Home Health Services

Affected Providers

Home health agencies and physicians and non-physician practitioners (NPPs) who refer patients to home health, order home health services, or certify patients’ eligibility for the Medicare home health benefit.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for home health is 6.7%, with a projected improper payment amount of $1.1 billion.

Denial Reasons

Insufficient documentation accounted for 51.4% of improper payments for home health services during the 2024 reporting period, while medical necessity (33.7%), incorrect coding (3.4%), no documentation (2.3%), and other errors (9.2%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Per 42 CFR 424.22, Medicare coverage of home health services requires physician certification of the patient’s eligibility for the home health benefit. Check eligibility.

Preventing Denials

Patient Needs Home Health Services

To qualify for the home health benefit, the patient must:

• Be confined to the home
• Be under the care of a physician or allowed practitioner
• Get services under a plan of care (POC) that a physician or allowed practitioner established and periodically reviews
• Need 1 of these:
  • Skilled nursing care that’s:
    • Reasonable and necessary
    • Needed on an intermittent basis
    • Not only needed for venipuncture to get a blood sample
  • Physical therapy
  • Speech-language pathology services
• Have a continuing need for occupational therapy

The patient has a continuing need for occupational therapy when:

• Services the patient requires meet the definition of occupational therapy services
• Patient eligibility for home health services was shown due to a prior need for skilled nursing care, speech-language pathology services, or physical therapy in the current or earlier certification period

Certification

A certification (versus recertification) happens anytime an official completes a start of care OASIS to initiate care.

For adequate physician or NPP certification and recertification, we require you to certify:

• The patient requires or required home health services because they are or were homebound (confined to home).
• The patient needs or needed intermittent skilled nursing services (other than venipuncture to get a blood sample), physical therapy, or speech-language pathology services. If a patient’s only skilled service need is for skilled oversight of unskilled services, we require you to include a brief narrative describing clinical justification of this need as part of the certification or as a signed addendum to the certification.
• You set up a POC and review it periodically.
• Officials offered services while the patient is or was under your care.
• You met face-to-face with the patient and it:
• Occurred no more than 90 days before, or within 30 days of, the start of home health care
• Was related to the primary reason the patient requires home health services
• Was done by an allowed provider type

The certifying physician or NPP must also document the date of the encounter.

42 CFR 424.22(b) has more information on home health recertification.

Patient Confined to Home

We consider a person homebound if they meet these 2 criteria:

Criterion 1

The patient must meet 1 of these requirements:

• Need supportive devices like crutches, canes, wheelchairs, and walkers; uses special transportation; or requires another person’s help to leave their home because of illness or injury
• Have a condition where leaving their home isn't medically advised

If the patient meets 1 of the requirements in Criterion 1, they must also meet both requirements in Criterion 2.

Criterion 2

• The patient can’t normally leave home
• Leaving home requires a considerable and taxing effort

We consider a person confined to home (homebound) if they don’t leave their home often or if they leave only for a short time for health care services, religious services, adult day care, or other unique or infrequent events (for example, funeral, graduation, barber, hairdresser services).

To clarify, to determine if the patient meets Criterion 2 of the homebound definition, the clinician needs to consider the illness or injury for which the patient met Criterion 1 and the context of the patient’s overall condition.

We don’t require the clinician to include standardized phrases showing the patient’s condition (for example, repeating the words “taxing effort to leave the home”) in the patient’s chart. Such phrases aren’t enough by themselves to meet Criterion 2 requirements. You typically need longitudinal clinical information about the patient’s health status to properly show that a patient is normally unable to leave home and that leaving home requires a considerable and taxing effort.

Clinical information about the patient’s overall health status may include, but we don’t limit it to, diagnosis, duration of condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, and other therapeutic interventions and results.

POC Content

For us to cover home health agency services, the individualized POC must specify the services necessary to meet the patient’s specific needs identified in the comprehensive assessment. The POC must also show responsible disciplines, the frequency and duration of all visits, and items listed in 42 CFR 484.60(a) that show the need for such services. All care provided must follow the POC.

If the POC includes a course of treatment for therapy services:

• The physician or allowed practitioner must decide the course of therapy treatment after consulting with a qualified therapist
• The plan must include measurable therapy treatment goals that directly relate to the patient’s illness or injury and patient’s resulting impairments
• The plan must include the expected duration of therapy services
• The plan must describe a course of treatment consistent with a qualified therapist’s assessment of the patient’s function

When you set up a POC, you must review and sign the POC after consulting with a home health agency provider at least every 60 days. Sign and date each patient POC review.

Supporting Documentation Requirements

The certifying physician’s medical record and the acute and post-acute care facility’s medical records (if the patient was directly admitted to home health) for the patient must justify referral for Medicare home health services. This includes documentation that confirms the patient’s need for skilled services and their homebound status.

Face-to-Face Encounter

Under 42 CFR 424.22(a)(1)(v)(A), a patient must have a face-to-face encounter with 1 of these:

• Certifying physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health
• Nurse practitioner or clinical nurse specialist working under state law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health
• Certified nurse-midwife, as authorized by state law, supervised by the certifying physician or an acute or post-acute care physician with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health
• Certified physician assistant, supervised by the certifying physician or under supervision of acute or post-acute care physician with privileges who cared for the patient in acute or post-acute care facility from which the patient was directly admitted to home health

42 CFR 424.22(b) has more information on home health recertification.