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 1862(B)(7)(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 § 424.22– Requirement for home health services
32. 42 CFR § 484.2 - Definitions
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, §6.2.3 The Use of the Patient’s Medical Record Documentation to Support the Home Health Certification, §6.2.1.1 Certification Requirements, §6.2.4 Coding, §6.2.5 Medical Necessity of Services Provided
53. Centers for Medicare and Medicaid Services, Outcome and Assessment Information Set OASIS-E Manual, Updated January 1, 2024 OASIS User Manuals | CMS
54. Palmetto Low Utilization Payment Adjustment (LUPA) Threshold Lookup: https://www.palmettogba.com/palmetto/jmhhh.nsf/DID/1TKOUO16TG#:~:text=The%20LUPA%20threshold%20ranges%20between,threshold%20of%205%20in%202021.
55. CGS Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator: https://www.cgsmedicare.com/medicare_dynamic/j15/lupa/lupa_threshold.aspx