Supporting Documentation Requirements

30.5.1.2 – Supporting Documentation Requirements (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21) As of January 1, 2015, documentation in the certifying physician or allowed practitioner’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined. Documentation from the certifying physician or allowed practitioner’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) used to support the certification of home health eligibility must be provided, upon request, to the home health agency, review entities, and/or the Centers for Medicare and Medicaid Services (CMS). In turn, an HHA must be able to provide, upon request, the supporting documentation that substantiates the eligibility for the Medicare home health benefit to review entities and/or CMS. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided. The certifying physician or allowed practitioner and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: • Need for the skilled services; and • Homebound status; The certifying physician or allowed practitioner and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter: • Occurred within the required timeframe, • Was related to the primary reason the patient requires home health services; and • Was performed by an allowed provider type. This information can be found most often in clinical and progress notes and discharge summaries. While the face-to-face encounter must be related to the primary reason for home health services, the patient’s skilled need and homebound status can be substantiated through an examination of all submitted medical record documentation from the certifying physician or allowed practitioner, acute/post-acute care facility, and/or HHA (see below). The synthesis of progress notes, diagnostic findings, medications, nursing notes, etc., help to create a longitudinal clinical picture of the patient’s health status. • Information from the HHA, such as the plan of care required per 42 CFR §409.43 and the initial and/or comprehensive assessment of the patient required per 42 CFR §484.55, can be incorporated into the certifying physician or allowed practitioner’s medical record for the patient and used to support the patient’s homebound status and need for skilled care. However, this information must be corroborated by other medical record entries in the certifying physician or allowed practitioner’s and/or the acute/post-acute care facility’s medical record for the patient. This means that the appropriately incorporated HHA information, along with the certifying physician or allowed practitioner’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. • The certifying physician or allowed practitioner demonstrates the incorporation of the HHA information into his/her medical record for the patient by signing and dating the material. Once incorporated, the documentation from the HHA, in conjunction with the certifying physician or allowed practitioner and/or acute/post-acute care facility documentation, must substantiate the patient’s eligibility for home health services.