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Physician Certification of Home Health Eligibility

July 22, 2014 by  
Filed under Home Health & Hospice

Certification of home health eligibility is requred and must be documented in the medical records.(July 22, 2014): The Affordable Care Act (ACA) requires that a certifying physician or an allowed non-physician provider (NPP) has a face-to-face encounter with a patient before certifying the patient’s eligibility for the home health benefit. The statute also requires certification of home health eligibility by a physician who documents that a face-to-face encounter occurred with the physician or an NPP who informed him of the encounter. If a certifying physician cannot do both the face-to-face encounter and the certification himself, a hospital physician may play a role in ensuring the process if properly completed.


I.  Certification of Home Health Eligibility is Required:

When a patient is admitted to home health from acute or post-acute care, the current procedures required for the home health certification would also apply to the face to face encounter. In many cases, the same physician who referred the patient to home health will also order the patient’s home health services, certify the patient’s eligibility to receive Medicare home health services, and sign the plan of care. This same physician would be responsible for documenting on the certification that he or an NPP working in collaboration with him had a face-to-face encounter with the patient.

II.  Problems That May Arise When Certification of Eligibility is Needed:

However, in some instances, one physician performing all of these functions may not be feasible. While in most cases, a patient’s primary care physician would be the physician who refers and orders home health services, documents the face to face encounter, certifies eligibility, and signs the plan of care, there are situations where this is not possible for the post-acute patient. For instance, many post-acute home health patients do not have a primary care physician. In other cases, the hospital physician might have primary responsibility for the patient’s care during the acute stay, and may or may not follow the patient for a period of time post-acute.

In circumstances such as these, it is not uncommon for the hospital physician to refer a patient to home health, initiate orders and a plan of care, and certify the patient’s eligibility for home health services. In the patient’s hospital discharge plan, the hospital physician should describe the community physician who will be assuming primary care responsibility for the patient upon discharge. Because there is a growing prevalence of NPPs in the acute and post-acute care settings, NPPs are also allowed to work with the community certifying physician regarding the NPP’s encounter with the patient in the acute and post-acute settings.

III. Final Remarks with Respect to the Certification of Home Health Eligibility:

Prior to 2011, the Centers for Medicare & Medicaid Services (CMS) manual guidance required that the same physician who signed the certification had to sign the plan of care. Now CMS allows additional flexibility associated with the plan of care when a patient is admitted to home health from an acute or post-acute setting. CMS allows physicians who attend to the patient in acute and post-acute settings to certify the need for home health care based on their face-to-face contact with the patient (which includes documentation of the face-to-face encounter), initiate the orders (plan of care) for home health services, and hand off the patient to his or her community-based physician to review and sign off on the plan of care. This accounts for the fact that, again, it is not always possible for the same physician to sign the certification and the plan of care, and it further allows the hospital physician to play a larger role in certifying the patient’s eligibility for the home health benefit.

Robert Liles represents health care providers in RAC and ZPIC appeals.Robert W. Liles, Esq., is a Managing Partner at Liles Parker, Attorneys & Counselors at Law.  Mr. Liles focuses his practice on fraud defense, internal audits/investigations, and compliance and regulatory matters. The attorneys at Liles Parker represent a wide variety of health care providers in administrative and civil proceedings. For a free consultation, call Mr. Liles at (800) 475-1906

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