Ensuring Medical Necessity for Home Health Services

When billing Medicare for home health services, providers must ensure that all services are medically and reasonably necessary. This requirement remains critical for both start of care episodes and all subsequent episodes.

What Documentation Should Be Submitted

The medical record from the certifying physician, allowed practitioner or acute/post-acute care facility should present a clinically consistent picture of the patient. It must include objective clinical documentation that supports both the need for skilled services and the patient’s homebound status.

For recertifications, to support the need for continued skilled care, providers must include clinical documentation that clearly demonstrates the patient’s ongoing need for skilled services in the home. Acceptable forms of documentation may include:

• Recent visit notes from the certifying practitioner or another qualified provider
• Recent laboratory or imaging results
• Skilled nursing or therapy visit notes from the previous episode of care
• The recertification Outcome and Assessment Information Set (OASIS) assessment

If the patient’s condition has changed, worsened or if a new condition has emerged, the documentation should reflect this and provide clinical evidence supporting the need for continued skilled care.

Why It Matters

Accurate and thorough documentation not only supports compliance with Medicare regulations but also ensures that patients receive appropriate care tailored to their evolving needs.

References

• CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 — Home Health Services
• Code of Federal Regulations, 42 CFR 424.22