Home Health Services Covered By Original Medicare
If youre eligible for Medicare-covered home health care, services covered may include:4
- Part-time or intermittent skilled nursing care
- Physical therapy
- Part-time or intermittent home health aide services
- Injectable osteoporosis drugs for women
Note: Medicare will not pay for 24-hour-a-day care or meals delivered to your home. It also wont cover homemaker, custodial or personal care if thats the only care you need.5
Additional Medicare Payment For Home Health Content
Beginning in January 2022, payment for Medicare Part B services provided by PTAs will be reduced by 15% due to a provision in the Balanced Budget Act of 2018.
This podcast provides an advocacy update focusing on the 2022 Medicare Physician Fee Schedule proposed rules. Where we areand what needs to happen next.
Get updates on the proposed Medicare physician fee schedule, what were doing to #FightTheCut, and how you can help.
The proposed 2022 Medicare Physician Fee Schedule rule includes deep cuts to critical services provided by dozens of health care providers, including PTs and PTAs.
As the U.S. health care system continues to struggle with a pandemic and its fallout, CMS keeps IRF payment changes relatively minimal.
Use this guide to help you identify when you must apply the CQ modifier, which we updated in March 2021 to reflect new details from CMS.
Time is up on the moratorium on recoupment for funds received through the Accelerated & Advance Payment program.
What Does Homebound Mean
If a practice is considering seeing patients in their home instead of the clinic then you must be sure the patient meets the definition of homebound.
According to Medicare patients must meet the following criteria to be considered homebound:
Criterion One: The patient must either: – due to their illness or injury, need to use crutches, canes, wheelchairs, and walkers or special transportation or the assistance of another person in order to leave their place of residence.OR
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Split Percentage Payments And Requests For Anticipated Payments
Except for low utilization home health agencies, providers must submit an initial claim, also called a Request for Anticipated Payment or “no-pay RAP,” for periods of care on or after Jan. 1, 2021. This establishes the home health period of care and is required every 30 days thereafter.
For periods of care on or after Jan. 1, 2021, the upfront split percentage payment on an initial RAP claim is 0%.
For periods of care prior to Jan. 1, 2021:
- HHAs participating in Medicare prior to Jan. 1, 2019 will continue to receive RAP payments. The upfront split percentage payment will be 20% on a RAP and 80% on a final claim.
- HHAs who began participating in Medicare on or after Jan. 1, 2019 will receive an entire payment with the final claim.
- HHAs with low utilization will be paid a standardized per visit payment instead of payment for a 30-day period of care.
Note: Claims recoupment will be initiated if a final claim is not received within 90 days of the statement From date or 60 days from the Paid date of the RAP.
A Home Health Agency Is An Agency Or Organization Which:
- Is primarily engaged in providing skilled nursing services and other therapeutic services Has policies established by a group of professionals , including one or more physicians and one or more registered professional nurses, to govern the services which it provides
- Provides for supervision of above-mentioned services by a physician or registered professional nurse
- Maintains clinical records on all patients
- Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality
- Has in effect an overall plan and budget for institutional planning
- Meets the federal requirements in the interest of the health and safety of individuals who are furnished services by the HHA and
- Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program.
For purposes of Part A home health services under Title XVIII of the Social Security Act, the term home health agency does not include any agency or organization which is primarily for the care and treatment of mental diseases.
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Range Of Home Health Benefits
Medicare does not cover:
- 24-hour care at home
- Custodial or personal care when this is the only home care you need.
- Household services such as shopping, cleaning and laundry when they are not related to your care plan.
- Meal delivery to your home
Medicares website has a search and comparison tool to help you find certified home health agencies in your area. If you have original Medicare, Parts A and B, you can choose any approved agency.
If you have a Medicare Advantage plan from a private insurance company, you may have to use an agency that the plan works with. Before you start receiving care, the agency should let you know, verbally and in writing, whether some of the services they provide are not covered by Medicare and what you would pay for them.
