CurrentAnthemPolicy N/A

Medicare Home Health Coverage Criteria — Home Health Prospective Payment System (HH PPS) / Chapter 7 excerpts

Governs Medicare home health payment, coverage conditions, and administrative requirements for home health agencies (HHAs), including the 30-day period payment rate, excluded services, case-mix and labor adjustments, NOA submission, recertification, and LUPA rules. Affects HHAs, practitioners certifying home health care, and payers administering Medicare-contracted benefits.

Policy Summary

PayerAnthem

PolicyMedicare Home Health Coverage Criteria — HH PPS (Chapter 7 excerpts)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a one-time Notice of Admission (NOA) to Medicare systems within 5 calendar days from the start of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-dayunit of payment under HH PPS

6home health disciplines in 30-day rate

432case-mix groups

5 daystimely NOA window

min 2 visitsLUPA minimum

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Coverage criteria and medical necessity

Wound care — covered with documented clinical findings

Wound care is covered as a skilled nursing service when documentation shows that the skills of a licensed nurse are necessary to provide services safely and effectively. Coverage decisions must be based on the totality of documented clinical findings, not solely on wound stage.

The following MUST be documented in the clinical record to support skilled wound care:

- Size, depth, and description of the wound (including color, odor, consistency, and quantity of drainage).

- Condition and appearance of the surrounding skin.

- Physician or allowed practitioner orders specifying active wound treatment and the plan of care with specific treatment instructions (e.g., sterile/complex dressings, NPWT, prescription medications).

- Rationale that explains why the wound requires the skills of a licensed nurse (complexity of dressing, need for sterile technique, risk of complications, need for assessment and change in treatment).

Skilled wound care is generally reasonable and necessary when wounds have characteristics such as:

- Open wounds draining purulent or colored exudate, or with a foul odor, or when the patient is receiving antibiotic therapy;

- Wounds with drains or T-tubes requiring manipulation;

- Wounds requiring irrigation or instillation into multiple tissue layers or packing with sterile gauze;

- Recently debrided ulcers;

- Pressure sores with partial tissue loss and signs of infection (foul odor or purulent drainage) or full thickness tissue loss exposing fat, muscle, or bone;

- Wounds with exposed internal vessels or masses at risk for hemorrhage during dressing changes;

- Open wounds or widespread skin complications after radiation therapy or due to immune deficiency or vascular insufficiency;

- Post-operative wounds with complications (infection, allergic reaction) or with underlying disease likely to impair healing (e.g., diabetes);

- Third-degree burns, and second-degree burns of size or complication requiring skilled care;

- Skin conditions requiring application of chemotherapeutic agents or other treatments that pose significant patient risk;

- Other open or complex wounds that can only be treated safely and effectively by a licensed nurse.

Billing, codes, and payment thresholds

Documentation, billing actions, and denial risks

Prior Authorization

Submit NOA within 5 calendar days of Start of Care

HHAs must submit a one-time Notice of Admission (NOA) to their Medicare contractor within 5 calendar days from the start-of-care date to establish the beneficiary’s home health period of care and trigger consolidated billing edits; the NOA covers contiguous 30‑day periods until discharge and there is no upfront payment with NOA submission.

Example: Start of care 1/1/2022 → NOA timely if submitted on or before 1/6/2022.

Denial Risk

Late NOA triggers proportional payment reduction and provider liability

If an NOA is submitted after the 5‑day timely window, Medicare reduces the period payment (including outlier payments) by the number of days from admission to the date the NOA is submitted and accepted divided by 30; visits occurring prior to an accepted NOA are not eligible for LUPA per‑visit payments and the reduction is a provider liability (the provider may not bill the beneficiary for it).

Key definitions and background

Home health services are multidisciplinary skilled services (skilled nursing, physical therapy, occupational therapy, speech‑language pathology, home health aide, and medical social services) provided to Medicare beneficiaries in the place of residence. Coverage requires physician or allowed practitioner certification, an individualized plan of care, and demonstration of intermittent skilled need or continued therapy requirement; documentation (plan of care, OASIS, medical record) must support the reasonable and necessary skilled services provided.

