It is important to understand that the services are only covered for patients who receive Medicare-covered home health service.
If there is no Medicare Covered home health services, the Certification/Recertification should not be billed or paid. As such, physician claims for certification/recertification of eligibility for home health services (G0180 and G0179, respectively) will not be covered if the HHA claim itself was non-covered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit.
(Medicare Benefit Policy Manual Chapter 7 - Home Health Services 30.5.4 – Physician Billing for Certification and Recertification (Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15))
Physician certification and recertification Healthcare Common Procedure Coding System (HCPCS) codes:
G0180 − Physician certification home health patient for Medicare-covered home health service under a home health plan of care (patient not present).
G0179 −Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present).
These services include creation and review of a plan of care and verification that the home health agency initially complies with the physician’s plan of care. The physician’s work in reviewing data collected in the home health agency’s patient assessment would be included in these services.
The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as a physician certifies that the following five requirements, outlined in 42 CFR Section 424.22(a)(1), are met:
- The patient needs intermittent skilled nursing (SN) care, physical therapy (PT), and/or speech-language pathology (SLP) services;
- The patient is confined to the home (that is, homebound);
- A plan of care has been established and will be periodically reviewed by a physician;
- Services will be furnished while the individual was or is under the care of a physician; and
- A face-to-face encounter:
- Occurred 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; - Was related to the primary reason the patient requires home health services; and
- Was performed by a physician or allowed Non-Physician Practitioner.
Note: The certifying physician must also document the date of the face-to-face encounter.
- Occurred no more than 90 days prior to the home health start of care date or within 30 days of
When should the physician complete the certification?
According to the regulations at 42 CFR 424.22(a)(2), the physician should complete the certification when the home health plan of care is established or as soon as possible thereafter. It is not acceptable to wait until the end of a 60-day episode of care to obtain a completed certification/recertification, and the certification must be completed prior to an HHA billing Medicare for reimbursement.
When should the physician complete the recertification, and what must he or she include in the recertification?
At, or near, the end of the initial 60-day episode, you must make a decision on whether to recertify the patient for a subsequent 60-day episode. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode and unless there is a:
- Patient-elected transfer
- Discharge with goals met and/or no expectation of a return to home health care. If a patient is discharged and then requires a new episode, the physician must complete a new certification (not a recertification).
Medicare does not limit the number of continuous episodes of recertification for patients who continue to be eligible for the home health benefit.
For more information, please see Medicare Home Health Benefits
