Hello and welcome to part 3 in our video series regarding referral, certification and oversight
of home health services for the Medicare beneficiary.
Home health eligibility criteria must be certified via a *certification statement* by a Medicare
enrolled physician.
The Centers for Medicare & Medicaid Services (CMS) do not require a specific form or format
for the certification, however all five eligibility criteria must be attested to by one certifying
physician.
The certifying physician must also document the date of the face-to-face encounter as
part of the certification, as he or she may not have performed the face-to-face encounter
- payment cannot be made for covered home health services that an agency provides without
physician certification.
Once signed by the Medicare enrolled physician, certification of the home health eligibility must
be forwarded and retained by the home health agency.
With regard to physician signatures, rubber stamp signatures are not acceptable.
However, hand written and electronic signatures are acceptable when signing the certification.
This is an example of a complete certification statement because it references all five eligibility
requirements as well as the date that the face-to-face encounter occurred.
It reads, I certify this patient is confined to his/her home and needs intermittent skilled
nursing care, physical therapy and/or speech therapy, or continues to need occupational
therapy.
This patient is under my care, and I have authorized the services on this plan of care,
and will periodically review the plan.
I further certify this patient had a face-to-face encounter that was performed on *insert date*
by a physician or Medicare allowed non-physician practitioner that was related to the primary
reason the patient requires home health services.
This statement would only be utilized by the physician that is overseeing home health agency
services.
The Centers for Medicare and Medicaid Services has offered a revised Plan of Care on their
website with an updated certification statement in locator 26 that includes all five of the
eligibility criteria and a location for the date of the face to face encounter.
As noted, the Centers for Medicare & Medicaid Services require that the date of the face
to face encounter be included as part of the certification.
Refer to locator 26 on the sample plan of care on the CMS.gov website for the example
provided in this presentation.
Per CMS regulations: - The Home health agency's generated medical
record documentation for the patient, by itself, is not sufficient in demonstrating the patient's
eligibility for Medicare home health services.
- It is the patient's medical record held by the certifying referring physician or entity
that must support the patient's eligibility for home health services.
This further illustrates the importance of the collaboration of documentation between
all entities caring for Medicare beneficiary in the home.
The physician recertifying the patient's eligibility is the physician who has been providing oversight
of home health services and plan of care.
Upon recertification, he or she will be attesting to the fact that the Medicare beneficiary
continues to meet all five home health eligibility criteria.
The number of Medicare subsequent episodes is not limited, however, recertification is
required at least every 60 days if home health services are to continue and the patient continues
to meet all five eligibility criteria.
Recertification is also dependent on whether or not the initial certification was valid
and met all eligibility criteria.
Regulations state that if the requirements for certification of eligibility are not met
during the initial episode, then subsequent episodes of care which require home health
recertification, will be non-covered - even if the requirements for the recertification
are met.
The home health agency should submit that specific documentation from the initial certification
to support a claim reviewed for recertification eligibility.
We recommend home health agencies submit the face-to-face encounter and the initial
plan of care to support that the beneficiary was initially eligible for home health services
in order to support the recertification.
Recertification must be obtained at least every sixty days since the same interval is
required for the review of the plan of care.
All recertifications must be signed and dated by the physician monitoring the plan of care,
indicate the continuing need for skilled services, and estimate in writing how much longer the
skilled services may be required.
This estimate should be patient specific and measurable.
Consider this example This is an example of a complete recertification
statement because it includes all required elements.
It is not required that your recertification statement look exactly like this, however,
it is an example for those of you struggling to document a complete recertification statement.
Notice it includes the estimate that is required at the time of recertification.
It is not required that this be part of your recert statement.
However it is required at the time of recertification, and perhaps incorporating it into your statement
that the recertifying physician signs will assist you in meeting this part of the regulation
as well.
The estimate should be patient specific, as with all documentation, and measurable.
It would not be expected that the estimate would simply state that home health services
are estimated to be required for 60 days (the length of the home health episode); rather
the estimate should reflect the expected timeframe based on the individual's need and the physician's
clinical judgment as to how long he estimates home health services would be needed.
Make sure the MD circles either weeks, months, or years, and fills in the number.
The form of the recertification and the manner of obtaining timely recertifications is up
to the individual home health agency and the physician monitoring the patients care in
the community.
The Medicare Conditions of Participation require that the recertification assessment be done
during the last 5 days of the previous episode, which are days 56-60.
Did you know that the physician providing the certification or recertification of home
health services can be reimbursed by Medicare for their services?
The Certification is a physician signed statement attesting to the fact that the patient meets
all five eligibility criteria for the first 60 days of home health services.
Certification is billed with code G0180.
Recertification is a statement signed by the physician overseeing home health services
attesting to the fact that the patient continues to meet all five eligibility criteria for
any subsequent 60 day episode.
Recertification is billed with code G0179.
The descriptions for these codes indicate that they are used to bill for certification
or recertification of patient eligibility for Medicare-covered home health services
under a home health plan of care (patient not present), including contacts with the
home health agency and review of reports of patient status required by physicians to affirm
the initial implementation of the plan of care that meets patient's needs, per certification
period.
Please see Chapter 7 of the Medicare Benefit Policy Manual for further information.
Remember, when using the HCPCS codes G0180 or G0179 for certification and recertification
there must be valid documentation in the medical record to support that these situations have
occurred and that the patient meets eligibility criteria.
Claims for these codes will not be covered if the home health agency claim itself is
non-covered due to certification/recertification ineligibility or because there was insufficient
documentation to support that the patient was eligible.
Remember that the medical record from that certifying physician is what is utilized to
support patient eligibility at the time of the SOC.home health agencies require all of
your documentation that may support the 5 eligibility criteria have been met.
Best Practices by the referring entity: Some hospitals are naming the community physician
who agrees to follow the patients home care services right in their discharge summary
documentation.
They are also including cues in the discharge summary for documentation of the homebound status,
need for skilled service and adding the discharge plan directly to their discharge summary as well
as a certification statement and physician signature at the bottom. This makes it significantly
easier for their case managers, discharge planners, social workers to ensure the proper
documentation to support that the 5 eligibility criteria are met and this documentation is
easily forwarded to the HHA with the referral for a SOC.
In conclusion, as per CR 9189: - The HHA's generated medical record documentation
for the patient, by itself, is not sufficient in demonstrating the patient's eligibility
for Medicare home health services.
- It is the patient's medical record held by the certifying referring physician or entity
that must support the patient's eligibility for home health services.
CMS has stated that It is the sole responsibility of the referring, certifying & community physicians
to record all pertinent HH information in the medical record and share the documentation
with the HHA.
The certifying physician must review and sign off on anything generated by the HHA and incorporated
into the patient's medical record that is used to support the certification of patient
eligibility (that is, agree with the material by signing and dating the entry).
HHA documentation should also be shared, as it compliments & supports documentation in
referring, certifying & community physicians records.
It is imperative that all documentation from all entities align and corroborate the eligibility
criteria for home health services.
In conclusion, collaboration of documentation pertinent to patient eligibility from all
entities is pertinent to the patient care continuum and transition to home health services.
Stay tuned to the National Government Services YouTube Channel for more educational opportunities,
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