Under a Physician's or Allowed Practitioner’s Care
Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.3)
The beneficiary must be under the care of a physician or allowed practitioner who is qualified to sign the physician certification and plan of care (42 CFR 424.22, (doctor of medicine, osteopathy or podiatric medicine)).
A patient is expected to be under the care of the physician or allowed practitioner who signs the plan of care. It is expected that in most instances, the physician who certifies the patient's eligibility for Medicare home health services, will be the same physician who establishes and signs the plan of care.
Physician Certification
Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.5.
The home health agency (HHA) must be acting upon a plan of care as described in §30.2, and a physician or allowed practitioner certification which meets the requirement of this section for HHA services to be covered.
- Physician or Allowed Practitioner Certification - Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.5.1)
- Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records will be used as the basis for the patient's eligibility.
- The supporting documentation must be provided upon request to the home health agency (HHA).
- The supporting documentation must substantiate the patient's need for skilled services and homebound status.
- The certifying physician and/or the acute/post-acute care facility medical record must contain the actual clinical note for the face-to-face encounter visit that demonstrates the encounter occurred within the required timeframe, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type.
- Medicare does not limit the number of continuous episode recertifications for beneficiaries who continue to be eligible for the home health benefit.
- The physician (re)certification may cover a period or less than, but not greater than 60 days.
The physician must certify that:
- Home health services are needed because the beneficiary is homebound.
- The beneficiary needs skilled nursing on an intermittent basis, physical therapy, or speech-language pathology.
- A plan of care has been established and is periodically reviewed by the physician or allowed practitioner.
- The beneficiary was under the care of the physician or allowed practitioner when the home health services were furnished.
For episodes with starts of care beginning January 1, 2011 and later, a face-to-face encounter must occur no more than 90 days prior to or within 30 days after the start of the home health care. The face-to-face encounter must be related to the primary reason the patient needs home health services, and be performed by an allowed provider type. The certifying physician or allowed practitioner must document the date of the encounter.
All documentation used to support the initial certification must be present in the documentation provided when submitting a claim for subsequent home health episodes. The initial certification must be supported by documentation in the certifying physician’s or allowed practitioner’s medical record.
The certification must be completed prior to the home health agency billing Medicare for reimbursement. However, physicians and allowed practitioners should complete the certification when the plan of care is established, or as soon as possible thereafter as described in Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.5.1). Refer to CGS Home Health Face-to-Face (FTF) Encounter Web page for additional information and resources.
Recertification/Plan of Care Review
At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for another 60-day episode. Under Home Health Prospective Payment System (HH PPS), the plan of care must be reviewed and signed by the physician or allowed practitioner every 60 days.
The physician must include an estimate of how much longer skilled services will be required. The estimate of how much longer skilled services will be required must be part of the recertification document. For recertifications made on and after January 1, 2019, this rule is eliminated. Refer to MM11104 for additional information.
Updated: 05.17.21
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