Home Health & Hospice

Physician certification requirement updates take effect

Homecare Insider, August 17, 2015

Last Tuesday, a CMS change request (CR 9189, Transmittal 602) saw in revisions and clarifications to physician (re)certification requirements that were first put forth in CY 2015 rulemaking.
More specifically, the change request instructs Medicare contractors to review a patient’s entire medical record to determine whether the individual meets the eligibility criteria for home health services. In other words, the physician-kept record must include information that supports all the required elements for certification, including:
  • The need for skilled service
  • Reason for homebound status
  • The occurrence of a valid face-to-face (F2F) encounter
Additionally, CMS directs contractors to consider all documentation from the home health agency that appears in the patient’s record when making its coverage determination—as long as the materials have been signed off by a physician prior to or at the time of the certification.
Agencies should ensure documentation practices promote compliance with these updated bounds of coverage consideration, as CMS requires providers to meet initial certification requirements to receive reimbursement for any subsequent care episodes.
According to the CR, if a contractor finds that the documentation in the certifying physician’s medical record—including any information supplied by the given patient’s home health provider—fails to demonstrate the patient is or was eligible to receive services under the Medicare home health benefit, payment on the home health claim will be denied. 
The CR also specifies the requirements for recertification and underscores that a recertification for home health services must include a statement by the certifying physician that reflects a continuing need for services, plus an estimate of how much longer this care will be required. 
To comply with these updated and clarified requirements, several Medicare contractors have instructed agencies to ensure the physician’s estimate articulates how much longer services will be needed for the entire spell of a patient’s illness. Since this is a physician estimate, the agency must obtain the information from the actual physician, either verbally or in writing. CMS does not provide instructions to contractors on how or where this statement needs to be located. 
To read the full change request, click here.
To access the CY 2015 final rule, click here.