Home Health Clinical FAQs
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- Can a physician's verbal order serve as the estimate of how much longer skilled services will be required?
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No, the estimate must be included as part of the recertification document.
New: 03.21.17
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- Do you recommend we request a signature log or attestation statements from all physicians?
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If the signatures on your certifications, orders and visit notes are legible or electronic, then a signature log or attestation statement is not necessary. However, if the signature is illegible and there is nothing to authenticate the signature, you will want to have a signature log or attestation statement. Review the Signature Guidelines for Home Health & Hospice Medical Review
quick resource tool for situations where a signature log or attestation statement would be appropriate. In addition, a sample attestation statement is available in the Medicare Learning Network (MLN) Matters article, MM6698
. If the signature is electronic, CGS recommends that you submit your agency's electronic signature policy.Reviewed: 03.21.17
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- Where is a resource to explain the various skilled nursing services (including teaching and training of a beneficiary/caregiver), provided under the Medicare home health benefit?
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The Internet Only Manuals (IOMs)
, published by CMS, contain information regarding the Medicare benefit. Medicare coverage and policy information is found in the Medicare Benefit Policy Manual (Pub. 100-02). Chapter 7of this resource contains the information specific to the Medicare home health benefit, including services covered under a home health plan of care such as skilled nursing.Reviewed: 03.21.17
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- Can the physician stamp a date when signing the certification or plan of care?
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No. The physician must sign and date orders and certifications. A stamped date would not provide authentication as to whether it was the physician who dated the documentation. However, in accordance with the Rehabilitation Act of 1973 a rubber stamp for a signature would be permitted in the case of an author with a physical disability who can provide proof of his/her inability to sign their signature due to a disability. By affixing the rubber stamp, the provider is certifying they have reviewed the document. Please refer to the Medicare Program Integrity Manual,(Pub. 100-08, Chapter 3, §3.3.2.4
) for more information on this topic.Reviewed: 03.21.17
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- How do I know where to direct my Medicare questions? Can CGS answer questions about survey issues, such as home health aide supervision requirements, or patient rights?
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Medicare, under the administration of the Centers for Medicare and Medicaid Services (CMS), has multiple facets of operation, many of which are run by contracting entities. As a Medicare Administrative Contractor (MAC), CGS's primary role is to process claims correctly. In order to do that, we also provide related functions and services such as Medical Review, education and customer service. CGS is not able to answer questions regarding the Conditions of Participation (CoPs), which is handled by each state's survey and certification office. Aide supervision and patient rights issues also fall under this area as well. To find your state survey office, go to www.cms.hhs.gov/apps/contacts/
on the CMS website. For more information about the various entities that contract with CMS to administer the Medicare program, refer to the Special Edition (SE) article #1123Reviewed: 03.21.17
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- Can CGS provide guidance on specific diagnosis codes to use for primary diagnosis on our home health claims?
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The diagnosis, whether primary or secondary, must originate with the physician, and be based on the patient's condition. The primary diagnosis must be the chief reason for skilled home health care. Secondary diagnoses should be those diagnoses that are directly related to or may impact the home health plan of care. There are five allowances for secondary diagnoses in M1022 on the OASIS. If there are more than five secondary diagnoses, these should be included on the plan of care. Any diagnoses and codes used as the primary (M1020) or secondary (M1022) must follow the ICD-10-CM coding guidelines for services provided on or after October 1, 2015 (ICD-9-CM for services provided prior to October 1, 2015. Payment does not impact the ICD-10-CM coding process, and CGS cannot provide any additional guidance beyond what is found in the ICD-10-CM coding guidelines.
Reviewed: 03.21.17
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- How do we know which supplies are routine or non-routine for a home health episode?
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A supply is considered non-routine when the item:
- Is directly identifiable for an individual patient;
- Can be identified and accumulated in a separate cost center; and
- Is ordered by the patient's physician and is specifically identified in the plan of care (POC)
In addition, an item meets the criteria for non-routine supplies when the HHA follows a consistent charging practice for Medicare and non-Medicare beneficiaries receiving the item.
