HH05: Home Health Claims – HCFA 485 Form/Face-to-face Requirements/Verbal Orders Copy
HCFA 485 Form & Face-to-face Requirements & Verbal Orders
Content of the Plan of Care
The HHA must be acting upon a physician plan of care that meets the requirements of this section for HHA services to be covered. The plan of care must contain all pertinent diagnoses, including:
- The patient’s mental status;
- The types of services, supplies, and equipment required;
- The frequency of the visits to be made;
- Rehabilitation potential;
- Functional limitations;
- Activities permitted;
- Nutritional requirements;
- All medications and treatments;
- Safety measures to protect against injury;
- Instructions for timely discharge or referral; and
- Any additional items the HHA or physician chooses to include.
- If the plan of care includes a course of treatment for therapy services:
- The course of therapy treatment must be established by the physician after any needed consultation with the qualified therapist;
- The plan must include measurable therapy treatment goals which pertain directly to the patient’s illness or injury, and the patient’s resultant impairments;
- The plan must include the expected duration of therapy services; and
- The plan must describe a course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function.
Specificity of Orders
The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.
Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided during the 60-day episode to home health patients.
Orders for services to be furnished “as needed” or “PRN” must be accompanied by a description of the patient’s medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained.
485 from a Billing Point of View – Needs to Match the OASIS and the Claim
- Medicare #
- Certification Period
- Frequency & Duration
- Physician Signature & Date Signed
- Date HHA received the signed POT
1. Allowed Provider Types
As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician himself or herself, a physician that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non- physician practitioner (NPP).
NPPs who are allowed to perform the encounter are:
- A nurse practitioner or a clinical nurse specialist working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician, with privileges, who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health;
- A certified nurse midwife, as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health;
- A physician assistant under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
2. Timeframe Requirements
The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.
In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed NPP must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patient’s condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.
3. Exceptional Circumstances
When a home health patient dies shortly after admission, before the face-to-face encounter occurs, if the contractor determines a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.
The face-to-face encounter can be performed via a telehealth service, in an approved originating site. An originating site is considered to be the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area.
The originating Face to Face sites authorized by law are:
- The office of a physician or practitioner;
- Critical Access Hospitals (CAH);
- Rural Health Clinics (RHC);
- Federally Qualified Health Centers (FQHC);
- Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
- Skilled Nursing Facilities (SNF); and
- Community Mental Health Centers (CMHC).
The certifying physician 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 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.
Information from the HHA, can be incorporated into the certifying physician’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’s and/or the acute/post-acute care facility’s medical record for the patient.
When services are furnished based on a physician’s oral order, the orders may be accepted and put in writing by HHA personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA’s internal policies. The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services.
The orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as HHA personnel who receive the oral orders notify that nurse or therapist before the service is rendered. Thus, the rendering of a service that is based on an oral order would not be delayed pending signature of the supervising nurse or therapist. Oral orders must be countersigned and dated by the physician before the HHA bills for the care in the same way as the plan of care.
Any increase in the frequency of services or addition of new services during a certification period must be authorized by a physician by way of a written or oral order prior to the provision of the increased or additional services
Services which are provided from the beginning of the 60-day episode certification period based on a request for anticipated payment and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care.
Services that are provided in the subsequent 60-day episode certification period are considered provided under the plan of care of the subsequent 60-day episode where there is an oral order before the services provided in the subsequent period are furnished and the order is reflected in the medical record. However, services that are provided after the expiration of the plan of care, but before the acquisition of an oral order or a signed plan of care are not considered provided under a plan of care.
Covered Verbal Order Examples
EXAMPLE 1: The HHA acquires an oral order for I.V. medication administration for a patient to be performed on August 2. The HHA provides the I.V. medication administration August 2 and evaluates the patient’s need for continued care. The physician signs the plan of care for the I.V. medication administration on August 15. The visit is covered since it is considered provided under a plan of care established and approved by the physician, and the HHA had acquired an oral order prior to the delivery of services.
EXAMPLE 2: The patient is under a plan of care in which the physician orders I.V. medication administration every 2 weeks. The last day covered by the initial plan of care is July 30. The patient’s next I.V. medication administration is scheduled for August 4 and the physician signs the plan of care for the new period on July 31. The I.V. medication administration on August 4 was provided under a new plan of care established and approved by the physician. The episode begins on the 61 day regardless of the date of the first covered visit.
EXAMPLE 3: The patient is under a plan of care in which the physician orders I.V. medication administration every 2 weeks. The last day covered by the plan of care is July 30. The patient’s next I.V. medication administration is scheduled for August 4 and the physician does not sign the plan of care until August 6. The HHA acquires an oral order for the I.V. medication administration before the August 4 visit, and therefore the visit is considered to be provided under a plan of care established and approved by the physician. The episode begins on the 61 day regardless of the date of the first covered visit.