How does Medicare Determine Whether Your Patient Qualifies for Home Health Service Coverage?

Under section 1814(a)(2)(C) and section 1835(a(2)(A) of the Medicare home health benefit, there are several requirements a patient must meet to be considered for coverage of Home Health Services.

The patient must be confined to the home;

Under a physician’s care;

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.

“Intermittent means skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite or predictable”

Patients must meet EACH of the criteria specified in this section and, once criteria has been met, payment can be made on their behalf.

Next week, you will learn what criteria is required for a patient to be considered “confined to the home.”

Section 30, Medicare Benefits Policy Manual.

Look for the next coding scenario soon!



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