100-02 Medicare Benefit Policy Manual: Chapter 7 - Home Health Services

Medicare Benefit Policy Manual
Chapter 7 - Home Health Services
Table of Contents
(Rev. 12382; Issued: 11-28-23)
(Rev. 12425 Issued: 12-21-23)
Transmittals for Chapter 7
10 - Home Health Prospective Payment System (HH PPS)
10.1 - National 30-Day Period Payment Rate
10.2 - Adjustments to the 30-Day Episode Rates
10.3 - Continuous 60-Day Episode Recertifications
10.4 - Submission of the Notice of Admission (NOA)
10.5 – Requirements for Submission of NOA
10.6 - Low Utilization Payment Adjustment (LUPA)
10.7 - Partial Payment Adjustment
10.8 - Outlier Payments
10.9 - Discharge Issues
10.10 - Consolidated Billing
10.11 - Change of Ownership Relationship to Periods Under the HH PPS
10.12 - Change of Ownership Relationship to Episodes Under PPS
20 - Conditions To Be Met for Coverage of Home Health Services
20.1 - Reasonable and Necessary Services
20.1.1 - Background
20.1.2 - Determination of Coverage
20.2 - Impact of Other Available Caregivers and Other Available Coverage on
Medicare Coverage of Home Health Services
20.3 - Use of Utilization Screens and "Rules of Thumb"
30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services
30.1 - Confined to the Home
30.1.1 - Patient Confined to the Home

30.1.2 - Patient's Place of Residence
30.2 - Services Are Provided Under a Plan of Care Established and Approved by
a Physician or Allowed Practitioner
30.2.1 - Definition of Allowed Practitioner
30.2. 2 - Content of the Plan of Care
30.2.3 - Specificity of Orders
30.2.4 - Who Signs the Plan of Care
30.2.5 - Timeliness of Signature
30.2. 6 - Use of Oral (Verbal) Orders
30.2.7 - Frequency of Review of the Plan of Care
30.2.8 - Facsimile Signatures
30.2. 9 - Alternative Signatures
30.2.10 - Termination of the Plan of Care - Qualifying Services
30.2.11 - Sequence of Qualifying Services and Other Medicare Covered
Home Health Services
30.3 - Under the Care of a Physician or Allowed Practitioner
30.4 - Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely
Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy,
Speech-Language Pathology Services, or Has Continued Need for Occupational
Therapy
30.5 - Physician or Allowed Practitioner Certification and Recertification of
Patient Eligibility for Medicare Home Health Services
30.5.1 - Physician or Allowed Practitioner Certification
30.5.1.1 - Face-to-Face Encounter
30.5.1.2 - Supporting Documentation Requirements
30.5.2 - Physician or Allowed Practitioner Recertification
30.5.3 - Who May Sign the Certification or Recertification
30.5.4 - Physician or Allowed Practitioner Billing for Certification and
Recertification
40 - Covered Services Under a Qualifying Home Health Plan of Care
40.1 - Skilled Nursing Care
40.1.1 - General Principles Governing Reasonable and Necessary Skilled
Nursing Care
40.1.2 - Application of the Principles to Skilled Nursing Services

40.1.2.1 - Observation and Assessment of the Patient's Condition
When Only the Specialized Skills of a Medical Professional
Can Determine Patient's Status
40.1.2.2 - Management and Evaluation of a Patient Care Plan
40.1.2.3 - Teaching and Training Activities
40.1.2.4 - Administration of Medications
40.1.2.5 - Tube Feedings
40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration
40.1.2.7 - Catheters
40.1.2.8 - Wound Care
40.1.2.9 - Ostomy Care
40.1.2.10 - Heat Treatments
40.1.2.11 - Medical Gases
40.1.2.12 - Rehabilitation Nursing
40.1.2.13 - Venipuncture
40.1.2.14 - Student Nurse Visits
40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching
40.1.3 - Intermittent Skilled Nursing Care
40.2 - Skilled Therapy Services
40.2.1 - General Principles Governing Reasonable and Necessary Physical
Therapy, Speech-Language Pathology Services, and Occupational
Therapy
40.2.2 - Application of the Principles to Physical Therapy Services
40.2.3 - Application of the General Principles to Speech-Language
Pathology Services
40.2.4 - Application of the General Principles to Occupational Therapy
40.2.4.1 - Assessment
40.2.4.2 - Planning, Implementing, and Supervision of Therapeutic
Programs
40.2.4.3 - Illustration of Covered Services
50 - Coverage of Other Home Health Services
50.1 - Skilled Nursing, Physical Therapy, Speech-Language Pathology Services,
and Occupational Therapy
50.2 - Home Health Aide Services
50.3 - Medical Social Services

50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than Covered
Osteoporosis Drugs), the Use of Durable Medical Equipment and Furnishing
Negative Pressure Wound Therapy Using a Disposable Device
50.4.1 - Medical Supplies
50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and
the Patient's Plan of Care
50.4.1.2 - Routine Supplies (Nonreportable)
50.4.1.3 - Nonroutine Supplies (Reportable)
50.4.2 - Durable Medical Equipment
50.4.3 – Covered Osteoporosis Drugs
50.4.4 - Negative Pressure Wound Therapy Using a Disposable Device
50.5 - Services of Interns and Residents
50.6 - Outpatient Services
50.7 - Part-Time or Intermittent Home Health Aide and Skilled Nursing Services
50.7.1 - Impact on Care Provided in Excess of "Intermittent" or "Part-
Time" Care
50.7.2 - Application of this Policy Revision
60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance
(Part A) and Supplementary Medical Insurance (Part B)
60.1 - Post-Institutional Home Health Services Furnished During A Home Health
Benefit Period - Beneficiaries Enrolled in Part A and Part B
60.2 - Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet
Threshold for Post-Institutional Home Health Services
60.3 - Beneficiaries Who Are Part A Only or Part B Only
60.4 - Coinsurance, Copayments, and Deductibles
70 - Duration of Home Health Services
70.1 - Number of Home Health Visits Under Supplementary Medical Insurance
(Part B)
70.2 - Counting Visits Under the Hospital and Medical Plans
80 - Specific Exclusions From Coverage as Home Health Services
80.1 - Drugs and Biologicals
80.2 - Transportation
80.3 - Services That Would Not Be Covered as Inpatient Services
80.4 - Housekeeping Services
80.5 - Services Covered Under the End Stage Renal Disease (ESRD) Program

80.6 - Prosthetic Devices
80.7 - Medical Social Services Furnished to Family Members
80.8 - Respiratory Care Services
80.9 - Dietary and Nutrition Personnel
80.10- Telecommunications Technology
90 - Medical and Other Health Services Furnished by Home Health Agencies
100 - Physicianor or Allowed Practitioner Certification for Medical and Other Health
Services Furnished by Home Health Agency (HHA)
110 - Use of Telehealth in Delivery of Home Health Services

10 - Home Health Prospective Payment System (HH PPS)
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
The unit of payment under the HH PPS is a national 30-day period rate with applicable
adjustments. The periods, rate, and adjustments to the rates are detailed in the following
sections.
10.1 - National 30-Day Period Payment Rate
(Rev. 12382; Issued: 11-28-23; Effective: 01-01-24; Implementation:01-02-24)
A. Services Included
The law requires the 30-day period to include all covered home health
services, including medical supplies, paid on a reasonable cost basis. That
means the 30-day period payment rate includes costs for the six home
health disciplines and the costs for routine and nonroutine medical
supplies. The six home health disciplines included in the 30-day period
payment rate are:
1. Skilled nursing services;
2. Home health aide services;
3. Physical therapy;
4. Speech-language pathology services;
5. Occupational therapy services; and
6. Medical social services.
The 30-day period payment rate also includes amounts for nonroutine
medical supplies and therapies that could have been unbundled to Part B
prior to HH PPS. (See §10.11.C for those services.)
B. Excluded Services
The law specifically excludes durable medical equipment (DME) from the
30-day period payment rate and consolidated billing requirements. DME
continues to be paid the fee schedule amounts or through the DME
competitive bidding program outside of the HH PPS rate.

Certain injectable osteoporosis drugs which are covered where a woman is
postmenopausal and has a bone fracture are also excluded from the 30-day
period payment rate, but must be billed by the home health agency (HHA)
while a patient is under a home health plan of care since the law requires
consolidated billing of these osteoporosis drugs. These osteoporosis drugs
continue to be paid on a reasonable cost basis.
Negative pressure wound therapy using a disposable device (dNPWT) that
is an integrated system comprised of a non-manual vacuum pump, a
receptacle for collecting exudate, and dressings for the purposes of wound
therapy (in lieu of a conventional NPWT DME system), is also excluded
from the 30-day period payment rate, but must be billed by the home
health agency (HHA) while a patient is under a home health plan of care
since the law requires consolidated billing of NPWT using a disposable
device.
Furnishing NPWT using a disposable device means the application of a new applicable
disposable device, as that term is defined in §1834 of the Social Security Act (the Act),
which includes only the device paid separately (specified by the assigned HCPCS code)
and does not include payment for the professional services.
10.2 - Adjustments to the 30-Day Period Payment Rate
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
A. Case-Mix Adjustment
A case-mix methodology adjusts the 30-day payment rate based on characteristics of the
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment
level, and other factors). The 30-day period payment rate is adjusted by a case-mix
methodology based on information from home health claims, other Medicare claims, and
data elements from the Outcome and Assessment Information Set (OASIS). The claims
information and OASIS data elements are used to group 30-day periods of care into their
case-mix groups.
The following case-mix variables are obtained from home health or other Medicare
claims:
• 	Admission Source-Institutional (i.e., acute hospital, inpatient rehabilitation
facility, skilled nursing facility, long-term care hospital, inpatient psychiatric
facility) or Community;
• 	Timing-Early (the first 30-day period of care) or Late (all subsequent 30-day
periods of care, unless there is a gap of more than 60-days between the end of
one period of care and the start of another),
• 	Clinical Group-As determined by the principal diagnosis reported on home
health claims; 30-day periods are assigned to one of 12 clinical groups
describing the primary reason for the home health encounter:

Clinical Groups
The Primary Reason for the Home Health Encounter is to
Provide:
Musculoskeletal Rehabilitation Therapy (physical, occupational or speech) for a musculoskeletal
condition
Neuro/Stroke Rehabilitation Therapy (physical, occupational or speech) for a neurological
condition or stroke
Wounds – Post-Op Wound Aftercare and
Skin/Non-Surgical Wound Care
Assessment, treatment & evaluation of a surgical wound(s);
assessment, treatment & evaluation of non-surgical wounds, ulcers,
burns, and other lesions
Behavioral Health Care Assessment, treatment & evaluation of psychiatric and substance
abuse conditions
Complex Nursing Interventions
Assessment, treatment & evaluation of complex medical & surgical
conditions including IV, TPN, enteral nutrition, ventilator, and
ostomies
Medication Management, Teaching and
Assessment (MMTA)
MMTA –Surgical Aftercare 	Assessment, evaluation, teaching, and medication management for
surgical aftercare
MMTA – Cardiac/Circulatory Assessment, evaluation, teaching, and medication management for
cardiac or other circulatory related conditions
MMTA – Endocrine Assessment, evaluation, teaching, and medication management for
endocrine related conditions
MMTA – GI/GU 	Assessment, evaluation, teaching, and medication management for
gastrointestinal or genitourinary related conditions
MMTA – Infectious
Disease/Neoplasms/Blood-forming Diseases
Assessment, evaluation, teaching, and medication management for
conditions related to infectious diseases, neoplasms, and blood-
forming diseases
MMTA –Respiratory Assessment, evaluation, teaching, and medication management for
respiratory related conditions
MMTA – Other
Assessment, evaluation, teaching, and medication management for a
variety of medical and surgical conditions not classified in one of
the previously listed groups
• 	Comorbidity Adjustment-As determined by certain secondary diagnoses
reported on home health claims; a 30-day period of care can receive no
comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity
adjustment.
The following case mix variable is determined from responses to certain items on the
OASIS assessment:
• 	Functional Impairment Level-As determined by responses to certain OASIS
items. A 30-day period of care can be assigned a low, medium, or high
functional impairment level.
Each 30-day period is assigned into one of 432 case-mix groups based on the variables
described above. Each group’s case-mix weight reflects the predicted mean cost of the
group relative to the overall average across all groups.
B. Labor Adjustments

