Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review of claims for Medicare home health services billed on dates of service from January 1, 2020, through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers may wish to consult when submitting claims.

Background

The Bipartisan Budget Act of 2018 (BBA of 2018) included several requirements for home health payment reform, effective January 1, 2020. The mandated home health payment reform resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM is designed to emphasize clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.

Under the PDGM, the national, standardized 30-day payment amount is adjusted to account for patient characteristics and other information, including the principal diagnosis, secondary diagnoses, and functional impairment level. The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. Under the new PDGM, a possible drop in therapy utilization and/ or the manipulation of other combinations of care to maximize payments could create potential vulnerabilities.

Reason for Review

The SMRC is tasked with performing claim review on a sample of home health claims from January 1, 2020, through December 31, 2020. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance. Applicable waivers and flexibilities established during the PHE will be utilized during claim review activities.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References/Resources

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

• Acute/post-acute care documentation to support home health eligibility
• Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
• History and Physical reports (include medical history and current list of medications)
• Documentation of all face-to-face (FTF) encounters from start of care
• Copy of physician’s or authorized non-physician provider’s order or referral for home health services if separate from plan of care
• Signed Consent Form
• Home Health start of care assessment
• All Physician or authorized non-physician provider’s orders, including medications and any DME prescribed for the beneficiary
• Initial certification and all re-certifications from start of care
• Homebound/not homebound status
• OASIS documentation (certifications, recertifications, follow-ups and significant change).
• Listing of most current beneficiary medications 
• Signed and dated overall plan of care including, short- and long-term goals with any updates to the plan of care
• Home Health Plan of Care
• PT/OT/SLP – Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
• Home Health skilled nursing, home health aide, or rehabilitation therapy notes including initial evaluations, re-evaluations, progress notes, and actual therapy minute grids
• Any other supporting/pertinent documentation
• Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
• Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
• Advance Beneficiary Notice of Liability (ABN); if applicable
• If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
• PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

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.

Public Laws

• Bipartisan Budget Act (BBA) 2018 (Pub. L. 115-123)
• 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

Code of Federal Regulations (CFR) Title 42

• § 409. Hospital Insurance Benefits.
• § 424. Conditions for Medicare Payment.
• § 424.516(f). Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment Status in the Medicare Program.
• § 424.535. Revocation of Enrollment in the Medicare Program.
• § 484. Home Health Services, Subpart A General Provisions, Subpart B. Patient Care, Subpart C. Organizational Environment, and Subpart E. Prospective Payment System for Home Health Agencies.

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. Form CMS-R-131 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 Feb 2, 2023