Counting Visits Under the Hospital and Medical Plans

70.2 - Counting Visits Under the Hospital and Medical Plans (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21) A. Visit Defined A visit is an episode of personal contact with the patient by staff of the HHA, or others under arrangements with the HHA, for the purpose of providing a covered home health service. Though visits are provided under the HH benefit as part of 30-day periods, and periods are unlimited, each visit must be uniquely billed as a separate line item on a Medicare HH claim, and data on visit charges is still used in formulating payment rates. B. Counting Visits Generally, one visit may be covered each time an HHA employee, or someone providing home health services under arrangements with the HHA, enters the patient's home and provides a covered service to a patient who meets the criteria in §30. If the HHA furnishes services in an outpatient facility under arrangements with the facility, one visit may be covered for each type of service provided. If two individuals are needed to provide a service, two visits may be covered. If two individuals are present, but only one is needed to provide the care, only one visit may be covered. A visit is initiated with the delivery of covered home health services and ends at the conclusion of delivery of covered home health services. In those circumstances in which all reasonable and necessary home health services cannot be provided in the course of a single visit, HHA staff or others providing services under arrangements with the HHA may remain at the patient's home between visits (e.g., to provide noncovered services). However, if all covered services could be provided in the course of one visit, only one visit may be covered. EXAMPLES: 1. If an occupational therapist and an occupational therapy assistant visit the patient together to provide therapy and the therapist is there to supervise the assistant, one visit is counted. 2. If a nurse visits the patient in the morning to dress a wound and later must return to replace a catheter, two visits are counted. 3. If the therapist visits the patient for treatment in the morning and the patient is later visited by the assistant for additional treatment, two visits are counted. 4. If an individual is taken to a hospital to receive outpatient therapy that could not be furnished in their own home (e.g., hydrotherapy) and, while at the hospital receives speech-language pathology services and other services, two or more visits would be charged. 5. Many home health agencies provide home health aide services on an hourly basis (ranging from 1 to 8 hours a day). However, in order to allocate visits properly against a patient's maximum allowable visits, home health aide services are to be counted in terms of visits. Thus, regardless of the number of continuous hours a home health aide spends in a patient's home on any given day, one "visit" is counted for each such day. If, in a rare situation, a home health aide visits a patient for an hour or two in the morning, and again for an hour or two in the afternoon, two visits are counted. C. Evaluation Visits The HHAs are required by regulations to have written policies concerning the acceptance of patients by the agency. These include consideration of the physical facilities available in the patient's place of residence, the homebound status, and the attitudes of family members for the purpose of evaluating the feasibility of meeting the patient's medical needs in the home health setting. When personnel of the agency make such an initial evaluation visit, the cost of the visit is considered an administrative cost of the agency and is not chargeable as a visit since at this point the patient has not been accepted for care. If, however, during the course of this initial evaluation visit, the patient is determined suitable for home health care by the agency, and is also furnished the first skilled service as ordered under the physician or allowed practitioner's plan of care, the visit would become the first billable visit in the 30-day period. The Medicare contractor will cover an observation and evaluation (or reevaluation) visit made by a nurse (see §40.1.2.1 for a further discussion of skilled nursing observation and evaluation visits) or other appropriate personnel, ordered by the physician or allowed practitioner for the purpose of evaluating the patient's condition and continuing need for skilled services, as a skilled visit. A supervisory visit made by a nurse or other appropriate personnel (as required by the conditions of participation) to evaluate the specific personal care needs of the patient or to review the manner in which the personal care needs of the patient are being met by the aide is an administrative function, not a skilled visit.