The labor portion of the 30-day period payment rate is adjusted to reflect the wage index
based on the site of service of the beneficiary. The beneficiary's location is the
determining factor for the labor adjustment. The HH PPS rates are adjusted by the pre-
floor and pre-reclassified hospital wage index. The hospital wage index is adjusted to
account for the geographic reclassification of hospitals in accordance with
§§1886(d)(8)(B) and 1886(d)(10) of the Social Security Act (the Act.) According to the
law, geographic reclassification only applies to hospitals. Additionally, the hospital wage
index has specific floors that are required by law. Because these reclassifications and
floors do not apply to HHAs, the home health rates are adjusted by the pre-floor and pre-
reclassified hospital wage index.
NOTE: The pre-floor and pre-reclassified hospital wage index varies slightly from the
numbers published in the Medicare inpatient hospital PPS regulation that reflects the
floor and reclassification adjustments. The wage indices published in the home health
final rule and subsequent annual updates reflect the most recent available pre-floor and
pre-reclassified hospital wage index available at the time of publication.
10.3 - Continuous 60-Day Recertifications
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
While HH PPS payment is now made for each 30-day period, the home health PPS
permits continuous 60-day recertifications for patients who continue to be eligible for the
home health benefit. Medicare does not limit the number of continuous 60-day
recertifications for beneficiaries who continue to be eligible for the home health benefit.
Each 60-day certification can include two 30-day payment periods.
Recertification is required at least every 60 days when there is a need for continuous
home health care after an initial 60-day certification. The recertification visit can be done
during the prior certification period. With some minor exceptions, the Medicare
Conditions of Participation at 42 CFR 484.55(d)(1), require that the recertification
assessment be done during the last 5 days of the previous certification period (for
example, during the initial 60-day certification period, the recertification visit is required
to be done on days 56-60).
10.4 - Submission of the Notice of Admission (NOA)
(Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, Implementation: 05-26-22)
Beginning January 1, 2022, HHAs will no longer submit Requests for Anticipated
Payment (RAPs). Instead, for each admission to home health, the HHA notifies Medicare
systems via submission of an NOA. The NOA is a one-time submission to establish that
the beneficiary is under a home health period of care and trigger home health
consolidated billing edits. The NOA covers contiguous 30-day periods of care until the
individual is discharged from Medicare home health services. There is no upfront
payment with the submission of the NOA.

The NOA must be submitted timely. All HHAs must submit an NOA to their Medicare
contractor within 5 calendar days from the start of care date to establish that the
beneficiary is under a Medicare home health period of care and also to trigger home
health consolidated billing edits required under section 1842(b)(6)(F) of the Act. For
example, if the start of care date is January 1, 2022, the NOA would be considered
timely-filed if it is submitted on or before January 6, 2022.
Example:
1/1/2022 = Day 0 (start of the first 30- day period of care)
1/6/2022 = Day 5 (An NOA submitted on or before this date would be considered
‘‘timely-filed’’.)
1/7/2022 and after = Day 6 and beyond (An NOA submitted on and after this date would
be considered untimely and would trigger the penalty.)
In instances where an NOA is not timely-filed, Medicare shall reduce the payment for a
period of care, including outlier payments, by the number of days from the home health
admission date until the date the NOA is submitted to, and accepted by, the A/B MAC
(HHH), divided by 30. No LUPA per-visit payments shall be made for visits that
occurred on days that fall within the period of care prior to the submission of the NOA.
This reduction shall be a provider liability, and the provider shall not bill the beneficiary
for it.
CMS may waive the consequences of failure to submit a timely-filed NOA if it is
determined that a circumstance encountered by a home health agency is exceptional and
qualifies for waiver of the consequence. An exceptional circumstance may be due to, but
is not limited to the following:
• Fires, floods, earthquakes, or similar unusual events that inflict extensive damage to the
home health agency’s ability to operate.
• A CMS or Medicare contractor systems issue that is beyond the control of the home
health agency.
• A newly Medicare-certified home health agency that is notified of that certification after
the Medicare certification date, or which is awaiting its user ID from its Medicare
contractor.
• Other situations determined by CMS to be beyond the control of the home health
agency.
If an HHA believes that there is a circumstance that may qualify for an exception, the
HHA must fully document and furnish any requested documentation to their MAC for a
determination of exception.
See Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, “Home Health
Agency Billing” for requirements regarding the notice of admission process.
10.5 - Requirements for Submission of the NOA
(Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, Implementation: 05-26-22)

For CY 2022, submission of the NOA can be made when the following criteria have been
met:
(1) The appropriate physician’s or allowed practitioner’s written or verbal order that sets
out the services required for the initial visit has been received and documented as
required at §§ 484.60(b) and 409.43(d);
(2) The initial visit within the 60-day certification period must have been made and the
individual admitted to home health care.
.
10.6 - Low Utilization Payment Adjustment (LUPA)
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
The LUPA threshold varies for a 30-day period of care depending on the payment group
to which it is assigned. For each payment group, the 10th percentile value of visits is used
to create a payment group-specific LUPA threshold with a minimum threshold of at least
2 visits for each group. A 30-day period with visits less than the LUPA threshold for the
payment group is paid the national per visit amount by discipline adjusted by the
appropriate wage index based on the site of service of the beneficiary. Such periods that
do not meet the LUPA threshold for the payment group are paid the wage-adjusted per
visit amount for each of the visits rendered instead of the full 30-day period payment
amount. The national per visit amounts by discipline (skilled nursing, home health aide,
physical therapy, speech-language pathology, occupational therapy, and medical social
services) are updated and published annually by the applicable market basket for each
visit type. To offset the full cost of longer, initial visits in some LUPA periods, the
LUPA payment is increased by an add-on amount for LUPAs that occur as the only 30-
day period or the initial 30-day period during a sequence of adjacent periods.
10.7 - Partial Payment Adjustment
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A. Partial Payment Adjustment Criteria
An HHA receives a national, standardized 30-day payment of a predetermined rate for
home health services unless CMS determines an intervening event warrants a new 30-
day period for purposes of payment.
The partial payment adjustment is a proportion of the period payment and is based on
the span of days including the start-of-care date (for example, the date of the first
billable service) through and including the last billable service date under the original
plan of care before the intervening event, defined as a—
● Beneficiary elected transfer, or
● Discharge and return to home health that would warrant, for purposes of payment, a
new OASIS assessment, certification of eligibility, and a new plan of care.
When a new 30-day period begins due to an intervening event, the original 30-day

period will be proportionally adjusted to reflect the length of time the beneficiary
remained under the agency’s care prior to the intervening event. The proportional
payment is the partial payment adjustment.
B. Methodology Used to Calculate Partial Payment Adjustment
The partial payment adjustment for the original 30-day period is calculated to reflect the
length of time the beneficiary remained under the care of the original HHA based on the
first billable visit date through and including the last billable visit date. The partial
payment adjustment will be calculated by using the span of days (first billable service
date through and including the last billable service date) under the original plan of care as
a proportion of the 30-day period. The proportion will then be multiplied by the original
case-mix and wage index to produce the 30-day payment.
C. Common Ownership Exception to Partial Payment Adjustment
The partial payment adjustment does not apply in situations of transfers among HHAs of
common ownership. Those situations would be considered services provided under
arrangement on behalf of the originating HHA by the receiving HHA with the ownership
interest until the end of the 30-day period. The common ownership exception to the
transfer partial payment adjustment does not apply if the beneficiary moved out of their
Metropolitan Statistical Area (MSA) or non-MSA during the 30-day period before the
transfer to the receiving HHA.
D. Beneficiary Elected Transfer Verification
In order for a receiving HHA to accept a beneficiary elected transfer, the receiving HHA
must document that the beneficiary has been informed that the initial HHA will no longer
receive Medicare payment on behalf of the patient and will no longer provide Medicare
covered services to the patient after the date of the patient's elected transfer in accordance
with current patient rights requirements at 42 CFR 484.50(d). The receiving HHA must
also document in the record that it accessed the Medicare contractor’s inquiry system to
determine whether or not the patient was under an established home health plan of care
and it must contact the initial HHA on the effective date of transfer. In the rare
circumstance of a dispute between HHAs, the Medicare contractor is responsible for
working with both HHAs to resolve the dispute. If the receiving HHA can provide
documentation of its notice of patient rights on Medicare payment liability provided to
the patient upon transfer and its contact of the initial HHA of the transfer date, then the
initial HHA will be ineligible for payment for the period of overlap in addition to the
appropriate partial payment adjustment. If the receiving HHA cannot provide the
appropriate documentation, the receiving HHA's RAP and/or final claim will be
cancelled, and full period payment will be provided to the initial HHA. For the receiving
HHA to properly document that it contacted the initial HHA on the effective date of
transfer it must maintain similar information as the initial HHA, including the same basic
beneficiary information, personnel contacted, dates and times. The initial HHA must also
properly document that it was contacted and it accepted the transfer. Where it disputes a
transfer, the initial HHA must call its Medicare contractor to resolve the dispute. The
Medicare contractor is responsible for working with both HHAs to resolve the dispute.

10.8 - Outlier Payments
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
When cases experience an unusually high level of services in a 30-day period, Medicare
systems will provide additional or "outlier" payments to the case-mix and wage-adjusted
30-day period payment. Outlier payments can result from medically necessary high
utilization in any or all-home health service disciplines. CMS makes outlier payments
when the cost of care exceeds a threshold dollar amount. The outlier threshold for each
case-mix group is the 30-day period payment amount for that group or the partial
payment adjustment amount for the 30-day period, plus a fixed dollar loss amount, which
is the same for all case-mix groups. The outlier payment is a proportion of the amount of
imputed costs beyond the threshold. CMS calculates the imputed cost for each 30-day
period by first taking the national per-visit payment amounts for each discipline and
calculating per-unit payment amounts (1 unit = 15 minutes). The per-unit amounts are
then multiplied by the number of units in the discipline and computing the total imputed
cost for all disciplines (summed across the six disciplines of care).
If the imputed cost for the 30-day period is greater than the sum of the case-mix and
wage-adjusted 30-day period payment plus the fixed dollar loss amount (the outlier
threshold), a set percentage (the loss sharing ratio) of the difference between the imputed
amount and outlier threshold will be paid to the HHA as a wage-adjusted outlier payment
in addition to the 30-day period payment.
The amount of the outlier payment is determined as follows:
1. 	Calculate the case-mix and wage-adjusted 30-day period payment (including non-
routine supplies (NRS));
2. 	Add the wage-adjusted fixed dollar loss amount. The sum of steps 1 and 2 is the
outlier threshold for the 30-day period;
3. 	Calculate the wage-adjusted imputed cost of the 30-day period by first
multiplying the total number of units for each home health discipline by the
national per unit amounts, and wage-adjusting those amounts. Sum the per
discipline wage-adjusted imputed amounts to yield the total wage-adjusted
imputed cost for the 30-day period;
4. 	Subtract the total imputed cost for the 30-day period (total from Step 3) from the
sum of the case-mix and wage-adjusted 30-day period payment and the wage-
adjusted fixed dollar loss amount (sum of Steps 1 and 2 - outlier threshold);
5. 	Multiply the difference by the loss sharing ratio; and
6. 	That total amount is the outlier payment for the 30-day period.
Effective January 1, 2010, an outlier cap precludes any HHA from receiving more than 10
percent of their total home health payment in outliers.

