To hospitals, case managers, and physician's offices we specialize in responsive and timely initiation of home health services. We keep geriatric patients out of the hospital and lower rehospitalization rates by providing empathetic, dignified, and quality health services in the comfort of the home. We help seniors rehabilitate, stay healthy, and independent at home.
As a post-acute provider, home health agencies have the responsibility of responding rapidly and ensuring the patient has what they need to successfully rehabilitate at home. Transitioning the patient back into the community and outpatient setting is one of our goals.
For patients coming from the community setting, our goal is to prevent any further exacerbation and be the eyes and ears of our partnering physicians on the ground. We are here to take care of our communities together, and with the proper plans and coordination we can achieve that goal together!
This Physician Resource Center is a reference to help and simplify the 2022/2023 home health process for physicians, case managers, and practice managers.
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Welcome to the Physician Resource Center
2023/2024 Home Health Process
Quick Reference Guide
The patient must have had a face-to-face encounter with a physician or an allowed non-physician practitioner within 90 days prior to or 30 days after the date of home health admission. (Nurse practitioner, Physicians’ Assistant)
The patient must be confined to the home and meet homebound criteria.
The services ordered must be medically necessary.
Receive services under an established or signed plan of care reviewed by a physician.
The Home Health Benefit Defined
The Centers for Medicare and Medicaid Services requires the following criteria be met before a beneficiary may qualify for the Home Health benefit. Those criteria are the following:
The patient must have had a face-to-face encounter with a physician or an allowed non-physician practitioner within 90 days prior to or 30 days after the date of home health admission. (Nurse practitioner, Physicians’ Assistant)
The patient must be confined to the home and meet homebound criteria.
The services ordered must be medically necessary.
Receive services under an established or signed plan of care reviewed by a physician.
The Home Health Benefit Defined
The Centers for Medicare and Medicaid Services requires the following criteria be met before a beneficiary may qualify for the Home Health benefit. Those criteria are the following:
*Note: The primary diagnosis listed on the face to face encounter should be the etiological disease or the principal condition that is causing other diagnosis. If the patient has been dealing with the condition for some time then there must be an exacerbation in the condition for the encounter to trigger the home health benefit. Chronic conditions alone do not qualify patients for the home health benefit. There must be an acute exacerbation of a chronic condition for the patient to qualify for the home health benefit.
An example would be a patient with Diabetes Miletus or CHF for 10 years. Why would a patient with this chronic condition need home nursing or therapy services now? A possible reason would be the acute exacerbation of symptoms such as severe pain limiting function, shortness of breath limiting activities, severe muscle weakness causing difficulty in ambulation, or poor balance/falling.
Occurred no more than 90 days prior to or 30 days after home health admission.
The reason for the face to face encounter must be related to the primary reason the patient needs home health services.
Was performed by a physician or an allowed non-physician practitioner.
The date of the encounter must be documented.
The Face to Face Encounter
The face to face encounter that the patient has with the physician is one of the most important criteria in qualifying a patient for home health services. If performed completely, it may alleviate the documentation burden that may arise later, and allow for a smooth delivery of home health services. Conditions of the home health certifying face-to-face encounter:
*Note: The ICD-10 codes should be more specific rather than generalized.
ICD M62.81: Muscle weakness (generalized)
ICD Z91.81: History of falling
ICD R26.89: Other abnormalities of gait and mobility
ICD R26.81: Unsteadiness on feet
ICD R29.6: Repeated falls
ICD R53.1: Weakness
ICD R29.6: Unspecified abnormalities of gait
ICD R26.2: Difficulty in walking, not elsewhere classified
ICD S72.001D: Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing
ICD S72.002D: Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing
ICD S81.801D: Unspecified open wound, right lower leg, subsequent encounter
ICD I13.2: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
ICD I12.0: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
ICD M19.90: Primary osteoarthritis, unspecified site
ICD M19.90: Unspecified osteoarthritis, unspecified site
ICD M06.9: Rheumatoid arthritis, unspecified
ICD C34.90: Malignant neoplasm of unspecified part of unspecified bronchus or lung
ICD Z46.6: Encounter for fitting and adjustment of urinary device
ICD R33.9: Retention of urine, unspecified
The Patient Driven Groupings Model
Beginning January 1st, 2020 CMS will implement the Patient Driven Grouping Model and will designate many diagnoses as questionable encounters. These diagnoses are non-covered and will not qualify patients for the home health benefit if used as the primary diagnosis. By some estimates up to 40% of the primary diagnoses currently used will be non-covered. For your convenience, we have listed the top 20 diagnoses that will no longer be covered as the primary diagnosis. (They may be covered as secondary diagnoses).
Examples of Homebound Status
– Patient is confined to the home due to a surgical wound on the right foot which causes them to be non-weight bearing on the right foot, limited mobility, ambulation, and at risk of falls. The patient requires help of family to leave the home. Leaving the home is medically contraindicated as it increases risk of infection and may delay healing.
