CMS Pub. 100-08, ch. 6, § 6.2.3

Support the Home Health Certification

(Rev. 704, Issued: 03-17-17, Effective: 04-17-17, Implementation: 04-17-17)

As mentioned in section 6.2.1.1 – Certification Requirements, for home health services to

be covered by Medicare, the certifying physician’s and/or the acute/post-acute care

facility’s medical record for the patient must contain sufficient documentation of the

patient’s medical condition(s) to substantiate eligibility for home health services. The

information may include, but is not limited to, such factors as the patient’s diagnosis,

duration of the patient’s condition, clinical course (worsening or improvement),

prognosis, nature and extent of functional limitations, other therapeutic interventions and

results, etc.

The physicians’/acute/post-acute care facility’s medical records can always stand alone

in substantiating eligibility for home health services. The physician’s/acute/post-acute

care facility’s record, in conjunction with appropriately incorporated HHA

documentation (e.g., Form 485/Plan of Care, OASIS, etc.), may also substantiate the

certification of eligibility for home health services. The HHA’s generated medical

record documentation for the patient, by itself, is not sufficient in demonstrating the

patient’s eligibility for Medicare home health services.

As noted earlier, per 42CFR424.22 (a) and (c) it is the patient’s medical record held by

the certifying physician and/or the acute/post-acute care facility that must support the

patient’s eligibility for home health services. Therefore, any documentation used to

support certification that was generated by the home health agency must be signed off

by the certifying physician and incorporated into the medical record held by the

physician or the acute/post-acute care facility’s medical record. Any information

provided to the certifying physician by the HHA and incorporated into the patient’s

medical record held by the physician or the acute/post-acute care facility’s medical

record (if the patient was directly admitted to home health) must corroborate the rest of

the patient’s medical record. This means that the HHA information, along with the

certifying physician’s and/or the acute/post-acute care facility’s medical record, creates

a clinically consistent picture that the patient is eligible for Medicare home health

services. This could include, but is not limited to, the plan of care required per 42 CFR

409.43, the initial and/or the comprehensive assessment of the patient required per 42

CFR 484.55, the inpatient discharge summary or multi-disciplinary clinical notes, etc.,

which must correspond to the dates of service being billed and not contradict the

certifying physician’s and/or the acute/post-acute care facility’s own documentation or

medical record entries. Once incorporated into the certifying physician’s medical record

for the patient, the HHA information can be used to support the patient’s homebound

status and need for skilled care, the reviewer shall consider all documentation from the

HHA that has been signed off in a timely manner and incorporated into the

physician/hospital record when making its coverage determination. HHA

documentation that is used to support the home health certification is considered to be

incorporated timely when it is signed off prior to or at the time of claim submission.

See section 6.2.6 Examples of Sufficient Documentation Incorporated into a

Physician’s Medical Record.

It is important to apply the review process to the entire patient’s medical record that is

received by the reviewer. Doing so assures that the reviewer is establishing that the HHA

generated medical record documentation corroborates other patient medical records

received and used to support the patient’s eligibility for home health services. Therefore,

the HHA generated documentation does not necessarily need to restate pertinent facts or

conditions, but instead the HHA generated medical records for the patient should be in

alignment with and not contradict other patient records. The HHA generated medical

record for the patient together with other medical records received must lead the reviewer

to confirm that the patient is eligible for home health services as established in 42 CFR

424.22(a)(1).