This policy provides guidelines for certification and recertification by physicians for home health services.

Payment can be made for covered home health services that a home health agency provides if a physician certifies that:

• The home health services are medically necessary because the individual is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology services, or continues to need occupational therapy; where a patient’s sole skilled service need is for skilled oversight of unskilled services the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
• A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
• The services are or were furnished while the individual was under the care of a physician.

As a condition for payment, prior to certifying a patient’s eligibility for the home health benefit the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient. The initial certification is incomplete without them.

Face-to-Face Encounter

The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient.

Certain NPPs may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. NPPs who are allowed to perform the encounter are:

• A nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law;
• A certified nurse-midwife as authorized by State law;
• A physician assistant under the supervision of the certifying physician

Encounter Documentation Requirements

• The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services. 
• The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.
• It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
• It is unacceptable for the physician to verbally communicate the encounter to the home health agency (HHA), where the HHA would then document the encounter as part of the certification for the physician to sign.

Timeframe Requirements

• The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.
• In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed NPP must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patient’s condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.

Exceptional Circumstances

When a home health patient dies shortly after admission, before the face-to-face encounter occurs, if it has been determined that a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.

If the below conditions are met, an encounter between the home health patient and the attending physician who cared for the patient during an acute/post-acute stay can satisfy the face-to-face encounter requirement.

• A physician who attended to the patient in an acute or post-acute setting, but does not follow the patient in the community (such as a hospitalist) may certify the need for home health care based on his/her contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then transfer/hand off the patient’s care to a designated community-based physician who assumes care for the patient; or
• A physician who attended to the patient in an acute or post-acute setting may certify the need for home health care based on his/her contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care.

Telehealth

The face-to-face encounter can be performed via a telehealth service, in an approved originating site.

See Medicare Advantage Medical Policy Bulletin Z-68 for more information on Telehealth Services.

Recertifications for Home Health Services

When services are continued for a period of time, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of the plan.

The physician must recertify that the individual continues to meet the guidelines for home health services as indicated above.
 
Recertifications must be signed by the physician who reviews the plan of treatment. The form of the recertification and the manner of obtaining timely recertifications are up to the individual home health agency.

The home health agency certification code (G0180) can be billed only when the patient has not received covered home health services for at least 60 days.

The home health agency recertification code (G0179) is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.

The home health agency recertification code (G0179) can be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

Provider News

04/2011, Physician certification of home health services requirements revised

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-1, Chapter 4, Section 30

CMS Online Manual Pub. 100-1, Chapter 5, Section 70

CMS Online Manual Pub. 100-2, Chapter 7

CMS Online Manual Pub. 100-4, Chapter 12, Section 180.1

Transmittal 68, CR 7377

Transmittal 139, CR 7329

MLN Matters Number: SE1038