30‑day period payment rate

30‑day period payment rate — definitionA national payment unit covering included home health services and routine/nonroutine medical supplies for a 30‑day period, adjusted by case‑mix and wage/labor components

Included disciplinesIncludes six home health disciplines: skilled nursing, home health aide, physical therapy, speech‑language pathology, occupational therapy, and medical social services

Case‑mix adjustment30‑day payment is adjusted by a case‑mix methodology using claims and OASIS data to assign periods to case‑mix groups

Policy Summary

PayerAnthem

PolicyMedicare Home Health Coverage Criteria — HH PPS (Chapter 7 excerpts)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a one-time Notice of Admission (NOA) to Medicare systems within 5 calendar days from the start of care.

SourceLink

On This Page

Prior Authorization

Ensure physician/practitioner order and initial visit documented before NOA submission

An NOA may only be submitted after the HHA has received and documented the physician's or allowed practitioner's written or verbal order for the initial visit and after the initial visit within the 60‑day certification period has been made and the individual admitted to home health care.

Documentation Required

Maintain NOA supporting documentation and request waivers when appropriate

Document and retain evidence that the physician's or allowed practitioner's written or verbal order for the initial visit was received and that the initial visit occurred within the 60‑day certification period; if requesting an exception to a late NOA, fully document the exceptional circumstance and furnish requested documentation to the MAC for waiver consideration.

Billing Rule

HHAs provide/arrange covered services and bill under consolidated billing

HHAs must provide covered home health services (except DME) either directly or under arrangement and must bill for such covered services; payment for these covered services is made to the HHA under the HH PPS.

Billing Rule

Bill covered home health services to the HHA (payment made to HHA)

Providers and other suppliers must bill covered home health services to the HHA (not separately to Medicare) while the patient is under the HHA plan of care; payment for those services is made to the HHA.

Documentation Required

Provide services under a physician/allowed practitioner plan of care

Services must be furnished under an individualized physician or allowed practitioner plan of care that specifies services necessary to meet needs identified in the comprehensive assessment, identifies responsible disciplines, and states frequency and duration (including required elements at 42 CFR 484.60(a)).

Billing Rule

Accept verbal orders for initial RAP but obtain signed plan of care for final payment

If a signed plan of care is not available at the start of a 30‑day period, the HHA may rely on documented verbal (oral) orders or a signed referral to submit an initial RAP/initial payment, but the verbal orders must be recorded, attested, signed by the RN/qualified therapist who received them, and countersigned by the physician or allowed practitioner before billing; final payment requires a signed and dated plan of care prior to claim submission for the period.

Billing Rule

Bill certification/recertification (G0180/G0179) under PFS

Certification (G0180) and recertification (G0179) for home health eligibility are billed as Part B claims under the Physician Fee Schedule using HCPCS codes G0180 and G0179 (patient not present).

Do not bill G0180/G0179 if there are no Medicare‑covered home health services or if the HHA claim was non‑covered due to incomplete certification/documentation.

Note

No specific prior‑authorization rules stated for skilled observation in excerpt

The policy does not establish an explicit prior authorization program in these excerpts; coverage for skilled observation is permitted while there is a reasonable potential for change, but no discrete prior‑auth requirements are specified here.

Documentation Required

Provide and document clinical necessity for skilled visits and injections

Visits and services must be supported by clinical necessity documented in the record; frequency, nature of injections, and other skilled services must be justified by individualized assessments and documentation demonstrating that licensed nurse or therapist skills are required.

Documentation Required

Document wound characteristics and plan of care to support skilled wound care

For wound care, document clinical findings that demonstrate licensed nurse skills are needed (wound size, depth, drainage characteristics, surrounding skin condition) and include specific plan‑of‑care instructions showing why skilled nursing is required at each visit.

Documentation Required

Order and document skilled nursing need for tube feedings and catheter procedures

Care involving tube feedings or catheter insertion/replacement/sterile irrigation must be ordered and documented as required to treat the illness or injury; these procedures are considered skilled nursing services when so required.

Documentation Required

Provide psychiatrist‑trained nursing under a physician plan of care and document active treatment

Psychiatric evaluation, psychotherapy, and teaching by a psychiatrically trained nurse must be provided under a physician‑established plan of care and documented as active treatment to be covered by Medicare; agencies primarily providing mental disease care are excluded.

Note

Send physician justification and duration estimate to HHA for extensions beyond ~2–3 weeks

When daily skilled nursing (7 days/week) is required beyond a short period (about 2–3 weeks), the HHA must forward medical documentation from the physician justifying the extension and provide an estimate of the additional duration required.

