Description
This review will determine whether the Home Health care is reasonable and necessary, based on documentation in the medical record.
Affected Code(s)
Revenue Codes: 042X, 043X, 044X, 023X, 055X, 056X, 057X
Applicable Policy References
1. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Sections 1814(a)(2)(C) - Conditions of and Limitations on payment for services
2. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
4. Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(m)- Payment for Telehealth Services
5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1835(a)(2)(A) – Procedure for payment of claims of providers of services
6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services; (o) Home Health Agency; (r) Physician.
7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Sections 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer; 1862(a)(1)(A) (I), and 1862(B)(7)(f)- Exclusions from Coverage and Medicare as a Secondary Payer
8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1891 – Conditions of Participation for Home Health Agencies; Home Health Quality
9. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, § 1895(b)(3)(B)(v)(IV)- Prospective Payment for Home Health Services
10. Coronavirus Aid, Relief, and Economic Security (CARES) Act, Pub. L. No. 116-136, § 3708- Improving Care Planning for Medicare Home Health Services, Effective Date: 03/01/2020
11. 42 CFR §405.929- Post-Payment Review
12. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
13. 42 CFR § 405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
14. 42 CFR § 405.986- Good Cause for Reopening
15. 42 CFR § 409.41 – Requirement for Payment
16. 42 CFR § 409.42 – Beneficiary qualifications for coverage of services
17. 42 CFR § 409.43 – Plan of care requirements
18. 42 CFR § 409.44 – Skilled services requirements
19. 42 CFR § 409.45 – Dependent services requirements
20. 42 CFR § 409.46 – Allowable administrative costs
21. 42 CFR § 409.47 – Place of service requirements
22. 42 CFR § 409.48- Visits
23. 42 CFR § 409.49- Excluded Services
24. 42 CFR § 414.65- Payment for Telehealth Services
25. 42 CFR § 424.22– Requirement for home health services
26. 42 CFR § 484.2 - Definitions
27. 42 CFR § 484.45- Condition of participation: Reporting OASIS information
28. Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 3 (Sections 170 – 190.34) Coverage Determinations, Section 170.1- Institutional and Home Care Patient Education Programs
29. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10- Certification and Recertification by Physicians for Hospital Services – General, Subsection 10.2- Who May Sign Certification or Recertification; Section 30- Certification and Recertification by Physicians and Allowed Practitioners for Home Health Services, Subsection 30.1- Content of Physician or Allowed Practitioner’s Certification
30. Medicare Benefit Policy Manual Chapter 7 - Home Health Services, Section 10.6 - Low Utilization Payment Adjustment (LUPA)
31. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 20- Conditions to be Met for Coverage of Home Health Services
32. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 30- Conditions Patient Must Meet to Qualify for Coverage of Home Health-Effective 01/01/2022; Implementation 05/26/2022
33. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 40- Covered Services Under a Qualifying Home Health Plan of Care
34. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 50- Coverage of Other Home Health Services
35. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 70- Duration of Home Health Services
36. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 80, Specific Exclusions from Coverage as Home Health Services, Subsection 80.10- Telecommunications Technology
37. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 110- Use of telehealth in Delivery of Home Health Services
38. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 60 – Services and Supplies - Subsection- 60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit (Rev. 11355; Issued: 04/14/22; Effective: 05/16/22; Implementation: 05/16/22)
39. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, Section 180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
40. Medicare Claims Processing Manual, Chapter 10 – Home Health Agency Billing, Section 10 – General Guidelines for Processing Home Health Agency (HHA) Claims
41. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §§ 3.2.3.1(A)- Outcome Assessment Information Set (OASIS) and (B)- Plan of Care, and 3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests; 3.3.1.1(B)- Medical Record Review; 3.3.2.1- Documents on Which to Base a Determination; 3.3.2.1.1- Progress Notes and Templates; 3.3.2.2-Absolute Words and Prerequisite Therapies; 3.3.2.4- Signature Requirements; 3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation; 3.5- Postpayment Medical Record Review of Claims; 3.6.2.1- Coverage Determinations; 3.6.2.2- Reasonable and Necessary Criteria; 3.6.2.4- Coding Determination
42. Medicare Program Integrity Manual, Chapter 6, Medicare Contractor Medical Review Guidelines for Specific Services, §6.2.3 The Use of the Patient’s Medical Record Documentation to Support the Home Health Certification, §6.2.1.1 Certification Requirements, §6.2.4 Coding, §6.2.5 Medical Necessity of Services Provided
43. Centers for Medicare and Medicaid Services, Outcome and Assessment Information Set OASIS-E Manual, Updated January 1, 2024 OASIS User Manuals | CMS
44. Palmetto Low Utilization Payment Adjustment (LUPA) Threshold Lookup: https://www.palmettogba.com/palmetto/jmhhh.nsf/DID/1TKOUO16TG#:~:text=The%20LUPA%20threshold%20ranges%20between,threshold%20of%205%20in%202021.
45. CGS Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator: https://www.cgsmedicare.com/medicare_dynamic/j15/lupa/lupa_threshold.aspx