Description
This review will determine whether the Home Health care is reasonable and necessary, based on documentation in the medical record.
Affected Code(s)
Revenue Codes: 042X, 043X, 044X, 023X, 055X, 056X, 057X
Applicable Policy References
1. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Sections 1814(a)(2)(C) - Conditions of and Limitations on payment for services
2. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
4. Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(m)- Payment for Telehealth Services
5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1835(a)(2)(A) – Procedure for payment of claims of providers of services
6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services
7. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(o) – Home Health Agency
8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(r) - Physician
9. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(aa)(5) – Rural Health Clinic Services and Federally Qualified Health Center Services
10. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(gg)(2) – Certified Nurse-Midwife Services
11. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
12. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Sections 1862(a)(1)(A) (I), and (f)- Exclusions from Coverage and Medicare as a Secondary Payer
13. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1891 – Conditions of Participation for Home Health Agencies; Home Health Quality
14. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, § 1895(b)(3)(B)(v)(IV)- Prospective Payment for Home Health Services
15. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1899B (i)- Standardized Post-Acute Care (PAC) Assessment Data for Quality, Payment, and Discharge Planning
16. Coronavirus Aid, Relief, and Economic Security (CARES) Act, Pub. L. No. 116-136, § 3708- Improving Care Planning for Medicare Home Health Services, Effective Date: 03/01/2020
17. 42 CFR §405.929- Post-Payment Review
18. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
19. 42 CFR § 405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
20. 42 CFR § 405.986- Good Cause for Reopening
21. 42 CFR § 409.41 – Requirement for Payment
22. 42 CFR § 409.42 – Beneficiary qualifications for coverage of services
23. 42 CFR § 409.43 – Plan of care requirements
24. 42 CFR § 409.44 – Skilled services requirements
25. 42 CFR § 409.45 – Dependent services requirements
26. 42 CFR § 409.46 – Allowable administrative costs
27. 42 CFR § 409.47 – Place of service requirements
28. 42 CFR § 409.48- Visits
29. 42 CFR § 409.49- Excluded Services
30. 42 CFR § 414.65- Payment for Telehealth Services
31. 42 CFR § 484.2 - Definitions
32. 42 CFR § 424.22– Requirement for home health services
33. 42 CFR § 484.45- Condition of participation: Reporting OASIS information
34. 42 CFR § 484.55- Condition of participation: Comprehensive assessment of patients
35. 42 CFR § 484.60- Condition of participation: Care planning, coordination of services, and quality of care
36. 42 CFR § 484.75- Condition of participation: Skilled professional services
37. 42 CFR § 484.110- Condition of participation: Clinical records
38. Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 3 (Sections 170 – 190.34) Coverage Determinations, Section 170.1- Institutional and Home Care Patient Education Programs
39. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10- Certification and Recertification by Physicians for Hospital Services – General, Subsection 10.2- Who May Sign Certification or Recertification
40. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 30- Certification and Recertification by Physicians and Allowed Practitioners for Home Health Services, Subsection 30.1- Content of Physician or Allowed Practitioner’s Certification
41. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 20- Conditions to be Met for Coverage of Home Health Services
42. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 30- Conditions Patient Must Meet to Qualify for Coverage of Home Health-Effective 01/01/2022; Implementation 05/26/2022
43. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 40- Covered Services Under a Qualifying Home Health Plan of Care
44. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 50- Coverage of Other Home Health Services
45. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 70- Duration of Home Health Services
46. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 80, Specific Exclusions from Coverage as Home Health Services, Subsection 80.10- Telecommunications Technology
47. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 110- Use of telehealth in Delivery of Home Health Services
48. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 60 – Services and Supplies - Subsection- 60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit (Rev. 11355; Issued: 04/14/22; Effective: 05/16/22; Implementation: 05/16/22)
49. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, Section 180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
50. Medicare Claims Processing Manual, Chapter 10 – Home Health Agency Billing, Section 10 – General Guidelines for Processing Home Health Agency (HHA) Claims
51. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §§ 3.2.3.1(A)- Outcome Assessment Information Set (OASIS) and (B)- Plan of Care, and 3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests; 3.3.1.1(B)- Medical Record Review; 3.3.2.1- Documents on Which to Base a Determination; 3.3.2.1.1- Progress Notes and Templates; 3.3.2.2-Absolute Words and Prerequisite Therapies; 3.3.2.4- Signature Requirements; 3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation; 3.5- Postpayment Medical Record Review of Claims; 3.6.2.1- Coverage Determinations; 3.6.2.2- Reasonable and Necessary Criteria; 3.6.2.4- Coding Determination
52. Medicare Program Integrity Manual, Chapter 6, Medicare Contractor Medical Review Guidelines for Specific Services, § 6.2- Medical Review of Home Health Services
53. Centers for Medicare and Medicaid Services (CMS), Outcome and Assessment Information Set (OASIS-D) Guidance Manual, Effective 01/01/2019 OASIS User Manuals | CMS