10.9 - Discharge Issues
(Rev. 12382; Issued: 11-28-23; Effective: 01-01-24; Implementation:01-02-24)
A. Hospice Election Mid-Period
If a patient elects hospice before the end of the 30-day period and there
was no partial payment adjustment or LUPA adjustment, the HHA will
receive a full 30-day period payment. The 30-day period with visits less
than the LUPA threshold for the payment group would be paid at the low
utilization payment adjusted amount.
B. Patient's Death
The documented event of a patient's death would result in a full 30-day
period payment, unless the death occurred in a low utilization payment
adjusted 30-day period. Consistent with all episodes in which a patient
receives four or fewer visits, if the patient's death occurred during a low
utilization adjusted 30-day payment period, the period would be paid at
the low utilization payment adjusted amount. In the event of a patient's
death during an adjusted 30-day period, the total adjusted period would
constitute the full 30- day period payment.
C. Patient is No Longer Eligible for Home Health (e.g., no longer
homebound, no skilled need)
If the patient is discharged because he or she is no longer eligible for the
Medicare home health benefit and has received visits meeting the LUPA
threshold for the payment group, then the HHA would receive the full 30-
day period payment. However, if the patient becomes subsequently
eligible for the Medicare home health benefit during the same 30- day
period and transferred to another HHA or returned to the same HHA, then
this would result in a partial payment adjustment.
D. Discharge Due to Patient Refusal of Services or is a Documented
Safety Threat, Abuse Threat or is Noncompliant
If the patient is discharged because he or she refuses services or becomes
a documented safety, abuse, or noncompliance discharge and has received
visits meeting the LUPA threshold for the payment group, then the HHA
would receive full period payment unless the patient becomes
subsequently eligible for the Medicare home health benefit during the
same 30-day period and transferred to another HHA or returned to the
same HHA, then this would result in a partial payment adjustment.
E. Patient Enrolls in Managed Care Mid-Period

If a patient's enrollment in a Medicare Advantage (MA) plan becomes
effective mid period, the 30-day period payment will be proportionally
adjusted with a partial payment adjustment since the patient is receiving
coverage under MA. Beginning with the effective date of enrollment, the
MA plan will receive a capitation payment for covered services.
F. Submission of Final Claims Prior to the End of the 30-day Period
The claim may be submitted upon discharge before the end of the 30-day
period. However, subsequent adjustments to any payments based on the
claim may be made due to an intervening event resulting in a partial
payment adjustment or other adjustment.
G. Patient Discharge and Financial Responsibility for Part B Bundled
Medical Supplies and Services
As discussed in detail under §10.11, below, the law governing the
Medicare HH PPS requires the HHA to provide all bundled home health
services (except DME) either directly or under arrangement while a
patient is under an open home health plan of care during an open episode.
Once the patient is discharged, the HHA is no longer responsible for
providing home health services including the bundled Part B medical
supplies and therapy services.
H. Discharge Issues Associated With Inpatient Admission
Overlapping Into Subsequent 60-Day Recertifications
1. If a patient is admitted to an inpatient facility and the inpatient stay
overlaps into what would have been the subsequent 60-day recertification
and there is no recertification assessment of the patient, then the new
certification begins with the new start of care date after inpatient
discharge.
2. If a patient is admitted to an inpatient facility and the inpatient stay
overlaps into what would have been the subsequent 60-day recertification
and there was a recertification assessment of the patient during days 56-60
and the patient returns home from the inpatient stay on day 61, if the home
health resource group (HHRG) remains the same then the 30-day period
of care following the inpatient stay would be considered continuous and
thus be considered a recertification. However, if the HHRG is different,
this would result in a new start of care OASIS and thus be considered a
new certification and begins with the new start of care date after inpatient
discharge.
3. If a patient is admitted to an inpatient facility and the inpatient stay
overlaps into what would have been the subsequent 60-day recertification
and there was a recertification assessment of the patient during days 56-60

and the patient returns home from the inpatient stay after day 61 (after the
first day of the next 60-day recertification of care), then a new
certification begins with the new start of care date after inpatient
discharge.
10.10 - Consolidated Billing
(Rev. 12382; Issued: 11-28-23; Effective: 01-01-24; Implementation:01-02-24)
For individuals under a home health plan of care, payment for all services
and supplies, with the exception of certain injectable osteoporosis drugs,
DME, and furnishing NPWT using a disposable device is included in the
HH PPS base payment rates. HHAs must provide the covered home health
services (except DME) either directly or under arrangement, and must bill
for such covered home health services. Payment must be made to the
HHA.
A. Home Health Services Subject to Consolidated Billing
Requirements
The home health services included in the consolidated billing governing
the HH PPS are:
• Part-time or intermittent skilled nursing services;
• Part-time or intermittent home health aide services;
• Physical therapy;
• Speech-language pathology services;
• Occupational therapy;
• Medical social services;
• Routine and nonroutine medical supplies;
• Covered osteoporosis drug as defined in §1861(kk) of the Act, but
excluding
other drugs and biologicals;
• Furnishing NPWT using a disposable device as that term is defined in
§1834 of the Act, which includes only the device paid separately
(specified by the assigned HCPCS code) and does not include payment for
the professional services.
• 	Medical services provided by an intern or resident-in-training of the
program of the hospital in the case of an HHA that is affiliated or
under common control with a hospital with an approved teaching
program; and
• Home health services defined in §1861(m) of the Act provided under
arrangement at hospitals, SNFs, or rehabilitation centers when they
involve equipment too cumbersome to bring to the home or are furnished
while the patient is at the facility to receive such services.
B. Medical Supplies
The law requires that all medical supplies (routine and nonroutine) be

provided by the HHA while the patient is under a home health plan of
care. The agency that establishes the 30-day period is the only entity that
can bill and receive payment for medical supplies during a 30-day period
for a patient under a home health plan of care. Both routine and
nonroutine medical supplies are included in the base rates for every
Medicare home health patient regardless of whether or not the patient
requires medical supplies during
the 30-day period
Due to the consolidated billing requirements, CMS provided additional
amounts in the base rates for those nonroutine medical supplies that have
a duplicate Part B code that could have been unbundled to Part B prior to
HH PPS. See §50.4 for detailed discussion of medical supplies.
Medical supplies used by the patient, provider, or other practitioners under
arrangement on behalf of the agency (other than physicians) are subject to
consolidated billing and bundled into the HHA 30-day period payment
rate. Once a patient is discharged from home health and not under a home
health plan of care, the HHA is not responsible for medical supplies.
DME, including supplies covered as DME, are paid separately from the
HH PPS and are excluded from the consolidated billing requirements
governing the HH PPS. The determining factor is the medical
classification of the supply, not the diagnosis of the
patient.
Certain injectable osteoporosis drugs are included in consolidated billing
under the home health benefit. However, payment is not bundled into the
HH PPS payment rates. HHAs must bill for the osteoporosis drug in
accordance with billing instructions. Payment is in addition to the HH PPS
payment.
Furnishing NPWT using a disposable device is included in consolidated
billing under the home health benefit. However, payment for the device is
not bundled into the HH PPS payment rates. HHAs must bill for NPWT
using a disposable device in accordance with billing instructions. Payment
is in addition to the HH PPS payment.
C. Relationship Between Consolidated Billing Requirements and Part
B Supplies and Part B Therapies Included in the Baseline Rates That
Could Have Been Unbundled Prior to HH PPS That No Longer Can
Be Unbundled
The HHA is responsible for the services provided under arrangement on
their behalf by other entities. Covered home health services at §1861(m)
of the Act (except DME) are included in the baseline HH PPS rates and
subject to the consolidated billing requirements while the patient is under

a plan of care of the HHA. The time the services are bundled is while the
patient is under a home health plan of care.
Physician services or nurse practitioner services paid under the physician
fee schedule are not recognized as home health services included in the
PPS rates. Supplies incident to a physician service or related to a
physician service billed to the Medicare contractor are not subject to the
consolidated billing requirements. The physician would not be acting as a
supplier billing the DME Medicare contractor in this situation.
Therapies (physical therapy, occupational therapy, and speech-language
pathology services) are covered home health services that are included in
the baseline rates and subject to the consolidated billing requirements. In
addition to therapies that had been paid on a cost basis under home health,
CMS has included in the rates additional amounts for Part B therapies that
could have been unbundled prior to PPS. These therapies are subject to the
consolidated billing requirements. There are revenue center codes that
reflect the ranges of outpatient physical therapy, occupational therapy, and
speech language pathology services and Healthcare Common Procedure
Coding System (HCPCS) codes that reflect physician supplier codes that
are physical therapy, occupational therapy, and speech-language
pathology services by code definition and are subject to the consolidated
billing requirements. Therefore, the above-mentioned therapies must be
provided directly or under arrangement on behalf of the HHA while a
patient is under a home health plan of care and cannot be separately billed
to Part B during an open 30-day period of care.
D. Freedom of Choice Issues
A beneficiary exercises his or her freedom of choice for the services under
the home health benefit listed in §1861(m) of the Act, including medical
supplies, but excluding DME covered as a home health service by
choosing the HHA. Once a home health patient chooses a particular HHA,
he or she has clearly exercised freedom of choice with respect to all items
and services included within the scope of the Medicare home health
benefit (except DME). The HHA's consolidated billing role supersedes all
other billing situations the beneficiary may wish to establish for home
health services covered under the scope of the Medicare home health
benefit during the certified episode.
E. Knowledge of Services Arranged for on Behalf of the HHA
The consolidated billing requirements governing HH PPS requires that the HHA provide
all covered home health services (except DME) either directly or under arrangement
while a patient is under a home health plan of care. Providing services either directly or
under arrangement requires knowledge of the services provided during the 30-day period.
In addition, in accordance with current Medicare conditions of participation and

Medicare coverage guidelines governing home health, the patient's plan of care must
reflect the physician or allowed practitioner ordered services that the HHA provides
either directly or under arrangement. An HHA would not be responsible for payment in
the situation in which they have no prior knowledge (unaware of physician or allowed
practitioner orders) of the services provided by an entity during a 30-day period to a
patient who is under their home health plan of care. An HHA is responsible for payment
in the situation in which services are provided to a patient by another entity, under
arrangement with the HHA, during a 30-day period in which the patient is under the
HHA's home health plan of care. However, it is in the best interest of future business
relationships to discuss the situation with any entity that seeks payment from the HHA
during a 30-day period in an effort to resolve any misunderstanding and avoid such
situations in the future
10.11 - Change of Ownership Relationship to Periods Under HH PPS
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
A. Change of Ownership With Assignment
When there is a change of ownership and the new owner accepts assignment of the
existing provider agreement, the new owner is subject to all the terms and conditions
under which the existing agreement was issued. The provider number remains the same
if the new HHA owner accepts assignment of the existing provider agreement. As long
as the new owner complies with the regulations governing home health PPS, billing, and
payment for 30-day periods with applicable adjustments for existing patients under an
established plan of care will continue on schedule through the change in ownership with
assignment. The 30-day period would be uninterrupted spanning the date of sale. The
former owner is required to file a terminating cost report. Instructions regarding when a
cost report is filed are in the Provider Reimbursement Manual, Part 1, §1500.
B. Change of Ownership Without Assignment
When there is a change of ownership, and the new owner does not take the assignment of
the existing provider agreement, the provider agreement and provider number of the
former owner is terminated. The former owner will receive partial payment adjusted
payments in accordance with the methodology set forth in the Medicare Claims
Processing Manual, Chapter 10, "Home Health Agency Billing," §40.2, and 42 CFR
484.235, based on the last billable visit date for existing patients under a home health
plan of care ending on or before the date of sale. The former owner is required to file a
terminating cost report. The new owner cannot bill Medicare for payment until the
effective date of the Medicare approval. The new HHA will not be able to participate in
the Medicare program without going through the same process as any new provider,
which includes an initial survey. Once the new owner is Medicare-approved, the HHA
may start a new 30-day period for purposes of payment, OASIS assessment, and
certification of the home health plan of care for all new patients in accordance with the
regulations governing home health PPS, effective with the date of the new provider
certification.

