The Use of the Patient’s Medical Record Documentation to

6.2.3 – The Use of the Patient’s Medical Record Documentation to 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).