Editor’s note: This article was originally published on Jan. 1, 2014. It has been updated with the latest information regarding Medicare coverage in 2020.
Billing And Coding For Physician Home Visits
Physician home visits have begun making a comeback, according to a recent report from the Association of American Medical Colleges . With 80% of U.S. adults age 65+ having one or more chronic diseases, this is a welcome development. Point of care testing along with advancements in home health technology and support have improved the physicians ability to cater to the needs of older weak patients with multiple comorbidities outside the office setting. Outsourcing medical coding can ensure accurate claim submission for optimal reimbursement for services provided. However, to qualify for coverage, the medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. The Office of Inspector General and several CMS contractors scrutinize physician home services billed to the Medicare program to ensure that house callsare medically necessary and not for the convenience of the patient, the patients family, or the physician .
Physician Home Visits must be Medically Necessary
Medicare.gov defines medically necessary as health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
CPT codes 99341 through 99350, Home Services codes, are used to report E/M services provided to a patient residing in his or her own private residence and not any type of facility. According to a 2017 AAPC report:
Codes for New Patients
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Medicare Medicaid And Billing
Like billing to a private third-party payer, billers must send claims to Medicare and Medicaid. These claims are very similar to the claims youd send to a private third-party payer, with a few notable exceptions.
Since these two government programs are high-volume payers, billers send claims directly to Medicare and Medicaid. That means billers do not need to go through a clearinghouse for these claims, and it also means that the onus for clean claims is on the biller.
Add Supporting Documents To Your Claim
As its unusual for beneficiaries to file their own claims, you should explain to Medicare why youre taking this action. This could be for any of the reasons discussed above.
In addition, you should include any documents that can support your claim. These supporting documents could include referrals to specialists and details of your medical history.
You may also need to complete an Authorization to Disclose Personal Health Information form. You should do this if:
- You want someone, such as a spouse or parent, to call the Medicare hotline about your claim on your behalf
- You want Medicare to reveal personal information about yourself and your claim to someone else
Unlike other forms involved in filing a Medicare claim, the Authorization to Disclose Personal Health Information form should be completed and submitted online.
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Medicare Part B Coverage For Home Health Pt
Most outpatient physical therapists think about home health services rehab as happening to patients prior coming into their clinic. However, Medicare patients are eligible for coverage of home health rehab services provided by private practices in the patients home as well. Medicare defines a home in the normal sense of an house, condo or apartment but also as any institution other than a hospital, Critical Access Hospital or SNF.
During challenging times, every option should be considered for the benefit of the patient and for the practice. Providing care in patients homes has its own challenges and benefits.
In this article we will explore eligibility requirements and the processes to see a patient and get paid by Medicare B. In this challenging pandemic period this may be an avenue for some patients to continue to receive rehabilitation care.
How To Bill Medicare For Home Health Services
This article was co-authored by Michael R. Lewis. Michael R. Lewis is a retired corporate executive, entrepreneur, and investment advisor in Texas. He has over 40 years of experience in business and finance, including as a Vice President for Blue Cross Blue Shield of Texas. He has a BBA in Industrial Management from the University of Texas at Austin.There are 9 references cited in this article, which can be found at the bottom of the page. This article has been viewed 36,295 times.
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What You Pay For Home Health Services
All eligible Medicare recipients pay the following for home health services:6
- $0 for home health services
- 20% of the Medicare-approved amount for durable medical equipment like a walker, wheelchair or hospital bed
Before home health care begins, your home health agency should explain your bill. This includes what Medicare will cover, what Medicare wont cover and how much youll owe . The details of what isnt covered by Medicare must be given to you in an Advance Beneficiary Notice before you receive any uncovered items or services.7
Submit Tps And Par Reports By Dec 31
HHAs that provide services in the above-listed states must submit TPS and PAR reports to the appropriate TRICARE contractor by Dec. 31 each year in order to avoid financial penalty.
