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Checklist: Home health referrals

The orders / referrals for home health services, as well as documentation to support a patient's homebound status, their need for skilled-service level of care and any face-to-face encounter with the patient must all be documented appropriately. This checklist is being provided as a tool to assist providers when responding to medical record documentation requests. It is the responsibility of the provider of services to ensure the correct submission of all required documentation.

Providers should refer to the CMS official guidelines in the Medicare Benefit Policy Manual, Chapter 7 -- Home Health Services as well as the Medicare Learning Network (MLN) Matters article SE 1436 -- Certifying Patients for the Medicare Home Health Benefit.

The following information should be properly documented in the patient's medical record and shared with the home health agency.

Check Documentation description
 

An order for home health services must indicate:

  • The type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services
  • Frequency of the services
 

The following two criteria must be met in the medical record documentation to support a homebound status.

Criteria one:

  • The type of support and/or supportive device or assistance required for the patient in leaving the home; or
  • The condition, such that leaving his or her home is medically contraindicated (e.g., a mental or psychological illness)

Criteria two:

  • Explain the patient’s normal inability to leave home; and define the taxing effort considering these areas:
    • Patient’s diagnosis
    • Duration of patient’s condition
    • Clinical course (e.g., worsening or improving)
    • Prognosis
    • Nature and extent of functional limitations
    • Other therapeutic interventions, results, etc.
    • Pain medications the patient may be taking
    • Rest periods needed
    • Oxygen needs
    • Continence issues
    • Confusion
    • Safety concerns
    • Other accommodations necessary for the patient to leave the home
 

Medical record documentation must also support the need for skilled level services. The medical record must disclose: 

  • Clinical information, that is individual and specific to the patient, describing services to be provided in the home:
    • Beyond a list of recent diagnoses, injury, procedure or codes
  • Why a skilled professional is necessary to the patient's care

Note: If care could be safely and effectively performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit.
 

Face-to-face encounter documentation the medical record must contain:

  • Progress notes written at the time of the patient one-on-one visit with the physician, nurse practitioner, physician’s assistant, 
  • certified nurse specialist or certified midwife; or
  • A discharge summary from the acute / post-acute facility if the patient is directly discharged with home health services
  • Documentation encounter occurred 90 days prior or 30 days after the start of care
  • Documentation to show encounter is related to the same reason the beneficiary needs home health services

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.