C. Change of Ownership - Mergers
The merger of a provider corporation into another corporation constitutes a change of
ownership. For information on specific procedures, refer to Pub. 100-07, State Operations
Manual, chapter 2, section 2202.17.
10.12 - Change of Ownership Relationship to Episodes Under PPS
(Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)
A. Change of Ownership With Assignment
When there is a change of ownership and the new owner accepts assignment of the
existing provider agreement, the new owner is subject to all the terms and conditions
under which the existing agreement was issued. The provider number remains the same
if the new HHA owner accepts assignment of the existing provider agreement. As long
as the new owner complies with the regulations governing home health PPS, billing, and
payment for episodes with applicable adjustments for existing patients under an
established plan of care will continue on schedule through the change in ownership with
assignment. The episode would be uninterrupted spanning the date of sale. The former
owner is required to file a terminating cost report. Instructions regarding when a cost
report is filed are in the Provider Reimbursement Manual, Part 1, §1500.
B. Change of Ownership Without Assignment
When there is a change of ownership, and the new owner does not take the assignment of
the existing provider agreement, the provider agreement and provider number of the
former owner is terminated. The former owner will receive partial episode payment
adjusted payments in accordance with the methodology set forth in the Medicare Claims
Processing Manual, Chapter 10, "Home Health Agency Billing," §40.2, and 42 CFR
484.235, based on the last billable visit date for existing patients under a home health
plan of care ending on or before the date of sale. The former owner is required to file a
terminating cost report. The new owner cannot bill Medicare for payment until the
effective date of the Medicare approval. The new HHA will not be able to participate in
the Medicare program without going through the same process as any new provider,
which includes an initial survey. Once the new owner is Medicare-approved, the HHA
may start a new episode for purposes of payment, OASIS assessment, and certification of
the home health plan of care for all new patients in accordance with the regulations
governing home health PPS, effective with the date of the new provider certification.
C. Change of Ownership - Mergers
The merger of a provider corporation into another corporation constitutes a change of
ownership. For information on specific procedures, refer to Pub. 100-07, State Operations
Manual, chapter 2, section 2202.17.
20 - Conditions To Be Met for Coverage of Home Health Services
(Rev. 1, 10-01-03)

A3-3116, HHA-203
Medicare covers HHA services when the following criteria are met:
1. 	The person to whom the services are provided is an eligible Medicare beneficiary;
2. 	The HHA that is providing the services to the beneficiary has in effect a valid
agreement to participate in the Medicare program;
3. 	The beneficiary qualifies for coverage of home health services as described in
§30;
4. 	The services for which payment is claimed are covered as described in §§40 and
50;
5. 	Medicare is the appropriate payer; and
6. 	The services for which payment is claimed are not otherwise excluded from
payment.
20.1 - Reasonable and Necessary Services
(Rev. 1, 10-01-03)
A3-3116.1. HHA-203.1
20.1.1 - Background
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
In enacting the Medicare program, Congress recognized that the physician or allowed
practitioner would play an important role in determining utilization of services. The law
requires that payment can be made only if a physician or allowed practitioner certifies the
need for services and establishes a plan of care. The Secretary is responsible for ensuring
that Medicare covers the claimed services, including determining whether they are
"reasonable and necessary."
20.1.2 - Determination of Coverage
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)
The Medicare contractor’s decision on whether care is reasonable and necessary is based
on information reflected in the home health plan of care, the OASIS as required by 42
CFR 484.55 or a medical record of the individual patient. Medicare does not deny
coverage solely on the basis of the reviewer's general inferences about patients with
similar diagnoses or on data related to utilization generally, but bases it upon objective
clinical evidence regarding the patient's individual need for care. Coverage of skilled
nursing care or therapy to perform a maintenance program does not turn on the presence
or absence of a patient’s potential for improvement from the nursing care or therapy, but
rather on the patient’s need for skilled care. Skilled care may be necessary to improve a

patient’s current condition, to maintain the patient’s current condition, to prevent or slow
further deterioration of the patient’s condition.
20.2 - Impact of Other Available Caregivers and Other Available
Coverage on Medicare Coverage of Home Health Services
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)
Where the Medicare criteria for coverage of home health services are met, patients are
entitled by law to coverage of reasonable and necessary home health services. Therefore,
a patient is entitled to have the costs of reasonable and necessary services reimbursed by
Medicare without regard to whether there is someone available to furnish the services.
However, where a family member or other person is or will be providing services that
adequately meet the patient's needs, it would not be reasonable and necessary for HHA
personnel to furnish such services. Ordinarily it can be presumed that there is no able
and willing person in the home to provide the services being rendered by the HHA unless
the patient or family indicates otherwise and objects to the provision of the services by
the HHA, or unless the HHA has first hand knowledge to the contrary.
Similarly, a patient is entitled to reasonable and necessary Medicare home health services
even if the patient would qualify for institutional care (e.g., hospital care or skilled
nursing facility care) and Medicare payment should be made for reasonable and
necessary home health services where the patient is also receiving supplemental services
that do not meet Medicare’s definition of skilled nursing care or home health aide
services.
EXAMPLE 1:
A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage
of home health services, requires the assistance of a home health aide for bathing and
assistance with an exercise program to improve endurance. The daughter is unwilling to
bathe her elderly father and assist him with the exercise program. Home health aide
services would be reasonable and necessary.
EXAMPLE 2:
A patient who is being discharged from a hospital with a diagnosis of osteomyelitis and
requires continuation of the I.V. antibiotic therapy that was begun in the hospital was
found to meet the criteria for Medicare coverage of skilled nursing facility services. If
the patient also meets the qualifying criteria for coverage of home health services,
payment may be made for the reasonable and necessary home health services the patient
needs, notwithstanding the availability of coverage in a skilled nursing facility.
EXAMPLE 3:
A patient who needs skilled nursing care on an intermittent basis also hires a licensed
practical (vocational) nurse to provide nighttime assistance while family members sleep.
The care provided by the nurse, as respite to the family members, does not require the

skills of a licensed nurse (as defined in §40.1) and therefore has no impact on the
beneficiary's eligibility for Medicare payment of home health services even though
another third party insurer may pay for that nursing care.
20.3 - Use of Utilization Screens and "Rules of Thumb"
(Rev. 1, 10-01-03)
A3-3116.3, HHA-203.3
Medicare recognizes that determinations of whether home health services are reasonable
and necessary must be based on an assessment of each beneficiary's individual care
needs. Therefore, denial of services based on numerical utilization screens, diagnostic
screens, diagnosis or specific treatment norms is not appropriate.
30 - Conditions Patient Must Meet to Qualify for Coverage of Home
Health Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
To qualify for the Medicare home health benefit, under §§1814(a)(2)(C) and
1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements:
• 	Be confined to the home;
• 	Under the care of a physician or allowed practitioner;
• 	Receiving services under a plan of care established and periodically reviewed by a
physician or allowed practitioner;
• 	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.
For purposes of benefit eligibility, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act,
"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 and
predictable).
A patient must meet each of the criteria specified in this section. Patients who meet each
of these criteria are eligible to have payment made on their behalf for services discussed
in §§40 and 50.
30.1 - Confined to the Home
(Rev. 1, 10-01-03)
A3-3117.1, HHA-204.1

30.1.1 - Patient Confined to the Home
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
For a patient to be eligible to receive covered home health services under both Part A and
Part B, the law requires that a physician or allowed practitioner certify in all cases that
the patient is confined to his/her home. For purposes of the statute, an individual shall be
considered “confined to the home” (homebound) if the following two criteria are met:
1. 	Criterion One:
The patient must either:
- 	Because of illness or injury, need the aid of supportive devices such as
crutches, canes, wheelchairs, and walkers; the use of special transportation; or
the assistance of another person in order to leave their place of residence
OR
- 	Have a condition such that leaving his or her home is medically
contraindicated.
If the patient meets one of the criterion one conditions, then the patient must ALSO meet
two additional requirements defined in criterion two below.
2. 	Criterion Two:
- 	There must exist a normal inability to leave home;
AND
- 	Leaving home must require a considerable and taxing effort.
To clarify, in determining whether the patient meets criterion two of the homebound
definition, the clinician needs to take into account the illness or injury for which the
patient met criterion one and consider the illness or injury in the context of the patient’s
overall condition. The clinician is not required to include standardized phrases reflecting
the patient’s condition (e.g., repeating the words “taxing effort to leave the home”) in the
patient’s chart, nor are such phrases sufficient, by themselves, to demonstrate that
criterion two has been met. For example, longitudinal clinical information about the
patient’s health status is typically needed to sufficiently demonstrate a normal inability to
leave the home and that leaving home requires a considerable and taxing effort. Such
clinical information about the patient’s overall health status may include, but is not
limited to, such factors as the patient’s diagnosis, duration of the patient’s condition,
clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, etc.

If the patient does in fact leave the home, the patient may nevertheless be considered
homebound if the absences from the home are infrequent or for periods of relatively short
duration, or are attributable to the need to receive health care treatment. Absences
attributable to the need to receive health care treatment include, but are not limited to:
• 	Attendance at adult day centers to receive medical care;
• 	Ongoing receipt of outpatient kidney dialysis; or
• 	The receipt of outpatient chemotherapy or radiation therapy.
Any absence of an individual from the home attributable to the need to receive health
care treatment, including regular absences for the purpose of participating in therapeutic,
psychosocial, or medical treatment in an adult day-care program that is licensed or
certified by a state, or accredited to furnish adult day-care services in a state, shall not
disqualify an individual from being considered to be confined to his home. Any other
absence of an individual from the home shall not so disqualify an individual if the
absence is of an infrequent or of relatively short duration. For purposes of the preceding
sentence, any absence for the purpose of attending a religious service shall be deemed to
be an absence of infrequent or short duration. It is expected that in most instances,
absences from the home that occur will be for the purpose of receiving health care
treatment. However, occasional absences from the home for nonmedical purposes, e.g.,
an occasional trip to the barber, a walk around the block or a drive, attendance at a family
reunion, funeral, graduation, or other infrequent or unique event would not necessitate a
finding that the patient is not homebound if the absences are undertaken on an infrequent
basis or are of relatively short duration and do not indicate that the patient has the
capacity to obtain the health care provided outside rather than in the home.
Some examples of homebound patients that illustrate the factors used to determine
whether a homebound condition exists are listed below.
• 	A patient paralyzed from a stroke who is confined to a wheelchair or requires the
aid of crutches in order to walk.
• 	A patient who is blind or senile and requires the assistance of another person in
leaving their place of residence.
• 	A patient who has lost the use of their upper extremities and, therefore, is unable
to open doors, use handrails on stairways, etc., and requires the assistance of
another individual to leave their place of residence.
• 	A patient in the late stages of ALS or neurodegenerative disabilities. In
determining whether the patient has the general inability to leave the home and
leaves the home only infrequently or for periods of short duration, it is necessary
(as is the case in determining whether skilled nursing services are intermittent) to
look at the patient's condition over a period of time rather than for short periods
within the home health stay. For example, a patient may leave the home (meeting

both criteria listed above) more frequently during a short period when the patient
has multiple appointments with health care professionals and medical tests in 1
week. So long as the patient's overall condition and experience is such that he or
she meets these qualifications, he or she should be considered confined to the
home.
• 	A patient who has just returned from a hospital stay involving surgery, who may
be suffering from resultant weakness and pain because of the surgery and;
therefore, their actions may be restricted by their physician or allowed practitioner
to certain specified and limited activities (such as getting out of bed only for a
specified period of time, walking stairs only once a day, etc.).
• 	A patient with arteriosclerotic heart disease of such severity that they must avoid
all stress and physical activity.
• 	A patient with a psychiatric illness that is manifested in part by a refusal to leave
home or is of such a nature that it would not be considered safe for the patient to
leave home unattended, even if they have no physical limitations.
The aged person who does not often travel from home because of frailty and insecurity
brought on by advanced age would not be considered confined to the home for purposes
of receiving home health services unless they meet one of the above conditions.
Although a patient must be confined to the home to be eligible for covered home health
services, some services cannot be provided at the patient's residence because equipment
is required that cannot be made available there. If the services required by an individual
involve the use of such equipment, the HHA may make arrangements with a hospital,
SNF, or a rehabilitation center to provide these services on an outpatient basis. (See
§50.6.) However, even in these situations, for the services to be covered as home health
services the patient must be considered confined to home and meet both criteria listed
above.
If a question is raised as to whether a patient is confined to the home, the HHA will be
requested to furnish the Medicare contractor with the information necessary to establish
that the patient is homebound as defined above.
30.1.2 - Patient's Place of Residence
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
A patient's residence is wherever he or she makes his or her home. This may be his or
her own dwelling, an apartment, a relative's home, a home for the aged, or some other
type of institution. However, an institution may not be considered a patient's residence if
the institution meets the requirements of §§1861(e)(1) or 1819(a)(1) of the Act..
Included in this group are hospitals and skilled nursing facilities, as well as most nursing
facilities under Medicaid. (See the Medicare State Operations Manual, §2166.)

