THIS ARTICLE IS INTENDED TO SUPPORT THE READER’S AWARENESS AND UNDERSTANDING.  IT IS NOT LEGAL ADVICE.   IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP.

An Actively Participating And Experienced Primary Care Physician , Working In Consultation With An Occupational Therapist Within Or Under The Arrangement Of A Medicare Certified Home Health Agency , In Order To Conduct Not Only The Initial Assessment Visit And The Start Of Care Comprehensive Assessment ,  But Also To Indicate Any  Need For Continuing Occupational Therapy,  Can Be A Very Important Key To The Development Of Specific, Comprehensive, Customized And Continuing Home Health Services That Follow That Doctor’s Customized , Written Plan Of Care For A Medicare Part A Beneficiary  .

There are two distinct home health services benefits under Medicare. The “Home Health Services” benefit is a potentially unlimited duration, longer term benefit to be furnished under Medicare Part A that is distinctly different from the “Post-Institutional Home Health Services” benefit that is a qualified, shorter term , “spell of illness” benefit to be furnished under Medicare Part B . The “home health services benefit” under Medicare Part A is not strictly limited and qualified to be furnished only during a home health “spell of illness” for up to 100 visits . That particular home services benefit is a different , more limited type of shorter term benefit under Medicare Part B called “post-institutional, spell of illness home health services” . See 42 USC Section 1395d(a)(3).

Home health services are : Part-time or intermittent skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample); Part-time or intermittent home health aide services; physical therapy; Speech-language pathology; occupational therapy; medical social services; medical supplies (including catheters, catheter supplies, ostomy bags, supplies related to ostomy care, and a covered osteoporosis drug.., but excluding other drugs and biologicals; Durable medical equipment while under the plan of care established by physician; medical services provided by an intern or resident-in-training under an approved teaching program of the hospital in the case of an HHA which is affiliated or under common control with a hospital; and services at hospitals, skilled nursing facilities, or rehabilitation centers when they involve equipment too cumbersome to bring to the home.

The term “part-time or intermittent” for purposes of coverage under §1861(m) of the Act means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). See Section 40 – Covered Services Under a Qualifying Home Health Plan of Care -Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3118, HHA-205

Medicare does not limit the number of continuous 60-day episode recertifications for beneficiaries who continue to be eligible for the home health benefit. See Section 30. 5.2 – Periodic Recertification – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11). The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed . Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. See 42 C.F.R. §409.32( c ) Criteria for skilled services and the need for skilled services.

To obtain Medicare Part A Home Health Care Services, home health care must follow a written plan of care that is established and periodically reviewed by a doctor of medicine osteopathy or podiatric medicine. Although such plan is established and periodically reviewed by such attending physician, it is established and reviewed by the doctor in consultation with the Medicare Certified Home Health Agency ( HHA) staff. The plan of care must be specific and comprehensive, covering all pertinent diagnosis . It is to be reviewed by the attending physician and HHA personnel at least every 60 days. There is no requirement that the certification be entered on any specific form or handled in any specific way as long as the approach adopted by the Medicare certified HHA permits the intermediary to determine that the physician certification requirement is met. Patients are accepted for treatment on basis of a reasonable expectation that the patient’s medical nursing and social needs can be met adequately by the home health agency (HHA) in the patient’s place of residence. Care follows a written plan of care that is established and periodically reviewed by a doctor of medicine osteopathy or podiatric medicine. The plan of care established by the attending physician in consultation with the agency covers all pertinent diagnoses- including mental status, types of services and equipment required, frequency of visits, prognosis, rehab potential, functional limitations activities permitted nutritional requirements medications and treatments ,any safety measures to protect against injury instructions for timely discharge or referral , and any other appropriate items . The total plan of care is reviewed by the attending physician and the HHA personnel as often as the severity of the patient’s condition requires , but at least every 60 days or more frequently when there is a beneficiary elected transfer; a significant change in condition resulting in a change in the case-mix assignment; or a discharge and return to the same HHA during the 60-day episode. Agency professional staffs promptly alert the physician to any changes that suggest the need to alter the plan of care. See 42 CFR § 484.18 (a)(b) ( Italics and Underlining Added For Emphasis )

