Healthcare Provider Solutions

Change Request (CR) 9189 was released July 10, 2015 was an implementation date of August 11, 2015. This CR was issued to update the Medicare Program Integrity Manual, Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services. The CR specifically updates the review protocol for documentation to be included in certifying and recertifying home health patients.

Certification Requirements:

When conducting a medical necessity review, the review contractor shall determine whether the supporting documentation addresses each of the following criteria for which a physician certified (attested to):

  • Homebound. Home health services are or were required because the individual is or was confined to the home (as defined in sections 1835(a) and 1814(a) of the Social Security Act).
  • Skilled Care. The patient needs or needed intermittent skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample), physical therapy, and/or speech language pathology services as defined in 42 CFR 409.42(c).
  • Plan of Care. A plan for furnishing the services has been established and is, or will be, periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine (a doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under state law). If the physician’s orders for home health services meet the requirements specified in 42 CFR 409.43 Plan of Care Requirements, this meets the requirement for establishing a plan of care as part of the certification of patient eligibility for the Medicare home health benefit.
  • Under Physician Care. Home health services will be or were furnished while the individual is or was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.
  • Face-to-Face Encounter. A face-to-face patient encounter occurred no more than 90 days prior to the home health start of care date or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type defined in 42 CFR 424.22(a)(1)(v). The certifying physician must also document the date of the encounter as part of the certification.

Per 42CFR 424.22 (a) and (c), the patient’s medical record must support the certification of eligibility. Documentation in the patient’s medical record shall be used as a basis for certification of home health eligibility. Therefore, reviewers will consider HHA documentation if it is incorporated into the patient’s medical record held by the certifying physician and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) and signed off by the certifying physician. The documentation does not need to be on a special form.

Recertification Requirements:

The contractor shall review for the certifying physician statement which must indicate the continuing need for services and estimate how much longer the services will be required.

As mentioned earlier in this section, the reviewer will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid.

Certification affects all subsequent episodes:

A physician certification/recertification of patient eligibility for the Medicare home health benefit is a condition for Medicare payment per sections 1814(a) and 1835(a) of the Social Security Act (the “Act”). The regulations at 42 CFR 424.22 list the requirements for eligibility certification and recertification. The requirements differ for eligibility certification and recertification; however, if the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will be non-covered—even if the requirements for recertification are met.

Key things to remember….

Recertification includes that the physician must include in his/her recertification statement of the patient an estimated amount of time that services will continue to be required! This is new and can be as simple as: “I certify that in my estimation continued services will be required for _______.”

A statement for the estimation of services is even if the original estimation extends beyond a 60-day recert episode.

Also, when sending charts to be medically reviewed you will need to send the certification documentation as well. If the certification requirements are not met all subsequent episodes are non-covered.

Lastly, there has been grave concern over when this is all required to be documented in the chart! CMS made an announcement that states: Probe and Educate Reviews – CMS will conduct pre-payment reviews of home health claims for episodes beginning on or after August 1, 2015. CMS contractors will conduct these reviews using a Probe and Educate strategy through an end date to be determined. The purpose of this Probe and Educate process is to ensure that HHAs understand the new patient certification requirements. Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about October 1, 2015.

So, any new portions of the certification and recertification requirements will be reviewed starting with episodes beginning on or after August 1, 2015!