Thus, if a patient is in an institution or distinct part of an institution identified above, the
patient is not entitled to have payment made for home health services under either Part A
or Part B since such an institution may not be considered their residence. When a patient
remains in a participating SNF following their discharge from active care, the facility
may not be considered their residence for purposes of home health coverage.
A patient may have more than one home and the Medicare rules do not prohibit a patient
from having one or more places of residence. A patient, under a Medicare home health
plan of care, who resides in more than one place of residence during a period of Medicare
covered home health services will not disqualify the patient's homebound status for
purposes of eligibility. For example, a person may reside in a principal home and also a
second vacation home, mobile home, or the home of a caretaker relative. The fact that
the patient resides in more than one home and, as a result, must transit from one to the
other, is not in itself, an indication that the patient is not homebound. The requirements
of homebound must be met at each location (i.e., the patient must meet both criteria listed
in section 30.1.1 above).
A. Assisted Living Facilities, Group Homes, and Personal Care Homes
An individual may be "confined to the home" for purposes of Medicare coverage of home
health services if he or she resides in an institution that is not primarily engaged in
providing to inpatients:
• 	Diagnostic and therapeutic services for medical diagnosis;
• 	Treatment;
• 	Care of injured, disabled or sick persons;
• 	Rehabilitation services or other skilled services needed to maintain a patient’s
current condition or to prevent or slow further deterioration; or
• 	Skilled nursing care or related services for patients who require medical or
nursing care.
If it is determined that the assisted living facility (also called personal care homes, group
homes, etc.) in which the individuals reside are not primarily engaged in providing the
above services, then Medicare will cover reasonable and necessary home health care
furnished to these individuals.
If it is determined that the services furnished by the home health agency are duplicative
of services furnished by an assisted living facility when provision of such care is required
of the facility under State licensure requirements, claims for such services should be
denied under §1862(a)(1)(A) of the Act. Section 1862(a)(1)(A) excludes services that are
not necessary for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member from Medicare coverage. Services to people
who already have access to appropriate care from a willing caregiver would not be
considered reasonable and necessary to the treatment of the individual's illness or injury.

Medicare coverage would not be an optional substitute for the services that a facility is
required to provide by law to its patients or where the services are included in the base
contract of the facility. An individual's choice to reside in such a facility is also a choice
to accept the services it holds itself out as offering to its patients.
B. Day Care Centers and Patient's Place of Residence
The current statutory definition of homebound or confined does not imply that Medicare
coverage has been expanded to include adult day care services.
The law does not permit an HHA to furnish a Medicare covered billable visit to a patient
under a home health plan of care outside his or her home, except in those limited
circumstances where the patient needs to use medical equipment that is too cumbersome
to bring to the home. Section 1861(m) of the Act stipulates that home health services
provided to a patient be provided to the patient on a visiting basis in a place of residence
used as the individual's home. A licensed/certified day care center does not meet the
definition of a place of residence.
C. State Licensure/Certification of Day Care Facilities
Per Section 1861(m) of the Act, an adult day care center must be either licensed or
certified by the State or accredited by a private accrediting body. State licensure or
certification as an adult day care facility must be based on State interpretations of its
process. For example, several States do not license adult day care facilities as a whole,
but do certify some entities as Medicaid certified centers for purposes of providing adult
day care under the Medicaid home and community based waiver program. It is the
responsibility of the State to determine the necessary criteria for "State certification" in
such a situation. A State could determine that Medicaid certification is an acceptable
standard and consider its Medicaid certified adult day care facilities to be "State
certified." On the other hand, a State could determine Medicaid certification to be
insufficient and require other conditions to be met before the adult day care facility is
considered "State certified".
D. Determination of the Therapeutic, Medical or Psychosocial Treatment of the
Patient at the Day Care Facility
It is not the obligation of the HHA to determine whether the adult day care facility is
providing psychosocial treatment, but only to assure that the adult day care center is
licensed/certified by the State or accrediting body. The intent of the law, in extending the
homebound exception status to attendance at such adult day care facilities, recognizes
that they ordinarily furnish psychosocial services.
30.2 - Services Are Provided Under a Plan of Care Established and
Approved by a Physician or Allowed Practitioner
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

30.2.1 – Definition of an Allowed Practitioner
(Rev. 11386, Issued: 04-27-22, Effective: 01-01-22, Implementation: 05-26-22)
Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for
eligibility, order home health services, and establish and review the care plan. Allowed
practitioners are defined at § 484.2 as a physician assistant (PA), nurse practitioner (NP),
or clinical nurse specialist (CNS) as defined at this part. NPs, CNSs, and PAs are required
to practice in accordance with state law in the state in which the individual performs such
services. Physician assistant means an individual as defined at § 410.74(a) and
(c). Clinical nurse specialist means an individual as defined at § 410.76(a) and (b), and
who is working in collaboration with the physician as defined at § 410.76(c)(3). Nurse
practitioner means an individual as defined at § 410.75(a) and (b), and who is working in
collaboration with the physician as defined at § 410.75(c)(3).
Individual states have varying requirements for conditions of practice, which determine
whether a practitioner may work independently without a written collaborative agreement
or supervision from a physician, or whether general or direct supervision and
collaboration is required. In the absence of State law governing collaboration,
collaboration is to be evidenced by NPs documenting their scope of practice in the
medical record, and indicating the relationships that they have with physicians to deal
with issues outside their scope of practice.
30.2. 2 - Content of the Plan of Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The HHA must be acting upon a physician or allowed practitioner plan of care that meets
the requirements of this section for HHA services to be covered. For HHA services to be
covered, the individualized plan of care must specify the services necessary to meet the
patient-specific needs identified in the comprehensive assessment. In addition, the plan of
care must include the identification of the responsible discipline(s) and the frequency and
duration of all visits as well as those items listed in 42 CFR 484.60(a) that establish the
need for such services. All care provided must be in accordance with the plan of care.
If the plan of care includes a course of treatment for therapy services:
• 	The course of therapy treatment must be established by the physician or allowed
practitioner after any needed consultation with the qualified therapist;
• 	The plan must include measurable therapy treatment goals which pertain directly
to the patient’s illness or injury, and the patient’s resultant impairments;
• 	The plan must include the expected duration of therapy services; and

• 	The plan must describe a course of treatment which is consistent with the
qualified therapist’s assessment of the patient’s function.
30.2.3 - Specificity of Orders
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01-11-21)
The orders on the plan of care must indicate the type of services to be provided to the
patient, both with respect to the professional who will provide them and the nature of the
individual services, as well as the frequency of the services.
EXAMPLE 1:
SN x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for
1 week; 3 times per week for 4 weeks; and 2 times per week for 3 weeks) for skilled
observation and evaluation of the surgical site, for teaching sterile dressing changes and
to perform sterile dressing changes. The sterile change consists of (detail of procedure).
Orders for care may indicate a specific range in the frequency of visits to ensure that the
most appropriate level of services is provided to home health patients under a home
health plan of care. When a range of visits is ordered, the upper limit of the range is
considered the specific frequency.
EXAMPLE 2:
SN x 2-4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical
site.
Orders for services to be furnished "as needed" or "PRN" must be accompanied by a
description of the patient's medical signs and symptoms that would occasion a visit and a
specific limit on the number of those visits to be made under the order before an
additional physician or allowed practitioner order would have to be obtained.
30.2.4 - Who Signs the Plan of Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The physician or allowed practitioner who signs the plan of care must be qualified to sign
the certification as described in 42 CFR 424.22.
30.2.5 - Timeliness of Signature
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A. Initial Percentage Payment

If a physician or allowed practitioner signed plan of care is not available at the beginning
of the 30-day period, the HHA may submit a RAP for the initial percentage payment
based on physician or allowed practitioner verbal orders OR a referral prescribing
detailed orders for the services to be rendered that is signed and dated by the physician or
allowed practitioner. If the RAP submission is based on verbal orders, the verbal order
must be recorded in the plan of care, include a description of the patient's condition and
the services to be provided by the home health agency, include an attestation (relating to
the physician's or allowed practitioner’s orders and the date received per 42 CFR 409.43),
and the plan of care is copied and immediately submitted to the physician or allowed
practitioner. A billable visit must be rendered prior to the submission of a RAP.
B. Final Percentage Payment
The plan of care must be signed and dated by a physician or allowed practitioner as
described who meets the certification and recertification requirements of 42 CFR 424.22
and before the claim for each 30-day period for services is submitted for the final
percentage payment. Any changes in the plan of care must be signed and dated by a
physician or allowed practitioner.
30.2.6 - Use of Oral (Verbal) Orders
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
When services are furnished based on a physician or allowed practitioner’s oral order, the
orders may be accepted and put in writing by personnel authorized to do so by applicable
State and Federal laws and regulations as well as by the HHA's internal policies. The
orders must be signed and dated with the date of receipt by the registered nurse or
qualified therapist (i.e., physical therapist, speech-language pathologist, occupational
therapist, or medical social worker) responsible for furnishing or supervising the ordered
services. The orders may be signed by the supervising registered nurse or qualified
therapist after the services have been rendered, as long as HHA personnel who receive
the oral orders notify that nurse or therapist before the service is rendered. Thus, the
rendering of a service that is based on an oral order would not be delayed pending
signature of the supervising nurse or therapist. Oral orders must be countersigned and
dated by the physician or allowed practitioner before the HHA bills for the care in the
same way as the plan of care.
Services which are provided from the beginning of the 60-day certification period based
on a request for anticipated payment and before the physician or allowed practitioner
signs the plan of care are considered to be provided under a plan of care established and
approved by the physician or allowed practitioner where there is an oral order for the care
prior to rendering the services which is documented in the medical record and where the
services are included in a signed plan of care.
Services that are provided in the subsequent 60-day certification period are considered
provided under the plan of care of the subsequent 60-day episode where there is an oral
order before the services provided in the subsequent period are furnished and the order is
reflected in the medical record. However, services that are provided after the expiration

of the plan of care, but before the acquisition of an oral order or a signed plan of care are
not considered provided under a plan of care.
EXAMPLE 1:
The HHA acquires an oral order for I.V. medication administration for a patient to be
performed on August 1. The HHA provides the I.V. medication administration August 1
and evaluates the patient's need for continued care. The physician or allowed practitioner
signs the plan of care for the I.V. medication administration on August 15. The visit is
covered since it is considered provided under a plan of care established and approved by
the physician or allowed practitioner, and the HHA had acquired an oral order prior to the
delivery of services.
EXAMPLE 2:
The patient is under a plan of care in which the physician or allowed practitioner orders
I.V. medication administration every 2 weeks. The last day covered by the initial plan of
care is July 31. The patient's next I.V. medication administration is scheduled for August
5 and the physician or allowed practitioner signs the plan of care for the new period on
August 1. The I.V. medication administration on August 5 was provided under a plan of
care established and approved by the physician or allowed practitioner.
EXAMPLE 3:
The patient is under a plan of care in which the physician or allowed practitioner orders
I.V. medication administration every 2 weeks. The last day covered by the plan of care is
July 31. The patient's next I.V. medication administration is scheduled for August 5 and
the physician or allowed practitioner does not sign the plan of care until August 6. The
HHA acquires an oral order for the I.V. medication administration before the August 5
visit, and therefore the visit is considered to be provided under a plan of care established
and approved by the physician or allowed practitioner.
Any increase in the frequency of services or addition of new services during a 60-day
certification must be authorized by a physician or allowed practitioner by way of a
written or oral order prior to the provision of the increased or additional services.
30.2.7 - Frequency of Review of the Plan of Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The plan of care must be reviewed and signed by the physician or allowed practitioner
who established the plan of care, in consultation with HHA professional personnel, at
least every 60 days. Each review of a patient's plan of care must contain the signature of
the physician or allowed practitioner and the date of review.

30.2. 8 - Facsimile Signatures
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The plan of care or oral order may be transmitted by facsimile machine. The HHA is not
required to have the original signature on file. However, the HHA is responsible for
obtaining original signatures if an issue surfaces that would require verification of an
original signature.
30.2.9 - Alternative Signatures
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
HHAs that maintain patient records by computer rather than hard copy may use
electronic signatures. However, all such entries must be appropriately authenticated and
dated. Authentication must include signatures, written initials, or computer secure entry
by a unique identifier of a primary author who has reviewed and approved the entry. The
HHA must have safeguards to prevent unauthorized access to the records and a process
for reconstruction of the records in the event of a system breakdown.
30.2.10 - Termination of the Plan of Care - Qualifying Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The plan of care is considered to be terminated if the patient does not receive at least one
covered skilled nursing, physical therapy, speech-language pathology service, or
occupational therapy visit in a 60-day certification period since these are qualifying
services for the home health benefit. An exception is if the physician or allowed
practitioner documents that the interval without such care is appropriate to the treatment
of the patient's illness or injury.
30.2.11 - Sequence of Qualifying Services and Other Medicare Covered
Home Health Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Once patient eligibility has been confirmed and the plan of care contains physician or
allowed practitioner orders for the qualifying service as well as other Medicare covered
home health services, the qualifying service does not have to be rendered prior to the
other Medicare covered home health services ordered in the plan of care. The sequence
of visits performed by the disciplines must be dictated by the individual patient's plan of
care. For example, for an eligible patient in an initial 60-day certification period that has
both physical therapy and occupational therapy orders in the plan of care, the sequence of
the delivery of the type of therapy is irrelevant as long as the need for the qualifying
service is established prior to the delivery of other Medicare covered services and the
qualifying discipline provides a billable visit prior to transfer or discharge in accordance
with 42 CFR 409.43(f).