Documentation Required

Ensure qualified therapist assessments and 30‑day reassessments with objective measures

Therapist‑ordered visits require an initial qualified therapist assessment and periodic objective reassessments (at least every 30 days); document objective ADL measures, patient response, and rationale that therapist skills are necessary.

Note

Verify patient meets §30 qualifying criteria and part‑time/intermittent thresholds

Coverage requires meeting the qualifying criteria in §30 (homebound, need for a qualifying skilled service) and services designated part‑time or intermittent when applicable (less than 8 hours/day and generally ≤28 hours/week); ensure the patient meets these criteria before billing.

Billing Rule

Meet four conditions and document orders/POC for nonroutine supplies to be reportable

Nonroutine supplies are reportable only if all four conditions are met: consistent charging practice across patients, directly identifiable to an individual patient, costs identifiable in a separate cost center, and furnished at the direction of the physician/allowed practitioner and specifically identified in the plan of care; ensure orders and plan‑of‑care entries reflect these items.

Billing Rule

Report A9272 on TOB 032x for separate dNPWT device payment starting CY2024

Beginning CY2024, HHAs must report HCPCS A9272 on the standard home health type of bill (TOB 032x) for separate payment of an applicable disposable NPWT device; nursing and therapy services related to the device are paid under the HH PPS and are not separately billable.

Billing Rule

Bill each unique home health visit as a separate line item

Each home health visit is an episode of personal contact and must be billed as a separate line item on the Medicare home health claim; count one visit each time HHA staff or contracted providers enter the home and provide a covered service.

Documentation Required

Document objective goals and rationale — therapy may be to improve, maintain, or prevent deterioration

Therapy coverage is based on the patient's need for skilled therapy (to improve, maintain, or prevent deterioration), not solely on potential for improvement; document objectives, measurable goals, and why therapist skills are required.

Note

Arrange outpatient equipment provision when needed but confirm homebound criteria

If required services need equipment not available at home, the HHA may arrange outpatient provision at a hospital, SNF, or rehabilitation center; the patient must still meet homebound criteria and the HHA remains responsible for plan‑of‑care coordination.

Documentation Required

Document complexity requiring RN management/evaluation of the care plan

When unskilled services are complex, the HHA must document that only an RN can manage and evaluate the care plan; record the complexity and clinical reasons in the medical record to justify RN involvement.

Documentation Required

Document patient choice when patient‑supplied items are used

If a patient prefers to use their own clinically appropriate supplies, the HHA should document the patient's choice in the record; the HHA is not required to duplicate patient‑provided supplies but should offer agency‑provided supplies if the patient requests them.

Denial Risk

Support claims with POC, OASIS, and medical record documentation

Medicare contractor coverage decisions rely primarily on the home health plan of care, the OASIS, or the patient's medical record; failure to document reasonable and necessary skilled care in these sources can result in denial.

Documentation Required

Ensure POC reflects ordered services HHA provides or arranges

The plan of care must accurately reflect physician or allowed practitioner orders for services the HHA provides or arranges during the 30‑day period; HHAs must have knowledge of services provided under arrangement and ensure orders are incorporated into the POC.

Documentation Required

Document longitudinal clinical evidence to support homebound status

To establish homebound status, document longitudinal clinical information including diagnosis, duration, course, prognosis, functional limitations, and interventions/results that demonstrate normal inability to leave home and that leaving requires considerable effort.

Documentation Required

Include detailed service type, responsible professional, frequency, and PRN limits in POC orders

Plan‑of‑care orders must specify the type of service, responsible professional, nature of services, frequency (upper limit if a range is used), and for PRN orders include triggering signs/symptoms and a specific visit limit before re‑ordering is required.

Documentation Required

Record, attest, sign, and obtain physician countersignature for verbal orders before billing

Oral (verbal) orders must be recorded in the plan of care with a description of condition and services, include an attestation and date, be signed and dated by the RN or qualified therapist who received them, and be countersigned and dated by the physician or allowed practitioner before the HHA bills for the care.

Documentation Required

Ensure face‑to‑face note and supporting documentation are in certifier records and available on request

Face‑to‑face supporting documentation must be present in the certifying provider's or facility medical record, show the encounter occurred within the required timeframe and related to the primary reason for home health, and certifying providers must be able to furnish these notes upon request; HHA documentation incorporated into certifier records must be signed/dated by the certifying provider.

