Home Health Services (2021)

What is Home Health service or Home care services?

“Home health service”, “Home care”, “home health care” and “in-home care” are phrases that are used interchangeably in the United States to mean any type of care given to a person in their own home. Home health care is a wide range of health care services that can be given in the home. Home health care is usually less expensive, more convenient, and just as effective as care we get in a hospital or skilled nursing facility.

The goal of home health care is to treat an illness or injury. Home health care helps us get better, regain our independence, and become as self-sufficient as possible.

In general, home health care includes part-time or intermittent skilled nursing care, and other skilled care services like physical therapy, occupational therapy, and speech-language pathology (therapy) services. Services may also include medical social services or assistance from a home health aide. Usually, a home health care agency coordinates the services your doctor orders for you.

Examples of skilled home health services include:

* Wound care for pressure sores or a surgical wound
* Physical and occupational therapy
* Speech-language therapy
* Patient and caregiver education
* Intravenous or nutrition therapy
* Injections
* Monitoring serious illness and unstable health status

Examples of home health aide services include:

* Help with basic daily activities like getting in and out of bed, dressing, bathing, eating, and using the bathroom
* Help with light housekeeping, laundry, shopping, and cooking for the patient.

What are the Conditions to be met for Coverage of Home Health Services?

Medicare covers HHA services when the following criteria are met:

1. The person to whom the services are provided is an eligible Medicare beneficiary;

2. The HHA that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program;

3. The beneficiary qualifies for coverage of home health services

* Be confined to the home;
* Under the care of a physician;
* Receiving services under a plan of care established and periodically reviewed by a physician;
* Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
* Have a continuing need for occupational therapy.

4. The services for which payment is claimed are covered

* When the patient meets the qualifying criteria in above # 3, Medicare covers skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy.Home health coverage is not available for services furnished to a qualified patient who is no longer in need of one of the above qualifying skilled services as specified in #3.Therefore, dependent services furnished after the final qualifying skilled service are not covered under the home health benefit, except when the dependent service was followed by a qualifying skilled service as a result of the unexpected inpatient admission or death of the patient or due to some other unanticipated event.

5. Medicare is the appropriate payer; and

6. The services for which payment is claimed are not otherwise excluded from payment.

What is National 60-Day Episode Rate?

The law requires the 60-day episode to include all covered home health services, including medical supplies, paid on a reasonable cost basis. That means the 60-day episode rate includes costs for the six home health disciplines and the costs for routine and nonroutine medical supplies. The six home health disciplines included in the 60-day episode rate are:

1. Skilled nursing services

2. Home health aide services;

3. Physical therapy;

4. Speech-language pathology services;

5. Occupational therapy services; and

6. Medical social services.

What is the CPT code to bill for Home health services and what would be the actual date of service?

Initial Certification or Initial Episodes

CPT code G0180 Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period

The “From” date for the initial certification must match the start of care (SOC) date, which is the first billable visit date for the 60-day episode. The “To” date is up to and including the last day of the episode which is not the first day of the subsequent episode. The “To” date can be up to, but never exceed a total of 60 days that includes the SOC date plus 59 days.

Re-Certification or Subsequent Episodes

CPT code G0179 Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period

If a patient continues to be eligible for the home health benefit, the home health PPS permits continuous episode recertifications. At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for a subsequent 60-day episode. An eligible beneficiary who qualifies for a subsequent 60-day episode would start the subsequent 60-day episode on day 61. The “From” date for the first subsequent episode is day 61 up to including day 120. The “To” date for the subsequent episode in this example can be up to, but never exceed a total of 60 days that includes day 61 plus 59 days. The 61st day would be the date of service for Re-certification.

Please note: Home health certification or recertification visit can be done during a prior episode.

How many Home health visits are covered for an individual?

Medicare does not limit the number of continuous episode recertifications for beneficiaries who continue to be eligible for the home health benefit. That is, to the extent that all coverage requirements are met, payment may be made on behalf of eligible beneficiaries under Part B for an unlimited number of covered home health visits.

What are the Specific Exclusions from Coverage as Home Health Services?

Drugs and biologicals are excluded from payment under the Medicare home health benefit.

Reference: https://www.cms.gov/manuals/Downloads/bp102c07.pdf