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June 14, 2021

Physician NPP Guide to Home Health

A patient must meet the following five criteria to meet eligibility for home health services:

  1. Homebound Status: No mandatory form or format requirement
    1. Found anywhere in the medical record from the referring physician or non-physician practitioner (NPP) office or the acute/post-acute care facility record documentation
    2. Documentation that supports the definition of "confined to the home" as per CMS regulations (CMS IOM Publication 1100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30)
  2. Need for Skilled Services: No mandatory form or format requirement
    1. Found anywhere in the medical record from the referring physician/ NPP office or the acute/post-acute care facility medical record documentation

      The six home health disciplines included in the 60-day episode rate are:

      1. Skilled Nurse on an intermittent/part-time basis
      2. Home Health aides on an intermittent/part-time basis
      3. Physical Therapy
      4. Occupational Therapy
      5. Speech Language Pathology
      6. Social Work
  3. Plan of Care: No mandatory form or format requirement
    1. Discharge plan from the acute/post-acute care facility at the time of the patient discharge prompting referral to home health
    2. Initial plan of care written by the referring certifying physician/NPP at the time of the patient's office visit that prompted the referral to home health
  4. Physician/NPP Oversight
    1. Documentation from the acute/post-acute care facility certifying patient eligibility must provide the name of the physician or NPP who agrees to monitor home health services in the community at the time of the referral when/if the certifying physician or NPP will not be providing oversight of home health services (Hospital, SNF, Inpatient Rehabilitation Facilities or Outpatient Surgery Center referrals).
    2. NPP's may complete and sign certification without physician counter signature
  5. Face-to-face Encounter Documentation: No mandatory form or format requirement
    1. Discharge summary from the acute or post-acute care facility written at the time of patient discharge prompting referral to home health services
    2. Progress note from the physician/NPP office at the time of the patient one on one visit with the physician or NPP in the office prompting referral to home health services
    3. Mandatory narrative regarding skilled oversight of unskilled care (when ordered)
    4. NPP's may complete and sign the face-to-face encounter without physician counter signature

Certification of Eligibility Criteria

  • Face-to-face encounter occurred and date
  • Face-to-face encounter must occur within 90 days before care begins or up to 30 days after care began
  • Required for all new start of care admissions
  • No mandatory form or format requirement
  • Statement from the certifying physician/NPP acknowledging all five eligibility (above) criteria have been met
  • Dated signature below the statement from a Medicare enrolled Physician/NPP

Recertification of Eligibility Criteria

  • Recertification is required at least every 60 days
  • Medicare does not limit number of continuous episodes recertifications for patients who continue to be eligible for HH benefit
  • Completed by the community physician that has been monitoring home health services
  • No mandatory form or format requirement
  • All above documentation regarding initial eligibility criteria must be included
  • Date of the face-to-face encounter at the time of the initial certification
  • Statement from the community physician/NPP that is overseeing home health services acknowledging that all five of the eligibility criteria (above) continue to be met
  • Date signature below the statement from a Medicare enrolled physician/NPP
  • Mandatory narrative regarding skilled oversight of unskilled care (when ordered)

Order/Referral for Home Health Services

  • Written and signed by the certifying and/or referring physician/NPP
  • Must be for the patient's current diagnosis as witness during the time of the face to face encounter visit with the doctor or NPP

Reminders:

  • The certifying physician/NPP must review and sign any documentation incorporated into the patient's home health agency medical record that is used to support the certification
  • Must include proof of PECOS validation for all physician/NPPs involved in the patient's care for all dates of service in the episode
  • Information from the home health agency can be incorporated into the certifying referring physician/NPP and/or community physician/NPP medical record for the patient

Resource: Medicare Benefit Policy Manual (cms.gov)External website

Reviewed: 12.09.22

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