NOTE: Dependent services provided after the final qualifying skilled service are not
covered under the home health benefit, except when the dependent service was not
followed by a qualifying skilled service due to unexpected inpatient admission, death of
the patient, or some other unanticipated event.
30.3 - Under the Care of a Physician or Allowed Practitioner
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The patient must be under the care of a physician or allowed practitioner who is qualified
to sign the certification and plan of care in accordance with 42 CFR 424.22.
A patient is expected to be under the care of the physician or allowed practitioner who
signs the plan of care. It is expected that in most instances, the physician or allowed
practitioner who certifies the patient’s eligibility for Medicare home health services, in
accordance with §30.5 below, will be the same physician or allowed practitioner who
establishes and signs the plan of care.
30.4 - Needs Skilled Nursing Care on an Intermittent Basis (Other than
Solely Venipuncture for the Purposes of Obtaining a Blood Sample),
Physical Therapy, Speech-Language Pathology Services, or Has
Continued Need for Occupational Therapy
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The patient must need one of the following types of services:
1. 	Skilled nursing care that is
• 	Reasonable and necessary as defined in §40.1;
• 	Needed on an "intermittent" basis as defined in §40.1.3; and
• 	Not solely needed for venipuncture for the purposes of obtaining blood
sample as defined in §40.1.2.13;or
2. 	Physical therapy as defined in §40.2.2; or
3. 	Speech-language pathology services as defined in §40.2.3; or
4. 	Have a continuing need for occupational therapy as defined in §§40.2.4.
The patient has a continued need for occupational therapy when:
1. 	The services which the patient requires meet the definition of "occupational
therapy" services of §40.2.4, and

2. 	The patient's eligibility for home health services has been established by virtue of
a prior need for skilled nursing care (other than solely venipuncture for the
purposes of obtaining a blood sample), speech-language pathology services, or
physical therapy in the current or prior certification period.
EXAMPLE: A patient who is recovering from a cerebrovascular accident (CVA) has an
initial plan of care that called for physical therapy, speech-language pathology services,
occupational therapy, and home health aide services. In the next certification period, the
physician or allowed practitioner orders only occupational therapy and home health aide
services because the patient no longer needs the skills of a physical therapist or a speech-
language pathologist, but needs the services provided by the occupational therapist. The
patient's need for occupational therapy qualifies him for home health services, including
home health aide services (presuming that all other qualifying criteria are met), because
in the prior certification period the beneficiary’s eligibility for home health services was
established by virtue of prior needs for physical therapy and speech-language pathology,
and occupational therapy was initiated while the patient still required physical therapy
and/or speech language-pathology.
30.5 - Physician or Allowed Practitioner Certification and
Recertification of Patient Eligibility for Medicare Home Health Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The HHA must be acting upon a plan of care as described in §30.2, and a physician or
allowed practitioner certification or recertification that meets the requirements of the
following sections in order for HHA services to be covered.
30.5.1 - Physician or Allowed Practitioner Certification
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A certification (versus recertification) is considered to be anytime that a Start of Care
OASIS is completed to initiate care. In such instances, a physician or allowed
practitioner must certify (attest) that:
1. 	The home health services are or were needed because the patient is or was confined to
the home as defined in §30.1.1;
2. 	The patient needs or needed skilled nursing services on an intermittent basis (other
than solely venipuncture for the purposes of obtaining a blood sample), or physical
therapy, or speech-language pathology services. Where a patient’s sole skilled service
need is for skilled oversight of unskilled services (management and evaluation of the care
plan as defined in §40.1.2.2), the physician or allowed practitioner must include a brief
narrative describing the clinical justification of this need as part of the certification, or as
a signed addendum to the certification;

3. 	A plan of care has been established and is periodically reviewed by a physician or
allowed practitioner;
4. 	The services are or were furnished while the patient is or was under the care of a
physician or allowed practitioner;
5. 	For episodes/periods with starts of care beginning January 1, 2011 and later, in
accordance with §30.5.1.1 below, a face-to-face encounter occurred no more than 90 days
prior to or within 30 days after the start of the home health care, was related to the
primary reason the patient requires home health services, and was performed by a
physician or non-physician practitioner. The certifying physician or allowed practitioner
must also document the date of the encounter.
Example Certification Statement:
I certify that this patient is confined to his/her home and needs intermittent skilled
nursing care, physical therapy and/or speech therapy or continues to need occupational
therapy. The patient is under my care, and I have authorized services on this plan of
care and will periodically review the plan. The patient had a face-to-face encounter
with a physician or an allowed non-physician practitioner on 11/01/2020 and the
encounter was related to the primary reason for home health care.
Physician or allowed practitioner’s Signature and Date Signed: 	John Doe, MD
11/05/2020
Physician or Allowed Practitioner’s Name and Address
John Doe, MD
2121 Washington Pkwy
Suite 220
Washington, DC 20000
NOTE: This represents one example of a valid certification statement. Certification
statements can be included in varying forms or formats as long as the content
requirements (#1-5 above) for the certification are met.
If the patient is starting home health directly after discharge from an acute/post-acute care
setting where the physician or allowed practitioner, with privileges, that cared for the
patient in that setting is certifying the patient’s eligibility for the home health benefit, but
will not be following the patient after discharge, then the certifying physician or allowed
practitioner must identify the community physician or allowed practitioner who will be
following the patient after discharge. One of the criteria that must be met for a patient to
be considered eligible for the home health benefit is that the patient must be under the
care of a physician or allowed practitioner (number 4 listed above). Otherwise, the
certification is not valid.

The certification must be complete prior to when an HHA bills Medicare for
reimbursement; however, physicians and allowed practitioners should complete the
certification when the plan of care is established, or as soon as possible thereafter. This is
longstanding CMS policy as referenced in Pub 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, chapter 4, section 30.1. It is not acceptable for
HHAs to wait until the end of a 60-day certification period to obtain a completed
certification/recertification.
30.5.1.1 – Face-to-Face Encounter
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
1. Allowed Provider Types
As part of the certification of patient eligibility for the Medicare home health benefit, a
face-to-face encounter with the patient must be performed by the certifying physician or
allowed practitioner himself or herself, a physician or allowed practitioner that cared for
the patient in the acute or post-acute care facility (with privileges who cared for the
patient in an acute or post-acute care facility from which the patient was directly admitted
to home health) or an allowed non-physician practitioner (NPP).
NPPs who are allowed to perform the encounter are:
• 	A nurse practitioner or a clinical nurse specialist working in accordance with State
law and in collaboration with the certifying physician or in collaboration with an
acute or post-acute care physician, with privileges, who cared for the patient in
the acute or post-acute care facility from which the patient was directly admitted
to home health;
• 	A certified nurse midwife, as authorized by State law, under the supervision of the
certifying physician or under the supervision of an acute or post-acute care
physician with privileges who cared for the patient in the acute or post-acute care
facility from which the patient was directly admitted to home health;
• 	A physician assistant under the supervision of the certifying physician or under
the supervision of an acute or post-acute care physician with privileges who cared
for the patient in the acute or post-acute care facility from which the patient was
directly admitted to home health.
NPPs performing the encounter are subject to the same financial restrictions with the
HHA as the certifying physician, as described in 42 CFR 424.22(d).
2. Timeframe Requirements
• 	The encounter must occur no more than 90 days prior to the home health start of
care date or within 30 days after the start of care.

• 	In situations when a physician or allowed practitioner orders home health care for
the patient based on a new condition that was not evident during a visit within the
90 days prior to start of care, the physician or an allowed NPP must see the
patient again within 30 days after admission. Specifically, if a patient saw the
physician or NPP within the 90 days prior to start of care, another encounter
would be needed if the patient’s condition had changed to the extent that
standards of practice would indicate that the physician or a non-physician
practitioner should examine the patient in order to establish an effective treatment
plan.
3. Exceptional Circumstances
When a home health patient dies shortly after admission, before the face-to-face
encounter occurs, if the contractor determines a good faith effort existed on the part of the
HHA to facilitate/coordinate the encounter and if all other certification requirements are
met, the certification is deemed to be complete.
4. Telehealth
The face-to-face encounter can be performed via a telehealth service, in an approved
originating site. An originating site is considered to be the location of an eligible
Medicare beneficiary at the time the service being furnished via a telecommunications
system occurs. Medicare beneficiaries are eligible for telehealth services only if they are
presented from an originating site located in a rural health professional shortage area or in
a county outside of a Metropolitan Statistical Area.
Entities that participate in a Federal telemedicine demonstration project approved by (or
receiving funding from) the Secretary of the Department of Health and Human Services
as of December 31, 2000, qualify as originating sites regardless of geographic location.
The originating sites authorized by law are:
• 	The office of a physician or practitioner;
• 	Hospitals;
• 	Critical Access Hospitals (CAH);
• 	Rural Health Clinics (RHC);
• 	Federally Qualified Health Centers (FQHC);
• 	Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
• 	Skilled Nursing Facilities (SNF); and
• 	Community Mental Health Centers (CMHC).
30.5.1.2 – Supporting Documentation Requirements
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
As of January 1, 2015, documentation in the certifying physician or allowed
practitioner’s medical records and/or the acute /post-acute care facility’s medical records

(if the patient was directly admitted to home health) will be used as the basis upon which
patient eligibility for the Medicare home health benefit will be determined.
Documentation from the certifying physician or allowed practitioner’s medical records
and/or the acute /post-acute care facility’s medical records (if the patient was directly
admitted to home health) used to support the certification of home health eligibility must
be provided, upon request, to the home health agency, review entities, and/or the Centers
for Medicare and Medicaid Services (CMS). In turn, an HHA must be able to provide,
upon request, the supporting documentation that substantiates the eligibility for the
Medicare home health benefit to review entities and/or CMS. If the documentation used
as the basis for the certification of eligibility is not sufficient to demonstrate that the
patient is or was eligible to receive services under the Medicare home health benefit,
payment will not be rendered for home health services provided.
The certifying physician or allowed practitioner and/or the acute/post-acute care facility
medical record (if the patient was directly admitted to home health) for the patient must
contain information that justifies the referral for Medicare home health services. This
includes documentation that substantiates the patient’s:
• 	Need for the skilled services; and
• 	Homebound status;
The certifying physician or allowed practitioner and/or the acute/post-acute care facility
medical record (if the patient was directly admitted to home health) for the patient must
contain the actual clinical note for the face-to-face encounter visit that demonstrates that
the encounter:
• 	Occurred within the required timeframe,
• 	Was related to the primary reason the patient requires home health services; and
• 	Was performed by an allowed provider type.
This information can be found most often in clinical and progress notes and discharge
summaries. While the face-to-face encounter must be related to the primary reason for
home health services, the patient’s skilled need and homebound status can be
substantiated through an examination of all submitted medical record documentation
from the certifying physician or allowed practitioner, acute/post-acute care facility,
and/or HHA (see below). The synthesis of progress notes, diagnostic findings,
medications, nursing notes, etc., help to create a longitudinal clinical picture of the
patient’s health status.
• 	Information from the HHA, such as the plan of care required per 42 CFR §409.43
and the initial and/or comprehensive assessment of the patient required per 42
CFR §484.55, can be incorporated into the certifying physician or allowed
practitioner’s medical record for the patient and used to support the patient’s
homebound status and need for skilled care. However, this information must be
corroborated by other medical record entries in the certifying physician or
allowed practitioner’s and/or the acute/post-acute care facility’s medical record
for the patient. This means that the appropriately incorporated HHA information,

along with the certifying physician or allowed practitioner’s and/or the acute/post-
acute care facility’s medical record, creates a clinically consistent picture that the
patient is eligible for Medicare home health services.
• 	The certifying physician or allowed practitioner demonstrates the incorporation of
the HHA information into his/her medical record for the patient by signing and
dating the material. Once incorporated, the documentation from the HHA, in
conjunction with the certifying physician or allowed practitioner and/or
acute/post-acute care facility documentation, must substantiate the patient’s
eligibility for home health services.
30.5.2 - Physician or Allowed Practitioner Recertification
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
At the end of the 60-day certification, a decision must be made whether or not to recertify
the patient for a subsequent 60-days. An eligible beneficiary who qualifies for a
subsequent 60-day certification would start the subsequent 60-day certification on day 61.
Under HH PPS, the plan of care must be reviewed and signed by the physician or allowed
practitioner every 60 days unless one of the following occurs:
• 	A beneficiary transfers to another HHA; or
• 	A discharge and return to home health during the 60-day certification.
For recertification of home health services, the physician or allowed practitioner must
certify (attest) that:
1. The home health services are or were needed because the patient is or was
confined to the home as defined in §30.1;
2. The patient needs or needed skilled nursing services on an intermittent basis (other
than solely venipuncture for the purposes of obtaining a blood sample), or physical
therapy, or speech-language pathology services; or continues to need occupational
therapy after the need for skilled nursing care, physical therapy, or speech-language
pathology services ceased. Where a patient’s sole skilled service need is for skilled
oversight of unskilled services (management and evaluation of the care plan as
defined in §40.1.2.2), the physician or allowed practitioner must include a brief
narrative describing the clinical justification of this need as part of the recertification,
or as a signed addendum to the recertification;
3. A plan of care has been established and is periodically reviewed by a physician or
allowed practitioner; and
4. The services are or were furnished while the patient is or was under the care of a
physician or allowed practitioner.

