Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part A Home Health billed on dates of service from January 1, 2024, through December 31, 2024. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Bipartisan Budget Act of 2018 (BBA of 2018) Title X, §51001, Home Health Payment Reform, outlined requirements for the home health payment reform to eliminate the use of therapy thresholds for case-mix adjustments 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) is the 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.

Under the PDGM, reductions in therapy utilization and reimbursement‑driven adjustments to care combinations may introduce potential vulnerabilities, particularly for home health services provided for 361 days or longer, as indicated by internal CMS data.

Reason for Review

The SMRC is tasked to perform data analysis and medical review activities on home health services within the recertification period when provided greater than or equal to 361 days; with dates of service January 1, 2024, through December 31, 2024.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

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.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

Please Note: Submit only the documentation listed below to support the Home Health start of care initial certification, the recertification for the dates of service (30-day payment periods) under review, and documentation to support Home Health services during the dates of service under review. It is not necessary to submit recertifications or documentation for other dates of service not under review.

1. Documentation to support the initial start of care certification period:
   1. Medical Record Documentation of the face-to-face (FTF) encounter and signed attestation for start of care
   2. Initial Start of Care Certification
   3. Signed and dated Initial Plan of Care for start of care including short- and long-term goals
2. Documentation to support the recertification dates of service under review:
   1. Recertification for date of service and justification for any delayed recertifications
   2. Signed and dated recertification Plan of Care for date of service; including short- and long-term goals with any updates to the plan of care
   3. Recertification FTF encounter and signed attestation for date of service to include homebound/not homebound status
   4. OASIS documentation (recertification date of service, follow-ups, and significant changes)
   5. PT/OT/SLP – Evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary to support the recertification date of service
   6. Beneficiary’s need for the level and frequency of home health services provided, including any changes during the period under review
   7. Home health skilled nursing, home health aide, or rehabilitation therapy notes including evaluation and re-evaluation, progress notes, and actual therapy minute grids to support the recertification date of service
3. Any other supporting/pertinent documentation needed to support home health services
4. Medical record documentation to support national and local requirements
5. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
6. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
7. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
8. 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
9. Please Note: The supplier or provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References

Social Security Act (SSA), Title XVIII

• 1814 (a)(2)(C) 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(a)(6) Basic Conditions

Public Law

• Bipartisan Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title X, §51001, Home Health Payment Reform. Retrieved from https://www.congress.gov/115/plaws/publ123/PLAW-115publ123.pdf
• Coronavirus Aid, Relief, and Economic Security (CARES) Act effective March 27, 2020. Retrieved from https://www.congress.gov/bill/116th-congress/house-bill/748/text

Internet-Only Manual (IOM), Publication (Pub.) 100-03, Medicare National Coverage Determination Manual (NCD)

• Chapter (Ch. 1), Part 3, § 170 Institutional and Home Care Patient Education Program
• Ch. 1, Part 4, §240.7 Postural Drainage Procedure and Pulmonary Exercise
• Ch. 1, Part 4, §290.1 Home Health Visits to a Blind Diabetic
• Ch. 1, Part 4, §290.2 Home Health Nurses’ Visits to Patients Requiring Heparin Injection

IOM, Pub. 100-01, General Information, Eligibility and Entitlement Manual

• 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, Pub. 100-02, Medicare Benefit Policy Manual (MBPM)

• Ch. 7 Home Health Services
• Ch. 16, § 20 Services Not Reasonable and Necessary

IOM, Pub.100-04, Medicare Claims Processing Manual (MCPM)

• Ch. 10 Home Health Agency Billing
• Ch. 23, § 10 Reporting ICD Diagnosis and Procedure Codes
• Ch. 30, § § 40, 50 Advance Beneficiary Notice of Noncoverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3. Verifying Potential Errors and Taking Corrective Actions
• Ch. 6. Medicare Contractor Medical Review Guidelines for Specific Services

CMS Coding Policies

• Outcome and Assessment Information Set OASIS-E Manual. Effective January 1, 2023-December 31, 2024

Local Coverage Determination (LCD)

• L33942 Physical Therapy – Home Health
• L34560 Home Health Occupational Therapy
• L34561 Home Health – Psychiatric Care
• L34562 Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances
• L34563 Home Health Speech-Language Pathology
• L34564 Home Health Physical Therapy
• L34565 Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia
• L35132 Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus

Local Coverage Article (LCA)

• A52845 Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances – Medical Policy Article
• A53050 Case Scenario 1-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease
• A53051 Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease
• A53052 Billing and Coding: Home Health Speech-Language Pathology
• A53055 Home-Based Fall Evaluations and Interventions
• A53057 Billing and Coding: Home Health Occupational Therapy
• A53058 Billing and Coding: Home Health Physical Therapy
• A56641 Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances
• A56648 Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia
• A56674 Billing and Coding: Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus
• A56756 Billing and Coding: Home Health – Psychiatric Care
• A57311 Billing and Coding: Physical Therapy – Home Health

Other

• The Centers for Medicare & Medicaid Services (CMS). Home Health Patient-Driven Groupings Model. Effective January 1, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM
• Overview of Patient-Driven Groupings Model (PDGM) – effective January 1, 2020. https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-02-12-PDGM-Presentation.pdf
• 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 .

Last Updated Apr 6, 2026