Home Health & Hospice Week

In its new operational guide for pre-claim review, the Centers for Medicare & Medicaid Services tells agencies they must include documentation from the medical record that supports the beneficiary is:

• Confined to the home at the time of services;

     o Medicare considers the person homebound if:

        1) There exists a normal inability to leave the home and
        2) Leaving home requires a considerable and taxing effort. Additionally, one of the following must also be true:

           a) Because of illness or injury, the person needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
           b) The person has a condition such that leaving his or her home is medically contraindicated

• Under the care of a physician;
• Receiving services under a plan of care established and periodically reviewed by a physician;
• In need of skilled services;
• Had a face-to-face encounter with a medical provider as mandated by the Affordable Care Act.

This encounter must:

     o occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care; and
     o be related to the primary reason the patient requires home health services; and was performed by a physician or non-physician practitioner.

Crucial: In a flow chart about the pre-claim request process, CMS instructs agencies to obtain the physician’s signature on the plan of care before submitting a request.

Note: The guide is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Downloads/PCRD_HH_Operational_Guide.pdf.