Home Health Billing Requirements: An Overview of Medicare’s Eligibility Standards
By: Gilbert Johnston
November 1, 2019
To Qualify for Home Health Care Under Medicare, Three Requirements must be Met:
The patient must be:
1) confined to his/her home
2) in need of skilled services, AND
3) be under the care of a physician & recommended for home health care by a physician
This article explains, in detail, what actions Medicare considers sufficient to meet each of these three requirements. This is a useful guide for both patients and clinicians looking to develop a firm understanding of the insurance coverage requirements for home health billing.
1) The Patient must be Confined to the Home
Basically, the patient must have an illness, injury, or condition that makes leaving his/her home considerably difficult.
Medicare has specific conditions that must be met:
- The patient must have an illness or injury, where movement requires help from:
- a piece of medical equipment, such as: crutches, canes, wheelchairs, or walkers
- special transportation
- another person (in order to leave one’s residence)
- The patient must have a condition, such that leaving one’s home is medically contraindicated (e.g. explicitly recommended against by a clinician).
- The patient must possess a normal inability to leave his/her home,
- Leaving one’s home must require considerable and taxing effort by the patient
In other words, if a person infrequently leaves his/her home, for short periods, and only for specific, important events, such as: to receive medical treatment, for religious services, to attend adult daycare programs, or for important life events (graduations, funerals, weddings, or only for necessities like, hair appointments, financial advice, etc.).
2) The Patient must be in Need of Skilled Services
Either Skilled Nursing Care or Therapy Services
Skilled Services that Qualify for Home Health Care:
- Intermittent Skilled Nursing (SN) Care
- care needed less than 7 days per week, for less than 8 hours per day
- Therapy Services:
- physical therapy
- speech-language pathology
- continuing occupational therapy
Therapy Service (PT, SLP, OT) Requirements:
- Services must be reasonable and necessary to treat the patient’s illness or injury.
- Services do not need to result in a cure or even an improvement. Services simply need to slow down the worsening of the patient’s condition.
- Services must require a skilled professional. Thus the services must be:
- inherently complex, meaning the effectiveness and safety of the treatment requires 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 accepted standards of treatment for the patient’s condition
3) Home Health Care must be Physician-Recommended and Physician-Managed
In other words, home health care must be recommended by a physician and then overseen by a physician.
1. The patient must be under the care of a physician:
- MD (medical)
- DO (osteopathy), OR
- Doctor of Pediatric Medicine
2. The patient must be recommended for home health care by a physician
In order to qualify for home-health benefits under Medicare, the patient must have a face-to-face encounter with a clinician, relating to the medical reason for which he/she requires home health care. That face-to-face encounter must occur no more than 90 days before beginning home health care OR no more than 30 days after beginning 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)
One important exclusion:
The home health physician cannot have a financial relationship with the home health recommending physician (i.e. the acute care, post-acute care, or certifying physician, nurse, or physician’s assistant)
- In order for patients to continue home health care, recertification is required every 60 days. Certification must:
- be signed and dated
- indicate the need for further skilled home health services
- estimate how much longer home health services will be needed
Note: A face-to-face encounter is NOT required for recertification.
The following information is needed to sufficiently document that certification requirements have been met:
- the medical records of the physician (at the acute or post-acute care facility) that recommended home health care (should the patient have been recommended for home health in this manner).
- these records must contain information showing the need for skilled services and the patient’s homebound status
- these records must contain information showing the face-to-face encounter occurred within the required timeframe, concerned the medical issues for which home heath care has been recommended, and was conducted by an allowed provider type
Note: Information from the home heath agency can be incorporated (such as the patient’s comprehensive assessment), but it must be corroborated by other medical records.
Note: The certifying physician must sign-off on any added information, such as that listed above.
Home Health Billing Notes:
- Physician certification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)
- Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)
- Episodes of care are 60 days
- Payment is made on a split system, with an initial and final payment.
- The first payment is made in a response to a request for anticipated payment.
- The second (and last) payment is made in response to a filed claim.
- For the beginning of home health billing cycle (the initial certification and the first 60 days):
- The initial payment is 60% of the total allowed amount.
- The final payment is 40% of the total allowed amount.
- For any following 60 day periods (after recertification):
- There’s a 50% split for both payments.
The Official Statute:
Click the link below to read the full Federal Regulation on Home Health Care.
42 CFR 424.22