Physician Services for Certification and Recertification of Medicare Covered Home Health Services
Effective April 1, 2012, WPS Medicare implemented a new edit monitoring physician services for certification and recertification of Medicare-covered home health services. We will deny claims that do not meet applicable criteria.
The home health agency certification code is valid when the patient begins a new episode of home health care and when the patient has not received Medicare-covered home health (HH) services for at least 60 days. The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician is certifying the patient's continued need for home health services. The home health agency recertification code is only valid once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapse and requires a new plan of care.
- Physician certification home health patient for Medicare covered home health service under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patients' needs, per certification period. Use G0180 to bill physician services for initial certification of Medicare-covered HH services.
- Physician recertification home health patient for Medicare covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patients' needs, per recertification period. Use G0179 to bill physician services for recertification of Medicare-covered HH services.
Enter "1" as the number of services in Item 24 of the CMS-1500 claim form or, if submitting electronically, in the ANSI format: 2400/SV104 (UN qualifier).
Note: Instructions apply to paper claims using the Form CMS-1500 and electronic claims using the 4010A1 version.
- The place of service code should represent the place where the majority of the plan development and review work was performed.
- The date of service is the date the service was performed, i.e., the date the plan was signed. A span of dates is not appropriate.
- No other services may be billed on the same claim as the physician services for certification or recertification.
Content of the Plan of Care and the Physician Signature
The plan of care must contain all pertinent diagnoses, and include:
- 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 Home Health Agency (HHA) or physicians choose to include.
The physician who signs the plan of care must be the same physician to sign the physician certification. Each review of a patient's plan of care must contain the signature of the physician and the date of review.
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 that 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.
- The plan must describe a course of treatment that is consistent with the qualified therapist's assessment of the patient's function.
Content of the Physician's Certification
No payment can be made for covered home health services that a home health agency provides unless a physician certifies that:
- The home health services are because the individual is confined to his/her home and needs intermittent skilled nursing care (other than solely for venipuncture for the purposes of obtaining a blood sample), physical therapy and/or speech-language pathology services, or continues to need occupational therapy;
- A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician;
- The services are or were furnished while the individual was under the care of a physician.
- The need for skilled oversight of unskilled services (management and evaluation of the care plan). 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.
Since the certification is closely associated with the plan of care (POC), the same physician who establishes the plan must also certify the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. The attending physician must sign and date the POC/certification prior to the claim being submitted for payment.
The home health agency certification code (G0180) is valid only when the patient has not received Medicare-covered home health services for at least 60 days.
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 an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. The encounter and documentation are a condition of payment. The initial certification is incomplete without them.
Face-to-Face Encounter (Effective January 1, 2011)
Additional guidance is available in the Special Edition MLN Matters article Home Health Face-to-Face Encounter - A New Home Health Certification Requirement.
The certifying physician must document that he or an allowed NPP had a face-to-face encounter with the patient. Certain NPPs may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. NPPs who are allowed to perform the encounter are:
- A nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with state law.
- A certified nurse midwife as authorized by state law.
- A physician assistant under the supervision of the certifying physician.
- NPPs performing the encounter are subject to the same financial restrictions with the HHA as the certifying physician.
Encounter Documentation Requirements
The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.
The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.
It is acceptable for the certifying physician to dictate the documentation content to one of the physician's support personnel to type. It is also acceptable for the documentation to be generated from a physician's electronic health record.
It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.
The HHA cannot provide the specific clinical details from the patient's face-to-face encounter in a document, call it a "sample," with the expectation, possibility, or probability that the physician would have all the information he or she would need to document the face-to-face for that particular individual and thus simply sign it as the official face-to-face documentation.
Time Frame 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 where 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 an NPP should examine the patient in order to establish an effective treatment plan.
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.
If the conditions below are met, an encounter between the home health patient and the attending physician who cared for the patient during an acute/post-acute stay can satisfy the face-to-face encounter requirement.
A physician who attended to the patient in an acute or post-acute setting, but does not follow the patient in the community (i.e., hospitalist), may certify the need for home health care based on his contact with the patient, and establish and sign the plan of care. The acute or post-acute physician would then transfer the patient's care to a designated community-based physician who assumes care for the patient.
A physician who attended to the patient in an acute or post-acute setting may certify the need for home health care based on his contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care.
At the end of the 60-day episode, a decision must be made whether to recertify the patient for a subsequent 60-day episode. An eligible beneficiary who qualifies for a subsequent 60-day episode would start the subsequent 60-day episode on day 61. Under the Home Health Prospective Payment System (HH PPS), the plan of care must be reviewed and signed by the physician every 60 days unless one of the following occurs:
- A beneficiary transfers to another HHA.
- A discharge and return to the same HHA during the 60-day episode.
Medicare does not limit the number of continuous episode recertification for beneficiaries who continue to be eligible for the home health benefit. The physician certification may cover a period less than but not greater than 60 days.
Counting 60-Day Episodes of Certification and Recertification of Home Health Services
The home health agency certification code can be billed only when the patient has not received Medicare-covered home health services for at least 60 days. The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period. The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapse and requires a new plan of care to start a new episode.
Note that the certification or recertification visit can be done during a prior episode.
The first 60-day episode ended on June 1. A new episode will begin on June 2 (on the 61st day) and continue through July 31. The next episode can start on August 1, which is the 61st day.
Reference: Medicare Benefit Policy Manual, Internet-Only Manual (IOM) Publication 100-02, Chapter 7, Section 10.4
- There is no requirement that the certification or recertification be entered on any specific form or handled in any specific way, as long as it can be determined, where necessary, that the certification and recertification requirements are met.
- WPS Medicare will deny HCPCS G0179 if billed more than once in 60 days by any physician.
For additional information or instructions of physician certification and recertification, see:
Medicare General Information, Eligibility and Entitlement Manual, IOM Publication 100-01, Chapter 4, Sections 10-60.
Medicare Benefit Policy Manual, IOM Publication 100-02, Chapter 7, Section 30.
Medicare Claims Processing Manual, IOM Publication 100-04, Chapter 12, Section 180 - Care Plan Oversight Services.
Information is also available from the CMS Home Health Agency Center.