Home Health Billing Requirements: An Overview of Medicare’s Eligibility Standards
Three requirements must be met in order to qualify for Medicare home health care:
1.The Patient must be met in order to quality for Medicare home health care
- The patient must have a disease or injury that makes movement difficult and necessitates the use of: a piece of medical equipment such as crutches, canes, wheelchairs, or walkers' special transportation another person (in order to leave one's home) OR
- The patient must have a medical condition that makes exiting the house dangerous (e.g. explicitly recommended against by a clinician).
- The patient must be unable to depart his or her home on a regular basis, AND
- leaving one's house must necessitate a significant and taxing effort on the part of the patient. In other words, if a person only leaves his or her house infrequently, for short periods of time, and only for specific, important events such as receiving medical treatment, attending religious services, attending adult daycare programs, or attending important life events (graduations, funerals, weddings, or only for necessities like, hair appointments, financial advice, etc.).
2.The Patient must require skilled services
Skilled services Eligible for Home Health Care:
- Intermittent Skilled Nursing (SN).Service is required less than seven days per week for less than eight hours per day OR
- Therapy Services: physical therapy, speech-language pathology, continuing occupational therapy
- Services must be reasonable and essential to address the patient's illness or injury.
- Services do not have to end in a cure or even an improvement. Services must merely prevent the patient's condition from getting worse.
- Services must necessitate the use of a skilled professional. Thus, the services must be: inherently complex, requiring the supervision of a skilled therapist consistent with the nature and severity of the condition: reasonable in amount (frequency, daily amount, total amount) , specific, safe, and effective under standards of treatment for the patient’s condition
3.Home Health Service must be Physician-Recommended and Physician Managed
- The patient must be under the supervision of a doctor: DO (osteopathy) OR MD (medical) OR DO (pediatric medicine)
- A physician must suggest home health care for the patient.
To qualify for Medicare home-health benefits, the patient must have a face-to-face encounter with a clinician regarding the medical reason for which he or she needs home health care. That face-to-face meeting must take place within 90 days of starting home health care OR within 30 days of starting home health care.
The face-to-face encounter can be with:
- the home health certifying physician
- the physician, who cared for the patient, at the acute or post-acute care facility in which home health care was recommended
- the nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant that works for either of the physicians in the first two conditions (the certifying physician or acute/post-acute care facility physician)
The home health physician cannot have a financial connection with the home health recommending physician (i.e. the acute care, post-acute care, or certifying physician, nurse, or physician's assistant).
Re-certification is needed every 60 days in order for patients to continue receiving home health care. Certification must be signed and dated, and it must show the need for additional skilled home health services.
Determine how long personal health care will be required.
Note: Re-certification does not require a face-to-face meeting.
The following material is required to adequately document that certification requirements have been met:
- the physician's medical records (at the acute or post-acute care facility) who suggested home health care (should the patient have been recommended for home health in this manner).
- These records must include information indicating the patient's need for skilled assistance as well as the patient's home-bound status.
- These records must include information demonstrating that the face-to-face encounter happened within the required time frame, addressed the medical issues for which home health care was suggested, and was carried out by an authorized provider type.
Note that information from the home health agency (such as the patient's comprehensive evaluation) can be included, but it must be supported by other medical documents.
Please keep in mind that any additional information, such as the ones mentioned above, must be approved by the certifying physician.