Refer a Patient to MedStar Health Home Care

There are several requirements for receiving home health care:

• Skilled medical care is necessary to treat the patient and can only be provided by an RN, LPN, physical therapist, occupational therapist, or speech therapist.
• Reasonable and necessary: The patient needs treatment that requires skilled interventions.
• Intermittent and part-time: The patient has an ongoing need for professional skilled services on an intermittent or part-time basis.
• Leaving the home is difficult and/or exhausting: Walking or moving requires assistance of another person or an assistive device (wheelchair, walker, etc.) The patient is only able to leave home periodically to receive medical care, pick up medications, shop for groceries, or attend to other necessities. 
• Face-to-face encounter: The Centers for Medicare and Medicaid Services (CMS) requires a face-to-face encounter between a provider and patient to certify patients for homecare services.
• Authorization and care of a physician or eligible provider: Homecare orders must be written and signed by a licensed physician or eligible provider. A provider must also be willing to follow the patient's care at home during the course of treatment.
  
   

Individuals who require IV drug or nutritional therapy are likely to qualify for in-home IV therapy services. Insurance coverage of home infusion services varies by insurance provider. While many insurance companies cover in-home IV therapy as long as certain conditions are met, Medicare coverage of these services may be limited. Privately insured patients should contact their insurance carriers to determine if home infusion services are covered by their plan.

Required referral information

The information and documentation listed below must be included with all home health care referrals submitted to MedStar Health Home Care.

• Type of referral (i.e., is it a start-of-care for a new patient or a resumption of care?)
• Demographic sheet to include:

• Patient’s first and last name
• Address – This should be the location where the patient will receive homecare services. It may differ from the patient's mailing address or home address.
• Phone number
• Email address
• Insurance information
• Emergency contact information
• Patient's primary language
• Patient-selected representative or power of attorney

• Face-to-face requirement documentation: CMS requires that a physician have a face-to-face encounter with a patient to certify him/her for home care. Clinical documentation of this encounter must include the primary reason the patient requires homecare and attached with the referral.
• Physician or qualified provider’s home care order (if face-to-face encounter documentation not required) that includes patient’s diagnosis requiring home care needs.
• Referring physician or qualified provider’s name and phone number
• Physician or qualified provider’s name and phone number who will be following the patient for home care services
• Medication profile
• Hospital transfer/discharge summary and date (if applicable)
• Patient's history and physical
  
  

In addition to the items listed above, the following information is also needed for infusion referrals:

• Current labs
• Signed physician's order with medication, dose, frequency, and duration
  (NOTE: A nurse's verbal orders are not acceptable)
• PICC line X-ray including indicated tip placement and length of PICC line
• Lab/blood work orders (if applicable) and the physician who should receive the results

CMS has a face-to-face requirement that calls for a physician encounter to certify patients for home care. Effective April 1, 2011, all Medicare patients receiving home care services must be seen by a physician 90 days prior to or 30 days after their admission to home healthcare services. Physician or qualified providers must document face-to-face encounters with patients and certify that the patient meets the criteria for home care and has a defined need for homecare services.

A face-to-face encounter and homecare certification form must be provided to the homecare agency prior to admission. In some cases, the homecare agency may refuse to accept patient referrals without receiving the documentation in advance. If documentation is not received within 30 days of the start of care, the homecare agency will be forced to discharge the patient.

To review a presentation that offers more detail and instructions for meeting this regulatory requirement, review the Guide to Home Health Certification. For more information about the face-to-face encounter requirement and answers to frequently asked questions, visit the CMS website.

MedStar Health Home Care’s goal is to make the documentation process easier. Please review the list of requirements and Medicare denial examples below to ensure your documentation is accurate and complete.

All documentation must include:

• The patient's name
• Date of encounter
• Explanation of clinical findings during encounter
• How clinical findings support homebound
• How clinical findings show need for skilled care
• Primary diagnosis and reason patient requiring home care
• Signed and dated by the certifying physician/qualified provider

Examples of documentation denied by Medicare:

• Diagnoses/clinical findings on face-to-face not related to home care ordered
• Altered documentation without acceptable notations for changes
• No date of face-to-face encounter
• Not clearly titled as face-to-face encounter
• Face-to-face completed by employee or representative of the home care agency

Medicare reimburses physicians for qualified time spent overseeing the care of patients receiving home healthcare services. Care plan oversight exists because CMS recognizes the importance of ongoing physician engagement in patient care. For details regarding care plan oversight, visit CMS.gov or review the Medicare Claims Processing Manual.

CMS requires physicians who order, refer, or receive payment for Medicare-covered home health service and supplies to enroll in the Provider Enrollment, Chain and Ownership System (PECOS). The Patient Protection and Affordable Care Act allows CMS to deny Medicare home health services or supply claims from physicians who are not registered in PECOS.

To access PECOS, visit PECOS.CMS.HHS.gov.

The experienced representatives in MedStar Health Home Care’s Call Center can assist you and answer your questions about home healthcare services and submitting referrals.

• Phone: 800-862-2166

• Fax: 888-862-6082