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Home Health ADR Mock Chart Checklist Suggestions

Documentation to Support the Five Eligibility Criteria  

  • Homebound Status – No mandatory form requirement
  • Need for Skilled Services – No mandatory form requirement
    • Found anywhere in the medical record in the acute/post-acute care facility medical record documentation
  • Plan of Care – No mandatory form or format
    • Discharge Plan from the acute/post-acute care facility at the time of patient discharge that prompted referral to HH
    • Initial Plan of Care written by the referring certifying physician at the time of  his/her office visit with the patient that prompted the referral to HH
  • Physician Oversight of HH Service
    • Documentation from the acute/post-acute care facility certifying eligibility provides the name of the physician who has agreed to monitor HH services in the community at the time of referral when the certifying physician will not be providing oversight of HH services (Hospital, SNF, Inpatient Rehabilitation Center or Outpatient Surgery Center referrals).
  • Face-to-Face Encounter Documentation– No mandatory form or format
    • Discharge summary from the acute or post-acute care facility written at the time of patient discharge prompting referral to HH
    • Progress Note from the physician office written at the time of the patient one on one visit with the physician in the office prompting referral to HH
    • Mandatory narrative regarding skilled oversight of unskilled care (when ordered)
    • **A nonphysician practitioner may complete and sign the FTF encounter without a counter signature
    • Certification – of Eligibility Criteria 

      Required for all new SOCs - No mandatory form or format

      • Statement from the certifying physician acknowledging all five eligibility criteria (as above) have been met
      • Dated Signature below the statement  from a Medicare enrolled physician
      • **Certification cannot be completed/signed by an NPP

      Recertification – of Initial Eligibility Criteria  

      By the community physician. No mandatory form or format

      • All above documentation regarding initial eligibility criteria
      • Date of FTF Encounter at the time of initial certification
      • Physician estimate regarding how much longer skilled services may be required
      • Statement from the community physician that is overseeing HH services acknowledging that all five eligibility criteria (as above) continue to be met
      • Dated signature below the statement from a Medicare enrolled physician
      • Mandatory narrative regarding skilled oversight of unskilled care (when ordered)
      • **Recertification cannot be signed by an NPP

      Order/Referral for Home Health Services

      • Written and signed by the certifying and/or referring physician
      • For the patients current diagnosis (as witnessed during the time of the FTF encounter visit with the doctor)
      • All pages are for the appropriate patient
      • Proof of PECOS Validation for all physicians involved in the patient’s care for all dates of service in the episode
      • Appropriate OASIS submission
      • Any and all therapy evaluations and reevaluations where applicable
      • The patients name is on each page (front and back where appropriate)
      • The correct dates of service for the claimed episode
      • Dates and signatures are clear and appropriate
      • Legibility of all handwritten documentation
      • Identifiable credentials for each clinician signature
        • Signature sheets as appropriate from agency and referring facility/office
      • Accuracy of documentation
      • All staples, paperclips, binder clips, sticky notes, rubber bands, etc. are removed prior to submission
      • Pages are not folded over, cut off or crinkled during copying/printing/faxing
      • Highlighter is not utilized
      • ADR is placed on the top of the medical record
      • Reminder: black ink copies best
      • Provider contact name and telephone number

      Tip: Documentation from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.

      • Information from the HHA can be incorporated into the certifying referring physician’s and/or the community physician’s medical record for the patient.
      • The certifying physician must review and sign any documentation incorporated into the patient’s medical record that is used to support the certification.
      • If this documentation is to be used for verification of the eligibility criteria, it must be dated prior to submission of the claim.
Home Health ADR Mock Chart Checklist Suggestions
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