01-119 Home Health Second Certification Period Findings of Medical Review
Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare home health Part A, billed with dates of service January 1, 2022, through December 31, 2022. Below are the review results:
| Project ID | Project Title | Error Rate for Reviewed Claims | No Response to ADR Denials |
|---|---|---|---|
| 01-119 | Home Health Second Certification Period | 86% | 17% |
Background
The Bipartisan Budget Act of 2018 (BBA of 2018) Title X, §51001 Home Health Payment Reform, outlined requirements for home health payment reform to eliminate use of therapy thresholds effective January 1, 2020. The requirements included patient-focused factors to account for individual beneficiary needs for self-care, quality of care, and resource utilization. The Patient-Driven Groupings Model (PDGM) was a result of the mandated home health payment reform. Units of payment were changed from a 60-day unit of payment to a 30-day unit of payment. The 30-day payment is adjusted to meet the above requirements and further includes patient characteristics, principal diagnosis, secondary diagnoses, and functional impairment level. Occupational Therapy (OT), Physical Therapy (PT), and Speech Language Pathology (SLP), should be determined by the individual needs of the beneficiary without limitations or restrictions.
Reason for Review
The SMRC was tasked to perform data analysis and medical review activities on home health services within the second certification period. The dates of service under review for this project were January 1, 2022, through December 31, 2022.
The SMRC conducted medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, and sub-regulatory guidance.
Common Reasons for Denial
- Invalid Physician Certification
- The initial physician’s certification was invalid due to missing key elements such as homebound status, a physician established and periodically reviewed Plan of Care, and a face-to-face encounter. Per Internet Only Manual (IOM), Publication (Pub.) 100-08, Medicare Program Integrity Manual (MPIM), Chapter (Ch.) 6, §§6.2.2.1 and 6.2.2, if required elements are missing from the initial certification, then all subsequent episodes will be denied.
- Services Not Being Reasonable and Necessary
- Documentation submitted does not support skilled nursing services are reasonable and necessary. Refer to CMS IOM Pub. 100-02, Ch. 7, §40.1, and 42 CFR 409.44(b). The documentation submitted did not support that the hands-on care required the skills of a nurse and could have been performed by the caregiver safely.
- Non-Response to the ADR
- The requested records were not received. Refer to IOM Pub. 100-08, Ch. 3, §3.2.3.8, 42 CFR 424.5(a)(6) and Social Security Act (SSA) Title XVIII, §§1815(a), 1833(e), and 1862(a)(1)(A). This section this requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. The requested documentation was not submitted or not submitted timely to support reasonable and necessary criteria.
References
Social Security Act (SSA) Title XI
- §1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA) Title XVIII
- §1814 (a)(2)(C), (a)(7) Conditions of and Limitations on Payment for Services
- §1815(a) Providers Must Furnish Information
- §1833(e) Payment of Benefits
- §1835(a)(2)(A) Procedure for Payment of Claims of Providers of Services
- §1861(m) Definitions of Services, Institutions, etc.
- §1862 Exclusion from Coverage and Medicare as a Secondary Payer
- §1879(a)(1) Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed
- §1895 Prospective Payment for Home Health Services
42 Code of Federal Regulations (CFR)
- §409.5 General description of benefits
- §424 Conditions for Medicare Payment
- §424.5 Basic Conditions
- §424.535 Revocation of Enrollment in the Medicare Program
- §484 Home Health Services, Subpart A General Provisions, and Subpart E Prospective Payment System for Home Health Agencies
Public Law
- Bipartisan Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title X, §51001, Home Health Payment Reform
- CMS Additional Emergency and Disaster-Related Policies and Procedures That May be Implemented Only with a SS 1135 Waiver. Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a §1135 Waiver(cms.gov)
- CMS Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers. Home Health Agencies: CMS Flexibilities to Fight COVID-19
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-136). Supporting America’s Health Care System in the Fight Against the Coronavirus
- Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. §5121. Disaster Relief and Emergency Assistance Amendments
National Coverage Determination (NCD) Institutional and Home care Patient Education Programs, Publication 100-3
- §170.1 Institutional and Home Care Patient Education Programs
Internet-Only Manual (IOM) General Information, Eligibility and Entitlement Manual Publication 100-01
- Ch. 1, §10.2 Home Health Services
- Ch. 4, §30 Certification and Recertification by Physicians and Allowed Practitioners for Home health Services
- Ch. 4, §80 Summary Table for Certifications/Recertifications
IOM Medicare Benefit Policy Manual Publication 100-02
- Ch. 7 Home Health Services
- Ch. 16, §20 Services Not Reasonable and Necessary
IOM, Medicare Claims Processing Manual, Publication 100-04
- Ch. 10 Home Health Agency Billing
- Ch. 23, §10 Reporting ICD Diagnosis and Procedure Codes
- Ch. 30, §50 Advance Beneficiary Notice of Noncoverage (ABN)
IOM, Medicare Program Integrity Manual, Publication 100-08
- Ch. 3. Verifying Potential Errors and Taking Corrective Actions
- Ch. 3, §3.3.2.4. Signature Requirements
- Ch. 6. Medicare Contractor Medical Review Guidelines for Specific Services
CMS Coding Policies
- Outcome and Assessment Information Set (OASIS)-D1 Guidance Manual. Effective January 1, 2020-current
Local Coverage Determinations (LCD)
- L33942 Physical Therapy – Home Health. Effective October 1, 2015
- L34560 Home Health Occupational Therapy. Effective October 1, 2015
- L34561 Home Health – Psychiatric Care. Effective October 1, 2015
- L34562 Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective October 1, 2015
- L34563 Home Health Speech-Language Pathology. Effective October 1, 2015
- L34564 Home Health Physical Therapy. Effective October 1, 2015
- L34565 Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective October 1, 2015
- L35132 Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus. Effective October 1, 2015
Local Coverage Articles (LCA)
- A52845 Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances – Medical Policy Article. Effective October 1, 2015
- A53050 Case Scenario 1-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
- A53051 Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
- A53052 Billing and Coding: Home Health Speech-Language Pathology. Effective October 1, 2015
- A53055 Home-Based Fall Evaluations and Interventions. Effective October 1, 2015
- A53057 Billing and Coding: Home Health Occupational Therapy. Effective October 1, 2015
- A53058 Billing and Coding: Home Health Physical Therapy. Effective October 1, 2015
- A56641 Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective July 4, 2019
- A56648 Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
- A56756 Billing and Coding: Home Health – Psychiatric Care. Effective August 1, 2019
- A57311 Billing and Coding: Physical Therapy – Home Health. Effective September 26, 2019
Other
- The Centers for Medicare & Medicaid Services (CMS). Home Health Patient-Driven Groupings Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM
- CMS. Medicare Learning Network ICN MLN20190214 February 2019. Overview of the Patient-Driven Groupings Model (PDGM). https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-02-12-PDGM-Presentation.pdf
- CMS. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model (cms.gov)
Last Updated Mar 31, 2025