Documentation Required

Document visit‑level clinical details and rationale for skilled care

HHA clinical notes for each visit must document the patient's current condition, skilled services provided, why nurse/therapist skills were required, patient/caregiver response to teaching, and the plan for the next visit to support continued skilled need.

Documentation Required

Document signs/rationale to justify observation beyond ~3 weeks

To justify extended skilled observation beyond the initial ~3‑week period, document rationale showing reasonable potential for future complication (e.g., abnormal/fluctuating vitals, weight changes, edema, drug toxicity signs, abnormal labs, respiratory changes) and link to the need for skilled nursing.

Documentation Required

Record complexity and teaching outcomes when RN re‑teaching is provided

Document complexity of unskilled care that requires RN involvement, reasons for re‑teaching or retraining, patient/caregiver responses, and reasons if teaching is unsuccessful to support continued skilled nursing.

Documentation Required

Record detailed wound findings and POC instructions at each wound care visit

For wound care visits, document wound size, depth, drainage characteristics (color, odor, consistency, quantity), surrounding skin condition, and physician‑ordered plan‑of‑care instructions at each visit to support the need for skilled wound interventions.

Documentation Required

Link venipuncture orders to diagnosis/symptom and document rationale/results

For venipuncture performed under a home health plan, ensure the physician/allowed practitioner order ties the draw to a specific symptom or diagnosis, document the clinical rationale and results in the home health record, and ensure testing frequency is consistent with accepted standards.

Documentation Required

Supervise and document student nurse visits per program requirements

When student nurses perform services, ensure they operate under general supervision of a registered/licensed nurse, that the HHA participates in an approved training program, and that all documentation requirements are fulfilled and retained.

Documentation Required

Include H&P, interventions, responses, plan, and objective measures in clinical notes

Clinical notes must include a pertinent history/physical, skilled services applied, patient/caregiver immediate response, plan for next visit, objective functional measures as applicable, and when care is maintenance rather than restorative, a detailed rationale and complexity of service.

Documentation Required

Therapists must perform initial objective ADL assessments and document results

Qualified therapists must perform and document initial assessments using objective ADL measures and document results in the clinical record; when more than one therapy discipline is provided, each discipline must assess and document.

Documentation Required

Document therapy response, objective measures, and physician‑approved goals

Document the patient's response to therapy, objective functional measurements at defined intervals, the need for therapist skills (including special complications), and the course and goals of therapy approved by the physician.

Documentation Required

Order and document home health aide frequency, tasks, and competency in POC

Physician or allowed practitioner orders for home health aide services should indicate frequency and the plan of care must delineate specific tasks and certify aide competency as required; aide services must be part‑time or intermittent to be covered.

Billing Rule

Ensure physician orders and POC identify nonroutine supplies and maintain cost documentation

Nonroutine supplies provided under a home health plan must be specifically ordered by the physician/allowed practitioner and identified in the plan of care; include these orders in the POC and maintain cost center documentation per nonroutine supply criteria.

Documentation Required

Maintain written acceptance policies and treat evaluation visits as administrative unless first skilled service provided

HHAs must have written patient acceptance policies, evaluate homebound status and feasibility for care in the home, and treat initial evaluation visits as administrative (not billable) unless the first skilled service is provided during that visit, in which case it becomes the first billable visit.

Denial Risk

Risk of cancelled claims, payment reductions, or denials from missing NOA/orders/transfer docs

Failure to timely submit NOA, to document required orders/initial visit, or to provide required transfer documentation (beneficiary notice of payment liability and contact with initial HHA) can lead to cancelled RAP/final claim, payment reductions, or denied claims.

Excluded services from 30‑day rate

Excluded services from 30‑day rateDurable medical equipment (DME), certain injectable osteoporosis drugs, and negative pressure wound therapy using a disposable device (dNPWT) are excluded from the 30‑day payment rate and billed separately by the HHA

Billing responsibilityAlthough excluded from the base 30‑day rate, certain items (e.g., covered osteoporosis drugs and dNPWT) must be billed by the HHA under consolidated billing instructions

DME paymentDME (including DME supplies) is paid separately under the DME fee schedule or competitive bidding program and excluded from consolidated billing

LUPA (definition)

LUPA — definitionLow Utilization Payment Adjustment (LUPA): payment group‑specific low‑visit adjustment using the 10th percentile of visits (min 2 visits) that converts the period to wage‑adjusted per‑visit payments

When LUPA appliesApplies when visits in a 30‑day period are less than the payment group‑specific LUPA threshold

