A certifying physician (or allowed non-physician practitioner) must have a face-to-face visit with the beneficiary before certifying the beneficiary’s eligibility for the home health benefit. The encounter must occur within 90 days before care begins or up to 30 days after care began.
The Centers for Medicare and Medicaid Services has implemented the following three changes to the encounter requirements effective Jan. 1, 2015, with implementation May 11, 2015:
CMS has eliminated the narrative requirement, however, the certifying physician is required to certify that a face-to-face encounter occurred and document the date of the encounter as part of the certification.
If a Home Health Agency claim is denied, the corresponding physician claim for certification/recertification patient eligibility for Medicare-covered home health services is considered non-covered.
CMS clarified that a face-to-face encounter is required for certifications, rather than initial episodes; and that a certification is generally considered to be any time a new start of care assessment is completed to initiate care. An allowed non-physician practitioner (NPP) working under the supervision of, or in collaboration with the physician may perform the face-to-face certification. These allowed NPPs include: A nurse practitioner or clinical nurse specialist, certified nurse mid-wife, or physician assistant.
No payment can be made for covered home health services that a Home Health Agency (HHA) provides unless a physician certifies that:
Home health services are needed because the individual is confined to home.
The individual needs intermittent skilled nursing care, physical therapy and/or speech-language pathology services.
A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician.
The services are or were furnished while the individual was under the care of the physician.
The individual had a face-to-face encounter with an allowed provider type no more than 90 days prior to or within 30 days after the start of home health care and encounter was related to the primary reason the patient requires home health services. The certifying physician must document the date of the encounter.
The patient’s medical record must contain information that justifies the referral for Medicare home health services, such as:
The patient’s medical record also must contain the actual clinical note for the face-to-face encounter visit that demonstrates that 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.
Information from the HHA, such as the initial and/or comprehensive assessment of the patient, can be incorporated into the certifying physician’s medical record and used to support the patient’s homebound status and need for skilled care. This information must be corroborated by other medical record entries in the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.
At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for an additional 60-day episode. The physician must include an estimate of how much longer the skilled services will be required and must attest that:
The home health services are or were needed because the patient is or was confined to the home;
The patient needs or needed skilled nursing services on an intermittent basis, or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing, physical therapy or speech language pathology services ceased;
A plan of care has been established and periodically reviewed by a physician; and
The services are or were furnished while the patient is or was under the physician’s care.
Physician Billing for Certification and Recertification
Physician certification and recertification claims are paid for under the Medicare Physician Fee Schedule and are billed using HCPCS codes G0180 (certification) and G0179 (re-certification). Physician claims for certification/re-certification will not be covered if the HHA claim itself was non-covered because the certification/recertification was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit.