complete a new certification (not
For a recertification, the physician or allowed practitioner must:
- Sign and date the POC once reviewed
- Show the continuing need for skilled services, occupational therapy, speech-language pathology services, or physical therapy when applicable.
- Medicare doesn’t cover the physician or allowed practitioner’s claim for certification or recertification of
eligibility for home health services (HCPCS codes G0180 and G0179, respectively) when:
- An HHA claim isn’t covered because the physician or allowed practitioner didn’t complete the certification
- The medical record didn’t contain enough documentation to show the patient’s eligibility to receive
Medicare home health services
- PDGM (this is a great add on also with our link PDGM for Dummies
- LUPA- Explains LUPA well- also a link How Can LUPAs Be Avoided in Home Health
- Covered Home Health Services
- Skilled Therapy
Medicare covers skilled therapy services when the patient’s current condition requires skilled therapy to maintain their current condition or to prevent or slow further deterioration.
The therapy services must be:
- Inherently complex, which means they can only be safely and effectively performed by a skilled therapist or therapist assistant under the supervision of a skilled therapist.
- Consistent with the nature and severity of the illness or injury and the patient’s particular medical needs, which include a reasonable amount, frequency, and duration of services
- Considered specific, safe, and effective treatment for the patient’s condition under accepted standards of medical practice
- Skilled Nursing
Medicare covers skilled nursing services (other than solely venipuncture for the purposes of obtaining a blood
sample) when (this list is not exhaustive, just examples):
- The patient needs the specialized judgment, knowledge, and skills of a registered nurse or a licensed vocational nurse (when allowed by regulation)
- The patient’s current condition requires skilled nursing services to maintain their current condition or to prevent or slow further deterioration
- Medicare covers these services so long as the patient requires skilled care for the services and the provider
delivers them safely and effectively.
- Intermittent Skilled Nursing Care
CMS defines intermittent skilled nursing care as skilled nursing care provided or needed on fewer than 7
days each week or less than 8 hours each day, for periods of 21 days or less (with extensions in exceptional
circumstances when the need for additional care is finite and predictable).
To meet the requirement for intermittent skilled nursing care, the patient must have a medically predictable
recurring need for skilled nursing services. Typically, a patient meets this requirement if they require a skilled
nursing service at least once every 60 days.
- Home Health Aide
Medicare covers home health aide services such as:
- Personal care
- Assistance with activities that support skilled therapy services
- Personal care of prosthetic or orthotic devices
OASIS can be very, very cumbersome and confusing. It can be overwhelming to understand what OASIS is or isn't asking. CMS has issued a guidance manual to explain OASIS. Luckily, it's only 395 pages. You can read it right here: OASIS Guidance Manual. Further, we wrote a blog (our most visited post) called OASIS Documentation for Dummies. This has a lot of help on guidance for OASIS documentation.
How Can Home Care Answers Help?
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