Medicare does not limit the number of continuous 60-day recertifications for
beneficiaries who continue to be eligible for the home health benefit. The certification
may cover a period less than but not greater than 60 days. Because the updated home
health plan of care must include the frequency and duration of visits to be made, the
physician or allowed practitioner does not have to estimate how much longer skilled
services will be needed for the recertification.
30.5.3 - Who May Sign the Certification or Recertification
(Rev. 10738, Issued: 05-07-21, Effective: 01-01-21, Implementation: 08-09-21)
The physician or allowed practitioner who signs the certification or recertification must
be permitted to do so by 42 CFR 424.22. A physician or other allowed non-physician
practitioner, other than the certifying physician or certifying allowed practitioner who
established the home health plan of care, may sign the plan of care or the recertification
statement in the absence of the certifying physician or certifying allowed practitioner.
This is only permitted when such physician or allowed non-physician practitioner has
been authorized to care for the certifying physician’s or allowed practitioner’s patients in
his/her absence. The HHA is responsible for ensuring that the physician or allowed non-
physician practitioner who signs the plan of care and recertification statement was
authorized by the physician or allowed practitioner who established the plan of care and
completed the certification for his/her patient in his/her absence. The physician or
allowed practitioner that performed the required face-to-face encounter must sign the
certification of eligibility, unless the patient is directly admitted to home health care from
an acute or post-acute care facility and the encounter was performed by a physician or
allowed practitioner in such setting.
30.5.4 – Physician or Allowed Practitioner Billing for Certification and
Recertification
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Certification and recertification claims are Part B claims paid for under the Physician Fee
Schedule. These claims are billed using HCPCS codes G0180 (certification) or G0179
(re-certification). The descriptions of these two codes indicate that they are used to bill
for certification or recertification of patient eligibility “for Medicare-covered home health
services under a home health plan of care (patient not present), including contacts with
the HHA and review of reports of patient status required by physicians or allowed
practitioners to affirm the initial implementation of the plan of care that meets patient's
needs, per certification period”. As noted above, these codes are for certification or
recertification for Medicare-covered home health services. If there are no Medicare-
covered home health services, these codes should not be billed or paid. As such, claims
for certification/recertification of eligibility for home health services (G0180 and G0179,
respectively) will not be covered if the HHA claim itself was non-covered because the
certification/recertification of eligibility was not complete or because there was
insufficient documentation to support that the patient was eligible for the Medicare home
health benefit.
40 - Covered Services Under a Qualifying Home Health Plan of Care

(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Section 1861(m)of the Act governs the Medicare home health services that may be
provided to eligible beneficiaries by or under arrangements made by a participating home
health agency (HHA). Section 1861(m) describes home health services as
• 	Part-time or intermittent skilled nursing care (other than solely venipuncture for
the purposes of obtaining a blood sample);
• 	Part-time or intermittent home health aide services;
• 	Physical therapy;
• 	Speech-language pathology;
• 	Occupational therapy;
• 	Medical social services;
• 	Medical supplies (including catheters, catheter supplies, ostomy bags, supplies
related to ostomy care, and a covered osteoporosis drug (as defined in §1861(kk
of the Act), but excluding other drugs and biologicals);
• 	Durable medical equipment while under the plan of care established by physician
or allowed practitioner;
• 	Medical services provided by an intern or resident-in-training under an approved
teaching program of the hospital in the case of an HHA which is affiliated or
under common control with a hospital; and
• 	Services at hospitals, skilled nursing facilities, or rehabilitation centers when they
involve equipment too cumbersome to bring to the home.
The term "part-time or intermittent" for purposes of coverage under §1861(m) of the Act
means skilled nursing and home health aide services furnished any number of days per
week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer
hours each week (or, subject to review on a case-by-case basis as to the need for care,
less than 8 hours each day and 35 or fewer hours per week). See §50.7.
For any home health services to be covered by Medicare, the patient must meet the
qualifying criteria as specified in §30, including having a need for skilled nursing care on
an intermittent basis, physical therapy, speech-language pathology services, or a
continuing need for occupational therapy as defined in this section.
40.1 - Skilled Nursing Care
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.1, HHA-205.1

To be covered as skilled nursing services, the services must require the skills of a
registered nurse, or a licensed practical (vocational) nurse under the supervision of a
registered nurse, must be reasonable and necessary to the treatment of the patient's illness
or injury as discussed in §40.1.1, below, and must be intermittent as discussed in §40.1.3.
Coverage of skilled nursing care does not turn on the presence or absence of a patient’s
potential for improvement from the nursing care, but rather on the patient’s need for
skilled care.
40.1.1 - General Principles Governing Reasonable and Necessary Skilled
Nursing Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
If all other eligibility and coverage requirements under the home health benefit are met,
skilled nursing services are covered when an individualized assessment of the patient’s
clinical condition demonstrates that the specialized judgment, knowledge, and skills of a
registered nurse or, when provided by regulation, a licensed practical (vocational) nurse
(“skilled care”) are necessary. Skilled nursing services are covered where such skilled
nursing services are necessary to maintain the patient’s current condition or prevent or
slow further deterioration so long as the beneficiary requires skilled care for the services
to be safely and effectively provided. When, however, the individualized assessment
does not demonstrate such a necessity for skilled care, including when the services
needed do not require skilled nursing care because they could safely and effectively be
performed by the patient or unskilled caregivers, such services will not be covered under
the home health benefit.
Skilled nursing care is necessary only when (a) the particular patient’s special medical
complications require the skills of a registered nurse or, when provided by regulation, a
licensed practical nurse to perform a type of service that would otherwise be considered
non-skilled; or (b) the needed services are of such complexity that the skills of a
registered nurse or, when provided by regulation, a licensed practical nurse are required
to furnish the services. To be considered a skilled service, the service must be so
inherently complex that it can be safely and effectively performed only by, or under the
supervision of, professional or technical personnel as provided by regulation, including
42 C.F.R. 409.32.
Some services may be classified as a skilled nursing service on the basis of complexity
alone (e.g., intravenous and intramuscular injections or insertion of catheters) and, if
reasonable and necessary to the treatment of the patient's illness or injury, would be
covered on that basis. If a service can be safely and effectively performed (or self-
administered) by an unskilled person, without the direct supervision of a nurse, the
service cannot be regarded as a skilled nursing service although a nurse actually provides
the service. However, in some cases, the condition of the patient may cause a service that
would ordinarily be considered unskilled to be considered a skilled nursing service. This
would occur when the patient's condition is such that the service can be safely and
effectively provided only by a nurse. A service is not considered a skilled nursing service
merely because it is performed by or under the supervision of a nurse. The unavailability

of a competent person to provide a non-skilled service, regardless of the importance of
the service to the patient, does not make it a skilled service when a nurse provides the
service.
A service that, by its nature, requires the skills of a nurse to be provided safely and
effectively continues to be a skilled service even if it is taught to the patient, the patient's
family, or other caregivers.
The skilled nursing service must be reasonable and necessary to the diagnosis and
treatment of the patient's illness or injury within the context of the patient's unique
medical condition. To be considered reasonable and necessary for the diagnosis or
treatment of the patient's illness or injury, the services must be consistent with the nature
and severity of the illness or injury, the patient's particular medical needs, and accepted
standards of medical and nursing practice. The determination of whether the services are
reasonable and necessary should be made in consideration that a physician or allowed
practitioner has determined that the services ordered are reasonable and necessary. The
services must, therefore, be viewed from the perspective of the condition of the patient
when the services were ordered and what was, at that time, reasonably expected to be
appropriate treatment for the illness or injury throughout the certification period.
A patient's overall medical condition, without regard to whether the illness or injury is
acute, chronic, terminal, or expected to extend over a long period of time, should be
considered in deciding whether skilled services are needed. A patient's diagnosis should
never be the sole factor in deciding that a service the patient needs is either skilled or not
skilled. Skilled care may, depending on the unique condition of the patient, continue to
be necessary for patients whose condition is stable.
As is outlined in home health regulations, as part of the home health agency (HHA)
Conditions of Participation (CoPs), the clinical record of the patient must contain
progress and clinical notes. Additionally, in Pub. 100-04, Medicare Claims Processing
Manual, Chapter 10; “Home Health Agency Billing”, instructions specify that for each
claim, HHAs are required to report all services provided to the beneficiary during each
30-day period, which includes reporting each visit in line-item detail. As such, it is
expected that the home health records for every visit will reflect the need for the skilled
medical care provided. These clinical notes are also expected to provide important
communication among all members of the home care team regarding the development,
course and outcomes of the skilled observations, assessments, treatment and training
performed. Taken as a whole then, the clinical notes are expected to tell the story of the
patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way,
the notes will serve to demonstrate why a skilled service is needed.
Therefore the home health clinical notes must document as appropriate:
• 	the history and physical exam pertinent to the day’s visit, (including the response or
changes in behavior to previously administered skilled services) and the skilled
services applied on the current visit, and
• 	the patient/caregiver’s response to the skilled services provided, and

• 	the plan for the next visit based on the rationale of prior results,
• 	a detailed rationale that explains the need for the skilled service in light of the
patient’s overall medical condition and experiences,
• 	the complexity of the service to be performed, and
• 	any other pertinent characteristics of the beneficiary or home
Clinical notes should be written so that they adequately describe the reaction of a patient
to his/her skilled care. Clinical notes should also provide a clear picture of the treatment,
as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care
should not be used. For example, terminology such as the following would not
adequately describe the need for skilled care:
• 	Patient tolerated treatment well
• 	Caregiver instructed in medication management
• 	Continue with POC
Objective measurements of physical outcomes of treatment should be provided and/or a
clear description of the changed behaviors due to education programs should be recorded
in order that all concerned can follow the results of the applied services.
EXAMPLE 1:
The presence of a plaster cast on an extremity generally does not indicate a need for
skilled nursing care. However, the patient with a preexisting peripheral vascular or
circulatory condition might need skilled nursing care to observe for complications,
monitor medication administration for pain control, and teach proper skin care to
preserve skin integrity and prevent breakdown. The documentation must support the
severity of the circulatory condition that requires skilled care. The clinical notes for each
home health visit should document the patient’s skin and circulatory examination as well
as the patient and/or caregiver application of the educational principles taught since the
last visit. The plan for the next visit should describe the skilled services continuing to be
required.
EXAMPLE 2:
The condition of a patient, who has irritable bowel syndrome or is recovering from rectal
surgery, may be such that he or she can be given an enema safely and effectively only by
a nurse. If the enema were necessary to treat the illness or injury, then the visit would be
covered as a skilled nursing visit. The documentation must support the skilled need for
the enema, and the plan for future visits based on this information.
EXAMPLE 3:

Giving a bath does not ordinarily require the skills of a nurse and, therefore, would not be
covered as a skilled nursing service unless the patient's condition is such that the bath
could be given safely and effectively only by a nurse (as discussed in §30.1 above).
EXAMPLE 4:
A patient with a well-established colostomy absent complications may require assistance
changing the colostomy bag because they cannot do it themselves and there is no one else
to change the bag. Notwithstanding the need for the routine colostomy care, changing the
colostomy bag does not become a skilled nursing service when the nurse provides it.
EXAMPLE 5:
A patient was discharged from the hospital with an open draining wound that requires
irrigation, packing, and dressing twice each day. The HHA has taught the family to
perform the dressing changes. The HHA continues to see the patient for the wound care
that is needed during the time that the family is not available and willing to provide the
dressing changes. The wound care continues to be skilled nursing care, notwithstanding
that the family provides it part of the time, and may be covered as long as the patient
requires it.
EXAMPLE 6:
A physician has ordered skilled nursing visits for a patient with a hairline fracture of the
hip. The home health record must document the reason skilled services are required and
why the nursing visits are reasonable and necessary for treatment of the patient's hip
injury.
EXAMPLE 7:
A physician has ordered skilled nursing visits for teaching of self-administration and self-
management of the medication regimen for a patient, newly diagnosed, with diabetes
mellitus in the home health plan of care. Each visit’s documentation must describe the
patient’s progress in this activity.
EXAMPLE 8:
Following a cerebrovascular accident (CVA), a patient has an in-dwelling Foley catheter
because of urinary incontinence, and is expected to require the catheter for a long and
indefinite period. The medical condition of the patient must be described and
documented to support the need for nursing skilled services in the home health plan of
care. Periodic visits to change the catheter as needed, treat the symptoms of catheter
malfunction, and teach proper catheter care would be covered as long as they are
reasonable and necessary, although the patient is stable, even if there is an expectation
that the care will be needed for a long and indefinite period. However, at every home
health visit, the patient’s current medical condition must be described and there must be
documentation to support the need for continued skilled nursing services.