Per‑visit paymentNational per‑visit amounts by discipline are used, wage‑adjusted by site of service; annual updates published

Partial Payment Adjustment

Partial Payment Adjustment — definitionProportional payment applied to an original 30‑day period when an intervening event (beneficiary‑elected transfer or discharge and return warranting new assessment/certification/plan) creates a new 30‑day period

Calculation methodPartial payment = span of days (first billable visit through last billable visit under the original plan) ÷ 30, multiplied by original case‑mix and wage index

Common ownership exceptionPartial payment adjustment does not apply to transfers among HHAs of common ownership unless beneficiary moved MSA/non‑MSA during the 30‑day period before transfer

Outlier Payment

Outlier Payment — definitionAdditional payment when wage‑adjusted imputed costs for a 30‑day period exceed the outlier threshold (case‑mix & wage‑adjusted 30‑day payment plus fixed dollar loss); outlier payment equals a proportion (loss‑sharing ratio) of the difference

Calculation stepsCompute case‑mix & wage‑adjusted 30‑day payment + fixed dollar loss (outlier threshold); compute wage‑adjusted imputed cost from per‑unit national rates; outlier = loss‑sharing ratio × (imputed cost − outlier threshold)

Cap on outliersTotal outlier payments to an HHA are limited so that outliers cannot exceed 10% of the HHA's total home health payments

Consolidated Billing / HH PPS

Consolidated Billing / HH PPS — definitionConsolidated billing bundles enumerated home health services and medical supplies into the HH PPS 30‑day base payment; HHAs must provide or arrange these services and bill for them

Included itemsIncludes part‑time/intermittent skilled nursing and aide, PT, SLP, OT, medical social services, routine and nonroutine supplies, covered osteoporosis drug (per §1861(kk)), and furnishing dNPWT devices (device billed separately)

DME exclusionDME (including DME supplies) is excluded from consolidated billing and paid separately

dNPWT and injectable osteoporosis drugs payment

dNPWT payment treatmentdNPWT device is included under consolidated billing but payment for the device is separate from the HH PPS; for CY2017–2023 separate payment covered device and related billing rules, and for services on/after Jan 1, 2024, separate payment is for the device only (device payment via HCPCS A9272 on TOB 032x as specified)

Nursing/therapy servicesNursing and therapy services to apply or manage the device are paid under the HH PPS (not separately for device‑only payment after CY2024)

Historical billing distinctionWhen a visit was solely to furnish dNPWT previously, HHAs submitted TOB 34x with CPT 97607/97608; after 2024 device claims are submitted on standard HH TOB per instructions

Intermittent skilled nursing (restated)

Intermittent skilled nursing — definition (restated)Skilled nursing care provided or needed on fewer than 7 days each week or less than 8 hours each day for periods of 21 days or less (extensions allowed in exceptional finite predictable circumstances)

Medically predictable recurring needEligibility requires a medically predictable recurring need, typically at least once every 60 days; exceptions with documentation may allow different intervals

Exception for diabeticsDaily skilled nursing may be covered beyond 'short periods' for diabetics unable to self‑administer insulin when no able/willing caregiver exists

Confined to the home (homebound)

Confined to the home (homebound) — definitionPatient is considered homebound if criterion one (needs supportive devices/special transportation/assistance to leave home or leaving is medically contraindicated) AND criterion two (normal inability to leave home and leaving requires considerable and taxing effort) are met

Allowed absencesAbsences for receiving health care treatment, therapeutic programs, or infrequent short nonmedical outings do not negate homebound status

Documentation guidanceClinicians should document longitudinal clinical information (diagnosis, duration, course, prognosis, functional limitations) to support homebound status

Qualifying skilled services

Qualifying services — listQualified skilled services include skilled nursing (not solely venipuncture), physical therapy, speech‑language pathology, and continued occupational therapy under defined conditions

Certification attestationPhysician or allowed practitioner must certify that services are needed because patient is or was homebound and needs intermittent skilled nursing, PT, or SLP (or continued OT), and must document plan of care

Venipuncture limitationVenipuncture cannot be the sole basis for eligibility; it may be covered when another qualifying skilled need exists

Face‑to‑face encounter (definition)

Face‑to‑face encounter — timeframe (definition)Face‑to‑face encounter must occur no more than 90 days prior to SOC or within 30 days after SOC, be related to primary reason for home health, and be performed by a physician or NPP; date must be documented

