Eligibility requirements for Medicare Part A home health services are very complex and can be confusing, particularly for clinicians who might not provide services under this benefit routinely. Home infusion providers do treat Medicare beneficiaries in the home setting so likely they have come in contact with patients who qualify for coverage under the home health benefit. Please note that to qualify for the Home Infusion Therapy (HIT) benefit the patient is not required to be homebound.
This article will detail eligibility requirements for Medicare home health patients—homebound, face-to-face, skilled need—and will discuss the new payment model, the Patient-Driven Groupings Model (PDGM). The article also includes case scenarios for home health patients that require IV therapy as well as other home health interventions for various disease processes and the Medicare Home Health Benefit and the HIT Benefit intertwine.
Qualifying Diagnosis
For home health agencies (HHAs) to be able to accept a patient referral, many criteria must be met. First, does the patient have a qualifying primary diagnosis under PDGM? Under PDGM, which began in January 2020, the Centers for Medicare and Medicaid Services (CMS) groups patients by clinical characteristics and level of need and pays HHAs a grouper driven 30-day payment based on the PDGM case-mix grouping. The model was designed to increase access to care for vulnerable populations needing certain services, including parenteral nutrition, complex care, wound care, and bathing, among others. The affect, however, is a reduction in the list of acceptable diagnoses. PDGM groups patients into 1 of 432 case-mix groups for the purposes of calculating payment. Most Medicare Advantage programs follow the PDGM rules although they pay per visit predominantly.
Face-to-Face Encounter
To be eligible for Medicare home health, the patient must also have a face-to-face (FTF) encounter either 90 days prior admission to home health or within 30 days after. It’s preferable that the FTF encounter take place prior to the HHA admission, because if it cannot be done within the first 30 days of the home health admission, he/she isn’t eligible—something you don’t want to discover after providing services. The FTF encounter must include that the patient was treated/assessed during this encounter for the primary reason for home health (i.e. the primary diagnosis) which must be acceptable under PDGM. If the patient is not treated or assessed for the primary reason for home care, that encounter cannot be used as the FTF.
Homebound Status
As mentioned above, the patient must be homebound to qualify for Part A home health services. This is confusing terminology because the patient can leave their home; however, it must be infrequent for medical appointment or treatments. CMS also allows infrequent outings, for example, to go to church or get a haircut. The homebound reasons must be patient-specific and documented. The record cannot simply say that it is a taxing effort or that the patient cannot drive himself. Rather, it should specify that the patient’s condition does not allow for outings, due to specific disease signs and symptoms. For example: inability to walk more than 20 feet due to dyspnea.
Skilled Need
Skilled need is another eligibility requirement for home health. This can be equated with medical necessity; however, it needs to be specific for each discipline seeing the patient. In home health, skilled nursing can be delivered by registered nurses (RNs), licensed practical nurses (LPNs)/licensed vocational nurses (LVNs). Therapy can be delivered by physical therapists (PTs), physical therapist assistants (PTAs), occupational therapists (OTs), certified occupational therapy assistants (COTAs), speech language pathologists (SLPs), medical social workers (MSWs), and home health aides. Skilled need is needs to be supported for such interventions as disease management, education and training on medications, procedures, such as wound care and IV care, gait and balance training, etc. Specific goals must be measurable and patient specific.
Intersection with the Home Infusion Therapy Benefit
How does the above foundation for the home health admission fit in with IV therapy for home health patients? When a Medicare-certified home health patient requires IVs, the HHA will have to work closely with the home infusion pharmacy as well as the practitioner responsible for certifying the home health episode of care.
Under the new Medicare Home Infusion Therapy (HIT) benefit, the HHA provides IV care under certain circumstances. If the care required falls under the Part B benefit (a drug that is one of 32 medications listed and delivered via a pump for 15+ minute infusion time) the HHA must be accredited as a HIT provider to perform the IV service. For IVs not covered by the HIT benefit (i.e. anti-infectives, parenteral nutrition, etc.), the nursing component of care is covered under the Part A home health episode of care. If the home health agency is not accredited as a HIT provider, the home health would need to work together with an accredited HIT provider to provide the IV services when the patient is being admitted for Medicare skilled home health services.
