To be filled out by the home care agency.
QUALIFYING ENCOUNTER TYPE FOR HOME CARE SERVICES (check all that apply)
To be filled out by physician conducting the initial certification for homecare admission.
Based on the clinical findings, I certify the patient is homebound and that the following intermittent home care services are medically necessary: (Check all that apply)
I have provided the home care agency with the following documentation to support the patient's medical necessity and substantiate their homebound status. (Check all that apply)
Physician, please sign, and return this form within 2 days and attach copies of documentation. Lack of supporting documentation could adversely affect the patient's ability to receive home care services. See reverse side to review examples of required content.
PART 1 - To Physician (For Signature) PART 2 - Clinical Record (Temporary Copy)
Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expect home health agencies to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient's eligibility for Medicare home health services. The encounter and documentation are a condition of payment.
DEFINITIONS AND DIRECTIONS: (This information is not all-inclusive)
Describe the patient's condition and symptoms, not just a list of diagnoses. Explain if this is a new problem or an exacerbation of a previous problem.
If this is a post-operative patient, for example:
Skilled Services Need:
Is there evidence that skilled therapy service (PT, OT, SLP) is needed? For example:
Is there evidence that Nursing is needed?
Description should not be limited to weakness, considerable and taxing effort, poor endurance. Include a description of the patient's condition and symptoms, not just a diagnosis and not just the need for an assistive device. Patient does not have to be bedridden.
The physician must certify that:
1. The home health services are needed because the patient is confined to the home (homebound).
2. The patient needs skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech language pathology services ceased. Where a patients sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in $220.127.116.11), the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
3. A plan of care has been established and is periodically reviewed by a physician;
4. The services are or were furnished while the patient is or was under the care of a physician;
5. For episodes with starts of care beginning January 1, 2011 and later, prior to initially certifying the home health patient's eligibility, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) had a face-to-face.
"I certify that in my estimation continued services will be required for (a) more than 60days (b) more than 120 days" where (a) and (b) will be check marks.