Provider documentationCertifying provider must document the date of the encounter and supporting clinical note in the medical record as evidence of the encounter

Repeat encounter when condition changesIf condition changed since a visit within prior 90 days, another encounter is required within 30 days after admission

Part‑time or intermittent (definition)

Part‑time or intermittent — definitionSkilled nursing and home health aide services furnished less than 8 hours each day and 28 or fewer hours each week (or, subject to case‑by‑case review, less than 8 hours/day and up to 35 hours/week)

ApplicationDefinition used to determine coverage under §1861(m) and in §50.7 for part‑time/intermittent services

Combined hours considerationHours are combined across disciplines when assessing part‑time/intermittent status

Certification / Recertification

Certification / Recertification — definitionPhysician or allowed practitioner attestation that patient is homebound, needs skilled services, has a plan of care, and is under the care of a physician; initial certification at Start of Care and recertification at end of each 60‑day episode

Recertification intervalPlan of care must be reviewed and signed by physician or allowed practitioner at least every 60 days unless transfer or discharge/return occurs

Certification elementsCertification must state confinement, skilled need, plan of care established and reviewed, services furnished while under physician care, and face‑to‑face encounter within timeframe

Skilled observation and assessment

Skilled observation & assessment — definitionNursing assessment where there is a reasonable potential for change requiring skilled personnel to identify and evaluate need for modification of treatment or initiation of procedures until stabilization; covered for about 3 weeks if no complication but may continue with documentation

Justifying signsSigns that may justify observation include abnormal/fluctuating vitals, weight changes, edema, drug toxicity signs, abnormal labs, or respiratory changes

Documentation requirementHome health record must document rationale showing reasonable potential for future complication to justify continued observation beyond ~3 weeks

Management & evaluation of the patient care plan

Management & evaluation of care plan — definitionSkilled nursing activities to ensure essential unskilled care achieves its purpose when complexity requires RN involvement to promote recovery and medical safety

Documentation needMedical record must describe complexity of unskilled services and why RN involvement is necessary

ExamplesUsed when unskilled tasks are complex or interrelated such that only an RN can ensure safe/effective care

Management and evaluation (RN)

Management and evaluation — RN roleSkilled nursing to ensure unskilled care is achieving its purpose when complexity of unskilled services necessitates RN involvement

When requiredRequired where underlying conditions or complications make RN oversight necessary for patient safety and recovery

Documentation supportPlan of care and medical record must explain why RN management is clinically necessary

Teaching and training

Teaching & training — definitionServices where the skill required is the ability to teach/retrain patients or caregivers and are reasonable and necessary to treat the illness/injury; teaching is skilled when nurse skill is required to instruct safely and effectively

Scope examplesIncludes teaching self‑injection, diabetes management, wound care, ostomy care, enteral feeding, catheter care, adaptive ADL techniques, prosthesis/braces care, medication regimen instruction

LimitsIf patient/family cannot be trained further or is already competent, further teaching is not reasonable and necessary; reasons should be documented

Skilled nursing wound care

Skilled nursing wound care — definitionCare of wounds when licensed nurse skills are needed to safely and effectively treat the wound; decision based on documented wound size, depth, drainage, and surrounding skin condition

When skilled care usually neededOpen wounds with purulent/colored exudate or foul odor, drains, irrigation/packing needs, recently debrided ulcers, infected/complicated pressure sores, exposed vessels, post‑radiation or immune/vascular issues, post‑op complications, third‑degree burns

Documentation requirementPlan of care must contain specific instructions and clinical findings to support skilled wound care at each visit

Venipuncture limitation

Venipuncture limitationVenipuncture cannot be the sole skilled service justifying home health eligibility after February 5, 1998; may be covered when another qualifying skilled need exists

Conditions for coverageOrder must be associated with a specific symptom/diagnosis; frequency consistent with accepted standards; record must document rationale and results

ExamplesMonitoring captopril or phenytoin every 3 months when stable; prothrombin monitoring monthly when adjusting dosage; diabetic monitoring per stability status

Intermittent skilled nursing (concise)

Intermittent skilled nursing — concise definitionSkilled nursing care provided or needed on fewer than 7 days each week, or less than 8 hours each day for periods of 21 days or less (extensions in exceptional finite predictable circumstances)

Typical expectationPatient should have a medically predictable recurring need, generally at least once every 60 days

