Home Health ADR Mock Chart Checklist Suggestions:

Documentation to Support the Five Home Health Eligibility Criteria

1.  Homebound Status: No mandatory form or format requirement
   • Found anywhere in the medical record from the referring physician or NPP office or the acute/post-acute care facility record documentation
   • Documentation that supports the definition of “confined to the home” as per CMS regulations (CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30)
2. Need for Skilled Services:  No mandatory form or format requirement
   • Found anywhere in the medical record from the referring physician/NPP office or the acute/post-acute care facility medical record documentation
3. Plan of Care:  No mandatory form or format requirement
   • Discharge plan from the acute/post-acute care facility at the time of the patient discharge prompting referral to home health
   • Initial plan of care written by the referring certifying physician/NPP at the time of the patient’s office visit that prompted the referral to home health
4.  Physician/NPP Oversight
   • Documentation from the acute/post-acute care facility certifying patient eligibility must provide the name of the physician or NPP who agrees to monitor home health services in the community at the time of the referral when/if the certifying physician or NPP will not be providing oversight of home health services (hospital, SNF, IRFs or outpatient surgery center referrals).
   • NPPs may complete and sign certification without physician counter signature
5.  Face-to-face Encounter Documentation:  No mandatory form or format requirement
   • Discharge summary from the acute or post-acute care facility written at the time of patient discharge prompting referral to home health services
   • Progress note from the physician/NPP office at the time of the patient one on one visit with the physician or NPP in the office prompting referral to home health services
   • Mandatory narrative regarding skilled oversight of unskilled care (when ordered)
   • NPPs may complete and sign the face-to-face encounter without physician counter signature

Certification of Eligibility Criteria

• Required for all new start of care admissions
• No mandatory form or format requirement
• Statement from the certifying physician/NPP acknowledging all five eligibility (above) criteria have been met
• Dated signature below the statement from a Medicare enrolled Physician/NPP

Recertification of Eligibility Criteria

• Completed by the community physician that has been monitoring home health services
• No mandatory form or format requirement
• All above documentation regarding initial eligibility criteria must be included
• Date of the face-to-face encounter at the time of the initial certification
• Statement from the community physician/NPP that is overseeing home health services acknowledging that all five of the eligibility criteria (above) continue to be met
• Date signature below the statement from a Medicare enrolled physician/NPP
• Mandatory narrative regarding skilled oversight of unskilled care (when ordered)

Order/Referral for Home Health Services

• Written and signed by the certifying and/or referring physician/NPP
• Must be for the patient’s current diagnosis as witness during the time of the face-to-face encounter visit with the doctor or NPP

Medical Record Documentation

• All pages must be for the appropriate patient
• Must include proof of PECOS validation for all physician/NPPs involved in the patient’s care for all dates of service in the episode
• Must have an appropriate OASIS submission
• Any and all therapy evaluations and reevaluations must be included (as applicable)
• The patient’s name must be included on each page (front and back where applicable)
• The records submitted must be for correct dates of service for the claimed episode
• Dates and signatures must be clear and appropriate
• Hand written documentation must be legible
• Must include identifiable credentials for each clinician signature
• Signature sheets (as appropriate) from agency and referring facility/office must be included
• Documentation must be accurate
• All staples, paperclips, binder clips, sticky notes, rubber bands, etc. must be removed prior to submission
• Pages must not be folded over, cut off or crinkled during copying/printing/faxing
• Highlighter must not be utilized
• ADR must be placed on the top of the medical record
• Provider contact name and telephone number must be included

Reminders

• Black ink copies best
• Documentation from the home health agency must be corroborated by other medical record entries and align with the time period in which services were rendered
• Information from the home health agency can be incorporated into the certifying referring physician/NPP and/or community physician/NPP medical record for the patient
• The certifying physician/NPP must review and sign any documentation incorporated into the patient’s medical record that is used to support the certification
• If this documentation is used for verification of the eligibility criteria, it must be dated prior to submission of the claim