Please note that even though non-routine supplies do not need to be line item billed on the final home health claim, they are still included in the total episode payment under the Home Health Prospective Payment System (HH PPS), and are therefore, not separately payable. The supply severity level (which is indicated by the fifth position of the HIPPS code) determines the payment amount HHAs receive for non-routine supplies. HHAs receive the supply severity payment amount regardless of whether non-routine supplies were provided to the beneficiary during the episode.
For a listing of nonroutine supplies that are included in HH PPS consolidated billing, please review the Consolidated Billing Master Supply List
. Supplies not on the list, but needed to carry out the plan of care, are bundled under consolidated billing for home health. For more information, please refer to the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 7, § 50.4.1), as well as the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 10.1.4).Reviewed: 03.21.17
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- Where can we find guidance regarding signature requirements?
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The Centers for Medicare & Medicaid Services (CMS) issued Medicare Learning Network (MLN) Matters article MM6698
, Complying with Medicare Signature Requirements fact sheet, and published information in the Medicare Program Integrity Manual (Pub. 100-08), Ch. 3, Section 3.3.2.4, which provides clarification on this topic.Reviewed: 03.21.17
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- Is the flushing of a central line or port considered a qualifying skill for the Medicare HH Benefit?
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Maintenance of a line or port by flushing with normal saline, and/or heparin requires the skills of a nurse, and is considered a skilled service under the Medicare Home Health Benefit. In order for this skilled service to be covered for payment, it must also be medically necessary and reasonable for the beneficiary to have a port or line maintained. This most commonly would be because of ongoing infusion treatments/medications being provided through this central line site. Documentation of the current treatment being provided through this site must be included in the patient record, even if the HHA is not providing this treatment. For additional information, refer to the Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, §40.1.1
.Reviewed: 03.21.17
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- Our policy has always been to require the physician signature on all pages of the certification. We have had physicians complain that if the pages are numbered, they only need to sign one page. Is this okay?
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Yes, when the plan of care (POC) is multiple pages in length, it is acceptable for the physician to sign one page of the POC, when it is clear the physician knew the POC was comprised of multiple pages. For example, the POC is three pages in length and the pages are numbered page 1 of 3, page 2 of 3, page 3 of 3.
Reviewed: 03.21.17
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- We have a patient on home health services that also needs to go to an outpatient clinic for IV therapy. Is this allowed?
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The Centers for Medicare & Medicaid Services (CMS) have published home health consolidated billing guidelines in the Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, §10.11
. Since IV therapy does not fall under the home health consolidated billing guidelines, it is allowable for a patient to receive IV therapy at an outpatient clinic.Reviewed: 03.21.17
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- Can the medical director sign the home health Plan of Care (POC) if the physician that initiated the POC is not willing or unavailable to do so?
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The Centers for Medicare & Medicaid Services does have guidelines regarding the physician that signs the POC in the Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, §30.2.6
, which states, "The plan of care must be reviewed and signed by the physician who established the plan of care, in consultation with HHA professional personnel, at least every 60 days. Each review of a patient's plan of care must contain the signature of the physician and the date of review."Reviewed: 03.21.17
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- Per Change Request (CR) 9474, the condition code 54 indicates that the home health agency provided no skilled services during the billing period, but the home health agency has documentation on file of an allowable circumstance. Could you give examples of when this could occur?
- Can the estimate of how much longer skilled services will be required on the recertification document just say until the end of the certification period?
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The estimate must state a specific time period. For example, 3 weeks, 10 days, etc. The estimate may not just say until the end of the certification period. If the estimate is until the end of the certification period, the estimate must state what will be accomplished during the time estimated. Example - Physical therapy will work with the patient to enable her to safely go up and down the 15 steps to get into her apartment.
Reviewed: 03.21.17
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