Medicare will pay for certain home care services. Physicians who care for older patients need to be familiar with the basic entry criteria for these services. Medicare was designed as an acute illness benefit rather than insurance to pay for the long-term care of older persons with chronic conditions. Thus, Medicare home health benefits are linked to transitions from acute care settings and to what Medicare refers to as a “skilled need.” Home health care services for Medicare patients are covered by Medicare Part A. Physicians and approved home health agencies are reimbursed for services as long as certain criteria are met. The basic requirements for Medicare to reimburse home health expenses are as follows: the physician certifies that the patient is homebound, the patient has a skilled need, the skilled need is reasonable and necessary, the rendered service is intermittent or part time, the physician completes the face-to-face encounter form, and the physician signs Form CMS-485, which is the plan of care.
To qualify as “homebound,” a patient must have a condition resulting from illness or injury that makes it a “considerable and taxing effort to leave the home” without the aid of supportive devices such as crutches, canes, wheelchairs or walkers, special transportation, or another person or if leaving the home is medically contraindicated. However, a person does not have to be bedridden or absolutely homebound. Absences from the home must be infrequent, of short duration, or for medically relevant services. Examples of nonmedical reasons for leaving the home are attending religious services or taking a stroll or drive. No specific definitions of “short duration” or “infrequent” are provided in the Medicare guidelines. Illnesses or injuries that result in a person’s confinement to the home include stroke, blindness, dementia, amputation, or a psychiatric problem in which the patient refuses to leave the home or would be unsafe leaving the home unattended.
A skilled need is required for a home care agency to receive reimbursement from Medicare for home health services. Skilled needs are those that require special training and certification to administer to be safe and effective, such as those provided by nurses or therapists. An example of a skilled need is the monitoring of a patient with a complex medical condition that requires adjustment of medicines and reevaluation by a skilled nurse. Other examples include wound care treatment, catheter care, physical therapy, training of patients or caregivers to manage medical conditions such as diabetes or wound treatment, and education and monitoring of new medications such as warfarin. Single home visits by a skilled nurse for the sole purpose of obtaining a blood specimen do not qualify as a skilled need. Once a person has home health services for a skilled need, other covered Medicare home health services such as social work, occupational therapy, and home health aide can also be obtained. Thus, the skilled nursing or physical therapy need unlocks the Medicare home health benefit for the patient, and a broad range of services may be used as appropriate for the care of the patient. Services can be provided as long as the skilled need exists.
Not all skilled needs are reimbursable. For example, if a patient has been managing his or her diabetes with injections without difficulty and the glucose is well controlled, training would not be appropriate, and payment would be denied. If the patient had been taking oral medications, however, and the physician adds insulin to the medical regimen, it would be appropriate to request nursing services to train the patient to manage diabetes with the new insulin regimen.
Reasonable and Necessary Skilled Needs
Skilled needs must be reasonable and necessary. Documentation should be provided on the plan of care (Form CMS-485) and any supplementary forms. If appropriate medical information is not present, the medical record will be reviewed by a regional intermediary designated by the Center for Medicare and Medicaid Services (CMS) to determine whether the services are reasonable and necessary. One example of a reasonable and necessary skilled need is that of the patient discharged home after hospitalization with heart failure. However, this person’s need would not qualify as reasonable and necessary if there were no documentation of changes to the medical regimen and Form CMS-485 documented the patient as having stable vital signs and no functional impairments. Another example provided in the Home Health Agency Manual is a patient who was discharged from the hospital after a hip fracture, and home health services were requested solely for monthly vitamin B12 injections. Although the injection is a skilled need, if there is no documentation of approved conditions for the administration of vitamin B12, there is no evidence that the injection is medically necessary or reasonable, and the claim would be denied.
Face-to-Face Encounter Requirement
A face-to-face encounter requirement for certification of eligibility for home health services was established in Section 6407 of the Affordable Care Act of 2010. It requires a physician to document that the physician, or a nonphysician practitioner working with the physician, had a face-to-face encounter visit with the patient within 90 days prior to the start of care, or 30 days after the start of care. The encounter must be related to the reason for referring the patient to home health services. This face-to-face encounter form is also required for recertification of hospice services (Table 19–1).
Table 19–1.Face-to-face encounter form. ||Download (.pdf) Table 19–1. Face-to-face encounter form.
|Encounter must occur within 90 days prior to start of treatment or within 30 days after start of treatment, and must be related to the reason for the home care referral. |
|Must be an encounter with a physician or a nonphysician provider working with the physician. |
|Form must include: |
Patient’s name, date of face-to-face encounter.
Name of the provider who performed the encounter.
Medical reason for the patient’s homebound status.
Patient’s clinical condition when seen.
How that clinical condition supports the need for medically necessary skilled home care services.
Physician’s signature, and the date of the physician’s signature. Must be an original signature, can be a faxed copy of the signed face-to-face encounter form.
Part-Time or Intermittent Service
“Intermittent” means skilled nursing care that is provided fewer than 7 days per week or less than 8 hours per day over a period of 21 days or less for a medical condition that is expected to require skilled services at least once every 60 days. Therefore, a one-time intravenous infusion (eg, the condition is not expected to recur and will not require intermittent service) would not qualify for reimbursement. Exceptions to the time limit may be made on an individual basis if appropriate documentation is provided.
Form CMS-485 is the comprehensive plan of care for each patient. This form lists diagnoses, medications, diet, activities, and services needed, such as wound treatments, in addition to other information. The patient must be under the care of a physician qualified to sign the physician certification at the time of enrollment into home health, and the physician must review and sign the form at least every 60 days. Additional state requirements regarding timing of signatures may also exist. Physicians can bill Medicare for certifying the plan of care.
Single visits are common reasons for payment denial for nonphysician home health services. If a patient complained of urinary symptoms, Medicare would not pay for a home health nurse to make a single visit to obtain a urinary specimen, even if the patient was diagnosed and treated with antibiotics for an infection. However, if the home health agency plans to follow up for re-evaluation of a skilled need, but a patient is hospitalized, placed in hospice, or dies after a single visit, the agency would be reimbursed for that visit.
Another common reason for denial is the determination of non-acute events (eg, when physical therapy is ordered for frail patients with medically stable diseases or with gradual progressive disability). Since its inception, Medicare has operated based on an acute care model, and reimbursements are primarily for acute events with a foreseeable period of recovery. In most cases, there must be a clear end point before services will be approved. Before home health services are requested, the physician should consider whether the service is expected to improve the patient’s condition.
Other common reasons for denial are failure of physicians to complete the face-to-face encounter form and failure to sign Form CMS-485. The plan of care should be reviewed at least every 60 days, updated, if needed, and signed.