Coverage implicationDefinition determines eligibility for home health services under §§1814/1835 and relates to payment rules

Skilled therapy service

Skilled therapy service — definitionA therapy service that can be performed safely/effectively only by or under general supervision of a qualified therapist and is reasonable and necessary to treat or restore/maintain function

When maintenance coveredMaintenance therapy covered if the complexity/special complications require therapist skills to perform safely or to design/reevaluate the maintenance program

Assessment requirementQualified therapist must perform initial assessment and periodic reassessments with objective measures

Skilled physical therapy / maintenance therapy

Skilled PT / maintenance therapyRange of motion testing and treatments by a qualified PT are skilled; ROM exercises are skilled only when part of active restorative treatment or when special medical complications require therapist skills

Unskilled ROM exclusionPassive ROM to maintain function in paralyzed extremities that can be done by unskilled persons is not skilled therapy

Maintenance ruleMaintenance therapy is covered only if therapist skills are required due to complexity or medical complications

Personal care definition

Personal care — definitionBathing, dressing, grooming, hair/nail/oral hygiene, feeding, assistance with elimination (including enemas unless nurse skills required), routine catheter/colostomy care, ambulation assistance, repositioning and transfers as needed to facilitate treatment or prevent deterioration

Aide incidental tasksHome health aide may perform incidental household tasks during a visit but primary purpose cannot be non‑health household tasks

Homebound & plan relationPersonal care services must be ordered in the plan of care and are subject to state law allowances

Home health aide services

Home health aide services — definitionHands‑on personal care and services needed to maintain the patient's health or facilitate treatment, permitted under State law and provided part‑time or intermittent per plan of care

Order & competencyPhysician or allowed practitioner order should indicate frequency; plan of care must delineate tasks and certify aide competency as required

Incidental household tasksIncidental household tasks may be performed but cannot be the primary purpose of a home health aide visit

Routine & nonroutine supplies

Routine supplies — definitionSupplies customarily used in small quantities during most home care visits; included in per‑visit/30‑day payment and generally not reportable

Nonroutine supplies — definitionPatient‑specific supplies directly identifiable to an individual, charged consistently, separable cost center, furnished at practitioner's direction and specified in plan of care

Reporting conditionsAll four conditions (consistent charging, patient‑identifiable, separable cost center, ordered and identified in plan of care) must be met for nonroutine supplies to be reportable

Nonroutine supplies (reportable)

Nonroutine supplies (reportable) — criteria1) Consistent charging practice; 2) Directly identifiable to an individual patient; 3) Cost identifiable and accumulated in a separate cost center; 4) Furnished at direction of physician/allowed practitioner and specified in the plan of care (all four required)

Ordering requirementNonroutine supplies must be specifically ordered by the physician/allowed practitioner or the order for services must require their use and be identified in the plan of care

Charge exclusionCharge for nonroutine supplies is excluded from per‑visit costs when criteria are met

Applicable disposable NPWT device (dNPWT)

Applicable disposable NPWT device (dNPWT)A disposable NPWT device is an integrated system with non‑manual vacuum pump, receptacle for exudate, and dressings; device payment separate from HH PPS and billing rules differ before/after Jan 1, 2024

CY2017–2023 vs CY20242017–2023: separate payment to HHA for applicable disposable device with TOB 34x when visit solely for device; on/after Jan 1, 2024: separate payment for device only (supply price method) and device reported per updated billing instructions (A9272 on TOB 032x)

Service billing distinctionNursing/therapy services related to wound care are paid under HH PPS; where visit solely furnishes device historically billed via TOB 34x, after 2024 device payment reporting changed

Visit (definition)

Visit — definitionA visit is an episode of personal contact with the patient by HHA staff (or those under arrangements) to provide a covered home health service; each visit must be uniquely billed as a separate line item on the Medicare HH claim

Counting visitsVisits are counted each time an HHA employee or contracted provider enters the patient's home and delivers a covered service

Data useVisit data are used in formulating payment rates even though payment is per 30‑day period

Evaluation visit

Evaluation visit — definitionAn initial agency evaluation to determine patient acceptance; administrative and not billable unless the first skilled service is provided during that visit, in which case it becomes the first billable visit

Acceptance policiesHHAs must have written policies concerning patient acceptance, including assessment of homebound status and feasibility of meeting needs in home setting

Conversion to billable visitIf first skilled service is furnished during the initial evaluation, the visit becomes the first billable visit in the 30‑day period