– Patient is confined to the home due to the use of narcotic pain medications associated with their diagnosis. The side-effects of usage causes dizziness, and disorientation which increases their risk of falls and makes it contraindicated for them to leave the home. Patient requires a rollator and leaving the home requires a taxing effort.
– Patient is confined to the home due to extreme weakness, poor balance, and shortness of breath. Patient has had multiple falls in the last 3 months and cannot ambulate for than 15 feet without shortness of breath. The patient uses a cane to walk and leaving the home is difficult for them.
– Patient is homebound due to COPD causing them to have poor balance and extreme shortness of breath and coughing when attempting to walk more than a few feet. Leaving the home is medically contraindicated and puts the patient at risk for falls.The patient may still be considered homebound if absences from the home are:
– For religious services
– For healthcare treatment
– For periods of relatively short duration
– To attend adult day care programs
– For infrequent events such as a trip to the barber or a funeralThe patient must have had a face-to-face encounter with a physician or an allowed non-physician practitioner within 90 days prior to or 30 days after the date of home health admission. (Nurse practitioner, Physicians’ Assistant)
The patient must be confined to the home and meet homebound criteria.
The patient must have had a face-to-face encounter with a physician or an allowed non-physician practitioner within 90 days prior to or 30 days after the date of home health admission. (Nurse practitioner, Physicians’ Assistant)
The patient must be confined to the home and meet homebound criteria.
Defining Confined to the Home
Patients will be considered confined to the home or homebound if the following two criteria are met:
Criteria 1
(only one element is required)
Criteria 2
(both must be met)
Defining Medical Necessity
Medical necessity is met when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgement, knowledge, and skills of an RN or when allowed an LVN are necessary to improve the condition or prevent or slow further deterioration. The needed services must be of such a complexity that the skills of an RN or LVN are required to furnish them. Services shall cease to be covered when the individualized assessment does not demonstrate a necessity for skilled services or if they can be safely and effectively performed by the patient or unskilled caregivers.
Some services are considered a skilled service based on complexity such as intravenous and intramuscular injections and the insertion of catheters. A service that, by its nature, requires a skilled clinician to be performed continues to be a covered skilled service even if taught to the family or caregivers.
Skilled services ordered must be reasonable and necessary and consistent with the treatment of the primary diagnosis and the reason for referral. They must conform with the nature and severity of the illness, the patient’s needs, and accepted medical and nursing standards.
Under certain circumstances, the evaluating RN/Therapist can provide supportive documentation from the home assessment to support the medical necessity for the home health needs. The physician would be required to sign these documents and retain a copy in their office as part of the patient’s medical records.Plan of Care: Hospital vs Community
Plan of Care is a requirement for patients receiving the Medicare home health benefit. Community physicians (primary care physicians and specialist) who order home health services for their patients would naturally receive the plan of care since the patient continues to be under their care during the duration of the home health services. In these scenarios, community providers play the role of referring and certifying physicians.
However, when the patient receives home health services ordered from a hospitalist, the referring and certifying physicians may be two distinct parties. As a post-acute focused home health company, we understand the importance of transitioning the patient back into the community. One of the keys to a successful transition is in proper coordination with primary care physicians. At every admission, we perform we encourage and instruct our patients to follow up with their primary care physician so that all their post-hospitalization needs are met. In many instances our nurses or therapists may assist the patient in scheduling their follow up appointments. We also coordinate with the primary care physician and other physicians who may be treating the patient. If the patient is having trouble seeing their primary care physician, the Plan of Care may be directed to the hospitalist since they ordered the services and was the last doctor to treat the patient.
The complete face-to-face encounter note.
Documentation that meets the homebound criteria.
Plan of care signed and dated.
Therapy evaluation signed and dated.
Agency generated records that support the face to face encounter (as needed).
The Review Choice Demonstration
On March 2, 2020, CMS implemented the Review Choice Demonstration in Texas. The program requires that agencies attain affirmations of coverage from CMS contractors. Failure to attain this affirmation may result in Medicare denying coverage for the ordered services. The good news is that the new rules do not create any new documentation requirements. They do however, create a need for timelier coordination between physicians and home health providers. Under these new conditions, it is of the utmost importance that referrals be as complete as possible when sent to a home health provider. To provide streamlined service and comply with the new requirements agencies will need the following records signed and dated within the first few days of a referral:
*Note: A complete list of rules may be found in section 30 of chapter 15 of the Medicare Benefit Policy Manual.
More information may be found at Palmetto GBABilling for Care Plan Oversight
Physicians who spend at least 30 minutes a month supervising a patient’s complex or multidisciplinary home health services and sign the plan of care, may bill for plan of care oversight if certain conditions are met. The following codes may be used:
HCPCS Code: Description
G0180: MD Certification of Home Health Agency
G0179: MD Recertification of Home Health Agency
G0181: Home Health Care Supervision
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