Home Health & Hospice

Know the Rules ... and the Enforcer

Homecare Insider, March 15, 2010

In the December 2009 issue, Homecare DIRECTION discussed a new requirement 42 CFR §424.22 for management and evaluation of a care plan:  “If management and evaluation is a service on the certification or recertification plan of care, the physician must include a brief narrative describing the clinical justification of this need.”  Effective January 1, 2010, the physician must write a paragraph that provides clinical justification for management and evaluation.  This could include a summary of the patient’s medical diagnoses or problems, limitations in activities of daily living or mental status, and the risk for or history of malnutrition, dehydration, skin breakdown, falls, infections, or other complications that point to inadequate care.

Beacon Health received this comment from a Beacon Institute member.
An FYI:  We called the state and the state said this requirement is for doctors to be in compliance; NOT home health agencies.  The state says there is nothing for home health to do regarding this.  Physicians would be subject to denial, without this statement, they cannot receive payment for care plan oversight.  We just want you to know that you are wrong!!

An FYI back to this agency:  Homecare DIRECTION was accurate in its information.  This agency is wrong on two important points

  • 42 CFR §424.22 is about conditions for Medicare payment of home health services and the requirements.  42 CFR §424.19 deals with care plan oversight.  (See for yourself on page 58133 (page 57 in the document) in the final rule to update the Prospective Payment System at — http://edocket.access.gpo.gov/2009/pdf/E9-26503.pdf.)
  • The agency’s intermediary or Medicare Administrative Contractor, not the state survey agency, will be the ones to review an agency’s compliance with this requirement.  Failing to comply will result in a denial of payment to the agency, not the physician.  It’s likely the Recovery Audit Contractors (RAC) will pay attention to this.  No physician certification on the plan of care, instant denial of payment.  


In the world of home health, it is very important to know the rules and keep up to date with the changes.  It is also important to know who has the authority to interpret and enforce the regulations.  Otherwise, there can be serious repercussions.  

“Ask an Expert” can provide clarification for many of today’s confusing issues.  Check out this feature of the Beacon Institute at —http://www.beaconhealth.org/beacon_institute.php.