Home Health

These FAQ (PDF) are the updated questions and responses about the 2021 Penalty for Delayed Request for Anticipated Payment (RAP) Submission for Home Health Agencies. These FAQ were developed as a result of the changes implemented by Change Request 11855.

Last Reviewed: 09/29/2023

When a home health patient dies shortly after admission, before the face-to-face encounter occurs, if the contractor determines a good faith effort existed on the part of the home health agency (HHA) to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.

If the following conditions are met, an encounter between the home health patient and the attending physician who cared for the patient during an acute/post acute stay can satisfy the face-to-face encounter requirement:

a) A physician who attended to the patient in an acute or post-acute setting, but does not follow the patient in the community (such as a hospitalist) may certify the need for home health care based on his/her contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then transfer/hand off the patient’s care to a designated community-based physician who assumes care for the patient.

b) A physician who attended to the patient in an acute or post-acute setting may certify the need for home health care based on his/her contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care.

Last Reviewed: 09/29/2023

No. Change Request 7182 (PDF) does not change the reporting requirements for HHAs. Claims must report all home health services provided to the beneficiary within the episode. Each service must be reported in line item detail. A separate G-code for therapy and a separate G-code for nursing for the same patient on the same day is acceptable.

Last Reviewed: 09/29/2023

A Medicare patient may be eligible to receive home health care for a condition not related to their terminal illness if the home health benefit criteria are met. The home health agency will bill their services to Medicare by including condition code 07, treatment of non-terminal condition for hospice patient, on their claim.

Last Reviewed: 09/29/2023

The Affordable Care Act requires the face-to-face encounter and corresponding documentation as a certification requirement. The face-to-face encounter is an additional certification requirement. Long-standing regulations have described the distinct content requirements for the plan of care (POC) and certification. Providers have the flexibility to implement the content requirements for both the POC and certification in a manner that works best for them. Many providers have implemented the requirements for the POC and certification by using one form which meets all the content requirements of both the POC and certification. This approach is acceptable and it will continue to be acceptable.

Last Reviewed: 09/29/2023

The specific granular error "The Face-to-Face Encounter Not Present" can not only be received if you did not submit documentation of the face-to-face encounter, but also if your submitted documentation upon medical review is deemed as not being valid according to the Medicare documentation requirements.

If you receive this error you should refer to the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-02 (PDF), Chapter 7, Section 30.5.1.2 for a complete listing of the home health face-to-face encounter documentation requirements.

Last Reviewed: 09/29/2023

Home Health Agencies are required to report on the claim the name and National Provider Identifier (NPI) of the physician who certifies/re-certifies the patient's eligibility (Certifying Physician). This is in addition to reporting the NPI and name of the physician who signs the patient's plan of care (Attending Physicians) when the attending physician is not the same physician who certified/recertified the patient’s eligibility to receive services under the Medicare Home Health benefit.

Last Reviewed: 09/29/2023

Information regarding retention of home health records can be found in the Code of Federal Regulations webpage which is available on the GPO website.

Code of Federal Regulations, 42 CFR - Section 484.48 (PDF) states that records should be retained for five years after the month in which the cost report to which the records apply is filed with the Fiscal Intermediary (FI). Your state law may have a more stringent rule regarding record retention.

Last Reviewed: 09/29/2023

If a hospice fails to obtain the recertification within the specified time (within two days of the date the recertification is due), then the hospice would submit the claim using Occurrence Span Code 77 and the dates would be from the date the certification was due through the date the patient was actually discharged.

If the reason recertification was not obtained is due to a missed face-to-face, the use of occurrence span code 77 is not permissible. If the required face-to-face encounter is not timely, the hospice would be unable to recertify the patient as being terminally ill, and the patient would cease to be eligible for the Medicare hospice benefit. In such instances, the hospice must discharge the patient from the Medicare hospice benefit because he or she is not considered terminally ill for Medicare purposes.

Last Reviewed: 09/29/2023

The value code 61 is reported with the core based statistical area (CBSA) code.

Last Reviewed: 09/29/2023

Effective January 1, 2009, home health agencies should use condition code D2 when submitting an adjustment that alters the change in revenue/HCPCS/HIPPS Rates codes.

Reference

• MLN Matters Article for CR 6002 (PDF)

Last Reviewed: 09/29/2023

For Medicare purposes, the term non-physician practitioner (NPP) includes: 

• Nurse practitioner or clinical nurse specialist, as those terms are defined in section 1861(aa)(5) of the Social Security Act, who is working in collaboration with the physician in accordance with State law
• Certified nurse-midwife, as defined in section 1861(gg) of the Social Security Act, as authorized by State law
• A physician assistant, as defined in section 1861(aa)(5) of the Social Security Act, under the supervision of the physician

References:

• Change Request 7329 (PDF)
• Centers for Medicare & Medicaid Services Internet-Only Manual (CMS IOM), Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1.1 (PDF)

Last Reviewed: 09/29/2023