Physician Certification of Patient Eligibility for the Medicare

6.2.1 - Physician Certification of Patient Eligibility for the Medicare Home Health Benefit (Rev.603, Issued: 07-21-15, Effective: 08-11-15, Implementation: 08-11-15) A physician certification/recertification of patient eligibility for the Medicare home health benefit is a condition for Medicare payment per sections 1814(a) and 1835(a) of the Social Security Act (the “Act”). The regulations at 42 CFR 424.22 list the requirements for eligibility certification and recertification. The requirements differ for eligibility certification and recertification; however, if the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will be non-covered—even if the requirements for recertification are met. Home health agencies (HHAs) should obtain as much documentation from the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria for certification and recertification have been met and must be able to provide it to CMS and its review entities upon request. Per the regulations at 42 CFR 424.22(c), 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. Therefore, for all medical necessity reviews, the Medicare review contractors shall review the certification documentation for any episode initiated with the completion of a start-of-care Outcome and Assessment Information Set (OASIS) assessment. This means that if the subject claim is for a subsequent episode of care, the HHA must submit all certification documentation as well as recertification documentation. The review contractor shall send a documentation request to the billing HHA requesting the supporting documentation from the certifying physician and/or the acute/post-acute care facility if the patient was directly admitted to home health from such setting (as defined in 42 CFR 424.22) that substantiates the patient’s eligibility for the Medicare home health benefit. For medical review purposes, the referring /certifying physician’s initial order for home health services for a patient initiates the establishment of a plan of care as part of the certification of patient eligibility for the Medicare home health benefit. The physician’s initial order must specify the medical treatment(s) to be furnished and does not eliminate the need for the plan of care as required in 42 CFR 409.43. If the review contractor finds that the documentation in the certifying physician’s medical record for that patient used as the basis for the certification of eligibility, which includes subsequent supporting documentation from the HHA (if incorporated into the certifying physician’s or acute/post-acute care facility’s medical record for that patient), is insufficient to demonstrate the patient is or was eligible to receive services under the Medicare home health benefit, the review contractor shall deny payment (in the case of prepayment review) or shall initiate an overpayment demand letter (in the case of post payment review). The review contractor shall only consider a plan of care and the certification or recertification for home health services from physicians who do not have a financial relationship with the HHA. The review contractor shall only consider documentation of the face-to-face encounter from physicians or allowed non-physician practitioners, as defined in 42 CFR 424.22, who do not have a financial relationship with the HHA (see 6.2.3). CMS does not require a specific form or format for the certification as long as a physician certifies that the five certification requirements, outlined in 42 CFR 424.22(a)(1) and section 6.2.1.1, are met.