The patient typically has multiple home health skilled needs while also receiving IV services. Example: he/she may have a wound infection with the nurse providing wound care in addition to IV services. The patient may also receive care from therapists, social workers, and aides.
If the HHA is accredited and providing all of the care, the home health POC will include all of the diagnoses, medications, interventions and goals, including for the IV services. This POC must be very specific in listing the drug, dosage, method of delivery, vascular device type, administration protocol, and who is to administer the drug and perform line care. Orders for how the IV care is to be performed must be specified in the POC and the patient’s home folder. The visit notes must then follow suit. The documentation cannot state, “IV line care per protocol or per physician orders.” It must state the specific procedure that follows the physician orders. IV patient documentation in HH clinical records are often non-compliant because of the lack of specificity and consistency/compliance with physician’s orders.
Home Health Patient Scenario #1
Home Health Inotropic Therapy
Patient is referred to home health for skilled nursing and occupational therapy following discharge from the hospital for treatment of heart failure stage D exacerbation. She has been hospitalized 3 times in the past 6 months and her condition has been refractory to conventional medical treatment. She was started on IV inotropic therapy and will require skilled nursing for administration of IV milrinone via an infusion pump. She has a PICC line in her right upper arm. The physician has ordered weekly labs as well. The patient is homebound due to the symptoms of her medical condition; her heart failure is severe and she is short of breath with minimal exertion, fatigues easily, and is not able to endure long periods outside of the home. The patient has comorbidities of coronary artery disease with ischemic cardiomyopathy, hypertension, chronic kidney failure, chronic atrial fibrillation, and is maintained on anticoagulant therapy with apixaban. She has a biventricular pacemaker and implantable cardioverter defibrillator (ICD) that was placed 6 months ago. She lives alone and has a private caregiver through a local county private aide agency who provides assistance with bathing, dressing, meal set up, and cleaning. Occupational therapy will provide education and training on energy conservation and activities of daily living (ADL) safety.
In this scenario, due to inotropes being a Category 1 HIT benefit applicable drug, the nursing component of care for the IV therapy is covered under the HIT benefit, not the home health episode. If the HHA has also been accredited and approved as an HIT supplier, it can care for the IV as well as the home health components for the patient. The home health portion for billing will include the nursing education of disease management, medication management, etc. The OT assisting with energy conservation and ADL is also skilled need. And the home health aide is allowed under Medicare Part A with a physician order when skilled services are ordered. All services surrounding the IV administration and care must be billed under the HIT benefit.
Home Health Patient Scenario #2
Home Health Catheter Infection
Patient is referred to home health for treatment of a catheter-associated infection involving his suprapubic catheter. The patient has a history of multiple urinary tract infections, probable colonization and the urine cultures have come back positive for pseudomonas-resistant to ciprofloxacin and enterococcus. The patient had the catheter exchanged in the emergency department and is referred to home health for administration of IV ertapenem. Skilled nursing will be required for daily IV administration through the patient’s current right upper chest port-a-cath. The order is for blood work twice this week due to the patient’s comorbidity of chronic kidney failure stage 3a, and a follow up urinalysis and culture in 2 weeks after the patient’s last dose. The patient is homebound due to his current infection, he has poorly controlled diabetes with peripheral vascular disease and is wheelchair bound due to bilateral, below-knee amputations. He lives with his wife who is able to provide care and assists with bathing, dressing, meals, and transportation. She is unable to manage the suprapubic catheter or the IV. The patient has a urologist who is managing the suprapubic catheter due to his neurogenic bladder.
In this scenario, the antibiotics, ciprofloxacin and enterococcus, are NOT covered under the Medicare HIT benefit. Therefore, the HIT benefit does NOT apply, and the nursing services would be covered under the Part A home health episode of care.
The new HIT benefit can be complex; in addition, the existing qualifiers under PDGM for home health—FTF, homebound, and skilled need—can result in many denials if requirements are not met. It is important that the regulations are well understood and carried out in the patient chart. HHA and HIT benefit providers are wise to work together and with their referral sources to achieve partnerships that provide the full range of services needed by the beneficiary in the most optimal site of care—their home.
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