Please submit your reports to us using the Upload a Document on our website or via postal mail or fax:
TRICARE West PDM Correspondence
Whos Eligible For Home Health Services
If you have Original Medicare , you may be eligible if:2
Note: If you need full-time skilled nursing care for a long time, its unlikely that youll be eligible for home health care services.3
Qualifying For The Home Health Benefit
The Part A home health benefit is paid in 60-day episodes and includes speech-language pathology, physical therapy, occupational therapy, skilled nursing, home health aide, and/or medical social services. The agency is responsible for providing all of the services a patient requires. If a Medicare beneficiary requires fewer than four visits during the 60-day episode, the home health agency will receive a lower payment, known as a low utilization payment , to reflect the lower cost of the short episode.
A critical factor in qualifying for a Part A episode of home health services is a physicians determination that the patient is confined to the home, or homebound. This means the patient has
- an illness or injury and requires the aid of supportive devices, special transportation, or the assistance of another person to leave their residence or
- a condition that requires the person to stay in the home and
- an inability to leave the home or leaving requires considerable and taxing effort.
A patient that is certified as “homebound” may still leave the home for specific reasons, such as attending religious services or going to medical appointments.
Additional requirements to qualify for a Part A episode for home health services are
- a face-to-face physician visit with the patient and
- a plan of care established by the certifying physician and
- a need for skilled nursing on an intermittent basis or
- a need for physical therapy or
- a need for speech-language pathology services.
Changes To The Home Health Payment System
Public and private health insurers, including Medicare, are moving toward alternative payment models in an effort to reduce costs and improve the quality of patient care. APMs are alternatives to traditional fee-for-service payment. Under APMs, all health care providersincluding audiologists and SLPsare held accountable for the increased quality and lower costs of the care they provide. CMS is shifting the HH PPS to an alternative payment model, as outlined below.
Patient-Driven Grouping Model
In 2018, CMS finalized a major overhaul to the HH PPS to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. This revised payment methodologythe Patient-Driven Grouping Model is driven by the patients clinical characteristics rather than amount or types of services provided. The PDGM was effective
Additionally, Congress mandated that therapy be removed as a determinant of payment and that the current 60-day episodes be split into 30-day payment periods. This obligates CMS to implement two of the key elements of the PDGM, also by 2020. Despite the removal of therapy as a factor in payment, CMS has issued detailed guidance stressing the value of therapy as part of the new payment system.
In addition to these Congressional mandates, key provisions of the final rule include:
What can I expect?
How can I respond?
To Qualify For Home Health Care Under Medicare Three Requirements Must Be Met:
The patient must be:
1) confined to his/her home
2) in need of skilled services, AND
3) be under the care of a physician & recommended for home health care by a physician
This article explains, in detail, what actions Medicare considers sufficient to meet each of these three requirements. This is a useful guide for both patients and clinicians looking to develop a firm understanding of the insurance coverage requirements for home health billing.
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Determining Eligibility For Home Health Care
The Patient Must Be In Need Of Skilled Services
Either Skilled Nursing Care or Therapy Services
Skilled Services that Qualify for Home Health Care:
- Intermittent Skilled Nursing Care
- care needed less than 7 days per week, for less than 8 hours per day
- Therapy Service Requirements:
- Services must be reasonable and necessary to treat the patients illness or injury.
- Services do not need to result in a cure or even an improvement. Services simply need to slow down the worsening of the patients condition.
- Services must require a skilled professional. Thus the services must be:
- inherently complex, meaning the effectiveness and safety of the treatment requires the supervision of a skilled therapist
- consistent with the nature and severity of the condition
- reasonable in amount
- specific, safe, and effective under accepted standards of treatment for the patients condition
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How To File Medicare Claims Step
Most Americans never need to file a Medicare claim. Usually, Medicare providers send claims directly to Medicare so their members dont need to do a thing. However, in some rare cases, people in Original Medicare may need to file their own claims. Follow these steps to make sure you file yours correctly.