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;
Prognosis;
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 choose 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. See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 30.2.1 – Content of the Plan of Care (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

Occupational therapists can conduct the initial assessment visit and the start of care comprehensive assessment on therapy-only patients for whom occupational therapy “establishes eligibility”  See 42 CFR § 484.55  Conditions of Participation, Comprehensive Assessment Of Patients

Occupational therapy has a vital role in home health services care. Occupational therapists assess and evaluate the patient’s home environment, evaluate functional status, identify possible safety issues, and identify other needs and strategies immediately , such as daily management of chronic conditions and adherence to daily medication administration routines. See the American Occupational Therapy Association ( AOTA) Fact Sheet On Occupational Therapy’s Role In Home Health @ https://www.aota.org/about-occupationaltherapy/professionals/pa/facts/home-health.aspx

As management of chronic conditions is in large part management of daily activities , occupational therapy brings expertise to help home health care recipients towards manageable daily habits and routines. With a core knowledge base in psychosocial issues, occupational therapists can address behavioral health conditions and train caregivers to provide appropriate cues and support to patients with cognitive limitations to optimize performance and reduce agitation or confusion. See the American Occupational Therapy Association ( AOTA) Fact Sheet On Occupational Therapy’s Role In Home Health @ https://www.aota.org/about-occupationaltherapy/professionals/pa/facts/home-health.aspx

The physician must certify that:
1. The home health services are or were needed because the patient is or was confined to the home as defined in §20.1;
2. The patient needs or needed 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 patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §40.1.2.2), 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 encounter with the patient as described in §30.5.1.1. The encounter and documentation are a condition of payment. The initial certification is incomplete without them. See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 30.5.1 – Content of the Physician Certification (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

A physician must certify that the medical and other health services covered by medical insurance, which were provided by (or under arrangements made by) the HHA, were medically required. This certification needs to be made only once where the patient may require over a period of time the furnishing of the same item or service related to one diagnosis. There is no requirement that the certification be entered on any specific form or handled in any specific way as long as the approach adopted by the HHA permits the intermediary to determine that the certification requirement is, in fact, met. A written physician’s order designating the services required would also be an acceptable certification. 100 – Physician Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA) (Rev. 1, 10-01-03) A3-3128, HHA-224

Although there must be a patient specific, comprehensive assessment that incorporates the HHA’s use of OASIS as a computerized assessment tool, there must also be an assessment of the patient based on objective clinical evidence regarding the patient’s individual need for care . Therefore denial of home health services by an HHA or the Medicare Contractor ( i.e. . fiscal intermediary) based on numerical utilization screens , diagnostic screens , diagnosis or specific treatment norms , a reviewer’s general inferences or OASIS alone is not appropriate . Each patient must receive, and an HHA must provide, a patient specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes . The comprehensive assessment must identify the patients continuing need for home care and meet the patient’s medical nursing rehabilitative, social and discharge planning needs. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of OASIS items, as specified by the secretary. 42 CFR § 484.55.

The intermediary’s decision on whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS as required by 42 CFR 484.55 or a medical record of the individual patient. Medicare does not deny coverage solely on the basis of the reviewer’s general inferences about patients with similar diagnoses or on data related to utilization generally, but bases it upon objective clinical evidence regarding the patient’s individual need for care. See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 20.1.2 – Determination of Coverage (Rev. 1, 10-01-03) A3-3113.1.B, HHA-203.1.B)

Medicare recognizes that determinations of whether home health services are reasonable and necessary must be based on an assessment of each beneficiary’s individual care needs. Therefore, denial of services based on numerical utilization screens, diagnostic screens, diagnosis or specific treatment norms is not appropriate. See Medicare Benefit Policy Manual, Ch.7 Home Health Services Section 20.3 – Use of Utilization Screens and “Rules of Thumb” (Rev. 1, 10-01-03) A3-3116.3, HHA-203.3