Home Health Medical Review

Home Health Medical Review Updated 08/14/2017

On November 6, 2014, The Centers for Medicare & Medicaid Services (CMS) issued final rule CMS-1611-F, Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule.  The HH PPS final rule (79 FR 66032) finalized a change that, beginning, January 1, 2015, requires home health agencies (HHA) to obtain documentation from the certifying physician's and/or the acute/post-acute care facility's medical record for the patient that served as the basis for the certification and eliminates the face-to-face encounter narrative as part of the certification of patient eligibility for the benefit.  Home health agencies should obtain as much documentation from the certifying physician and/or the certifying acute/post-acute care facility as they deem necessary to substantiate that the home health patient eligibility criteria have been met.  Home health agencies are required to provide this documentation to CMS upon request. More information regarding the revised home health medical review guidelines can be found in the Reviewing Home Health Claims document in the downloads section below and in the Program Integrity Manual, Chapter 6.2.3 (PDF). Additionally, CMS has developed a review tool that may be helpful in submitting claims that meet Medicare requirements. This tool, also located in the downloads section below, is not designed to be a comprehensive review tool, but was developed to help HHAs avoid the common denial reasons CMS has seen over the past few years.

Probe and Educate Reviews

CMS is conducting pre-payment reviews of home health claims for episodes that began on or after August 1, 2015. CMS contractors will conduct these reviews using a Probe and Educate strategy through an end date to be determined.  The purpose of this Probe and Educate process is to ensure that HHAs understand the new patient certification requirements. Additional details regarding the selection of Home Health claims for review as part of the Probe and Educate process are outlined in MLN Matters, Selecting Home Health Claims for Probe and Educate Review: Episodes that Begin on or After August 1, 2015, which is accessible via the following link: MLN Matters ® Number:SE1524 (PDF) Medicare Administrative Contractors (MACs) have completed round 1 “probe and educate” reviews of home health claims for episodes that began on or after August 1, 2015. During the first round, approximately 49,000 claims were reviewed from 11,201 home health providers. Based on the results of the initial reviews, the MACs conducting individualized educational efforts. In January 2017, MACs began the second round of Home Health Probe and Educate reviews. The round two reviews are expected to conclude in September.

Probe and Educate Review Findings

Recent MAC reviews illustrate that the majority of claim denials occurring under the Home Health Probe & Educate process relate to certification requirements. These include the following:

  • Issues related to the Face to Face requirements; including no signature by the certifying physician and encounter notes not supporting all of the elements of eligibility.
  • Recertification with no estimate of continued need for service and recertification denials because the initial certification was missing/incomplete or invalid.
  • The other major denial relates to claims denied for 56900, no response to the additional documentation request (ADR).

Targeted Probe and Educate Reviews

CMS believes results of the Home Health Probe and Educate program have been favorable based on the decrease in the number of claim errors after providers received education. CMS is now further improving this strategy by moving from a broad Probe and Educate program to a more targeted one. When performing medical review as part of Home Health Targeted Probe and Educate (HH TPE), Medicare Administrative Contractors (MACs) will focus on specific Home Health Agencies (HHA) who have been identified through data analysis as being a potential risk to the Medicare trust fund or who vary significantly from their peers rather than all HHAs. TPE involves the review of 20-40 claims per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. This term is intended to convey that the number of claims reviewed is relatively small in comparison with previous provider specific review where the number of claims reviewed for an individual provider may have been much larger. After each round of TPE review, providers are offered individualized education based on the results of their reviews (Please see the TPE Process Flowchart in the downloads section below). In addition to education at the conclusion of each 20-40 claim review, MACs may also educate HHAs throughout the review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the probe.

Providers/HHAs with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Audit Contractor (RAC), etc. Providers may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS. This HH TPE program is set to begin in the fall of 2017.

Clinical Templates Updated 03/27/18

CMS hosted a series of Special Open Door Forum calls in 2015 to provide an opportunity for physicians, home health agencies and/or all other interested parties to provide feedback on the draft Home Health Progress Note paper template. The draft template has since been completed and undergone the required Paperwork Reduction Act (PRA) approval process. The use of this documentation tool is completely voluntary.

The final approved Home Health Progress Note Paper Template is available in the Downloads section, below.

For more information on clinical templates and to view the latest draft templates and suggested clinical data elements (CDEs), see the Clinical Templates webpage.


Page Last Modified:
10/08/2020 02:07 PM