EXAMPLE 9:
A patient with advanced multiple sclerosis undergoing an exacerbation of the illness
needs skilled teaching of medications, measures to overcome urinary retention, and the
establishment of a program designed to minimize the adverse impact of the exacerbation.
The clinical notes for each home health visit must describe why skilled nursing services
were required. The skilled nursing care received by the patient would be covered despite
the chronic nature of the illness.
EXAMPLE 10:
A patient with malignant melanoma is terminally ill, and requires skilled observation,
assessment, teaching, and treatment. The patient has not elected coverage under
Medicare's hospice benefit. The documentation should describe the goal of the skilled
nursing intervention, and at each visit the services provided should support that goal. The
skilled nursing care that the patient requires would be covered, notwithstanding that the
condition is terminal, because the documentation and description must support that the
needed services required the skills of a nurse.
40.1.2 - Application of the Principles to Skilled Nursing Services
(Rev. 1, 10-01-03)
A3-3118.1.B, HHA-205.1.B
The following discussion of skilled nursing services applies the foregoing principles to
specific skilled nursing services about which questions are most frequently raised.
40.1.2.1 - Observation and Assessment of the Patient's Condition When
Only the Specialized Skills of a Medical Professional Can Determine
Patient's Status
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
Observation and assessment of the patient's condition by a nurse are reasonable and
necessary skilled services where there is a reasonable potential for change in a patient's
condition that requires skilled nursing personnel to identify and evaluate the patient's
need for possible modification of treatment or initiation of additional medical procedures
until the patient's clinical condition and/or treatment regimen has stabilized. Where a
patient was admitted to home health care for skilled observation because there was a
reasonable potential of a complication or further acute episode, but did not develop a
further acute episode or complication, the skilled observation services are still covered
for 3 weeks or so long as there remains a reasonable potential for such a complication or
further acute episode.
Information from the patient's home health record must document the rationale that
demonstrates that there is a reasonable potential for a future complication or acute
episode and, therefore, may justify the need for continued skilled observation and

assessment beyond the 3-week period. Such signs and symptoms as abnormal/fluctuating
vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab
values, and respiratory changes on auscultation may justify skilled observation and
assessment. Where these signs and symptoms are such that there is a reasonable potential
that skilled observation and assessment by a licensed nurse will result in changes to the
treatment of the patient, then the services would be covered. However, observation and
assessment by a nurse is not reasonable and necessary for the treatment of the illness or
injury where fluctuating signs and symptoms are part of a longstanding pattern of the
patient's condition which has not previously required a change in the prescribed
treatment.
EXAMPLE 1:
A patient with atherosclerotic heart disease with congestive heart failure requires
observation by skilled nursing personnel for signs of decompensation or adverse effects
resulting from newly prescribed medication. Skilled observation is needed to determine
whether the new drug regimen should be modified or whether other therapeutic measures
should be considered until the patient's clinical condition and/or treatment regimen has
stabilized. The clinical notes for each home health visit should reflect the deliberations
and their outcome.
EXAMPLE 2:
A patient has undergone peripheral vascular disease treatment including a
revascularization procedure (bypass). The incision area is showing signs of potential
infection, (e.g., heat, redness, swelling, drainage) and the patient has elevated body
temperature. For each home health visit, the clinical notes must demonstrate that the
skilled observation and monitoring is required.
EXAMPLE 3:
A patient was hospitalized following a heart attack. Following treatment he was
discharged home. Because it is not known whether increasing exertion will exacerbate
the heart disease, skilled observation is reasonable and necessary as mobilization is
initiated in the patient’s home. The patient’s necessity for skilled observation must be
documented at each home health visit until the patient's clinical condition and/or
treatment regimen has stabilized.
EXAMPLE 4:
A frail 85-year old man was hospitalized for pneumonia. The infection was resolved, but
the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.
The patient is discharged to the HHA for monitoring of fluid and nutrient intake and
assessment of the need for tube feeding. Observation and monitoring by skilled nurses of
the patient's oral intake, output and hydration status is required to determine what further
treatment or other intervention is needed. The patient’s necessity for skilled observation

and treatment must be documented at each home health visit, until the patient's clinical
condition and/or treatment regimen has stabilized.
EXAMPLE 5:
A patient with glaucoma and a cardiac condition has a cataract extraction. Because of the
interaction between the eye drops for the glaucoma and cataracts and the beta-blocker for
the cardiac condition, the patient is at risk for serious cardiac arrhythmia. Skilled
observation and monitoring of the drug actions is reasonable and necessary until the
patient's condition is stabilized. The patient’s necessity for skilled observation must be
documented at each home health visit, until the clinical condition and/or patient's
treatment regimen has stabilized.
EXAMPLE 6:
A patient with hypertension suffered dizziness and weakness. The physician found that
the blood pressure was too low and discontinued the hypertension medication. Skilled
observation and monitoring of the patient's blood pressure and medication regimen is
required until the blood pressure remains stable and in a safe range. The patient’s
necessity for skilled observation must be documented at each home health visit, until the
patient's clinical condition and/or treatment regimen has stabilized.
EXAMPLE 7:
A patient has chronic non-healing skin ulcers, Diabetes Mellitus Type I, and spinal
muscular atrophy. In the past, the patient’s wounds have deteriorated, requiring the
patient to be hospitalized. Previously, a skilled nurse has trained the patient’s wife to
perform wound care. The treating physician orders a continuation of skilled care for a
subsequent 60-day certification period, at a frequency of one visit every 2 weeks to
perform observation and assessment of the patient’s skin ulcers to make certain that they
are not worsening. This order is reasonable and necessary because, although the
unskilled family caregiver has learned to care for the wounds, the skilled nurse can use
observation and assessment to determine if the condition is worsening.
40.1.2.2 - Management and Evaluation of a Patient Care Plan
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
Skilled nursing visits for management and evaluation of the patient's care plan are also
reasonable and necessary where underlying conditions or complications require that only
a registered nurse can ensure that essential unskilled care is achieving its purpose. For
skilled nursing care to be reasonable and necessary for management and evaluation of the
patient's plan of care, the complexity of the necessary unskilled services that are a
necessary part of the medical treatment must require the involvement of skilled nursing
personnel to promote the patient's recovery and medical safety in view of the patient's
overall condition.

EXAMPLE 1:
An aged patient with a history of diabetes mellitus and angina pectoris is recovering from
an open reduction of the neck of the femur. He requires, among other services, careful
skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to
preserve muscle tone and body condition, and observation to notice signs of deterioration
in his condition or complications resulting from his restricted, but increasing mobility.
Although a properly instructed person could perform any of the required services, that
person would not have the capability to understand the relationship among the services
and their effect on each other. Since the combination of the patient's condition, age, and
immobility create a high potential for serious complications, such an understanding is
essential to ensure the patient's recovery and safety. The management of this plan of care
requires skilled nursing personnel until nursing visits are not needed to observe and
assess the effects of the non-skilled services being provided to treat the illness or injury
until the patient recovers. Where nursing visits are not needed to observe and assess the
effects of the non-skilled services being provided to treat the illness or injury, skilled
nursing care would not be considered reasonable and necessary, and the management and
evaluation of the care plan would not be considered a skilled service.
EXAMPLE 2:
An aged patient with a history of mild dementia is recovering from pneumonia which has
been treated at home. The patient has had an increase in disorientation, has residual chest
congestion, decreased appetite, and has remained in bed, immobile, throughout the period
with pneumonia. While the residual chest congestion and recovery from pneumonia
alone would not represent a high risk factor, the patient's immobility and increase in
confusion could create a high probability of a relapse. In this situation, skilled oversight
of the unskilled services would be reasonable and necessary pending the elimination of
the chest congestion and resolution of the persistent disorientation to ensure the patient's
medical safety. For this determination to be made, the home health documentation must
describe the complexity of the unskilled services that are a necessary part of the medical
treatment and which require the involvement of a registered nurse in order to ensure that
essential unskilled care is achieving its purpose. Where visits by a licensed nurse are not
needed to observe and assess the effects of the unskilled services being provided to treat
the illness or injury, skilled nursing care would not be considered reasonable and
necessary to treat the illness or injury.
EXAMPLE 3:
A physician orders one skilled nursing visit every 2 weeks and three home health aide
visits each week for bathing and washing hair for a patient whose recovery from a CVA
has left him with residual weakness on the left side. The cardiovascular condition is
stable and the patient has reached the maximum restoration potential. There are no
underlying conditions that would necessitate the skilled supervision of a licensed nurse in
assisting with bathing or hair washing. The skilled nursing visits are not necessary to
manage and supervise the home health aide services and would not be covered.

40.1.2.3 - Teaching and Training Activities
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.1.B.3, HHA-205.1.B.3
Teaching and training activities that require skilled nursing personnel to teach a patient,
the patient's family, or caregivers how to manage the treatment regimen would constitute
skilled nursing services. Where the teaching or training is reasonable and necessary to
the treatment of the illness or injury, skilled nursing visits for teaching would be covered.
The test of whether a nursing service is skilled relates to the skill required to teach and
not to the nature of what is being taught. Therefore, where skilled nursing services are
necessary to teach an unskilled service, the teaching may be covered. Skilled nursing
visits for teaching and training activities are reasonable and necessary where the teaching
or training is appropriate to the patient's functional loss, illness, or injury.
Where it becomes apparent after a reasonable period of time that the patient, family, or
caregiver will not or is not able to be trained, then further teaching and training would
cease to be reasonable and necessary. The reason why the training was unsuccessful
should be documented in the record. Notwithstanding that the teaching or training was
unsuccessful, the services for teaching and training would be considered to be reasonable
and necessary prior to the point that it became apparent that the teaching or training was
unsuccessful, as long as such services were appropriate to the patient's illness, functional
loss, or injury.
In determining the reasonable and necessary number of teaching and training visits,
consideration must be given to whether the teaching and training provided constitutes
reinforcement of teaching provided previously in an institutional setting or in the home or
whether it represents initial instruction. Where the teaching represents initial instruction,
the complexity of the activity to be taught and the unique abilities of the patient are to be
considered. Where the teaching constitutes reinforcement, an analysis of the patient's
retained knowledge and anticipated learning progress is necessary to determine the
appropriate number of visits. Skills taught in a controlled institutional setting often need
to be reinforced when the patient returns home. Where the patient needs reinforcement
of the institutional teaching, additional teaching visits in the home are covered.
Re-teaching or retraining for an appropriate period may be considered reasonable and
necessary where there is a change in the procedure or the patient's condition that requires
re-teaching, or where the patient, family, or caregiver is not properly carrying out the
task. The medical record should document the reason that the re-teaching or retraining is
required and the patient/caregiver response to the education.
EXAMPLE 1:
A physician has ordered skilled nursing care for teaching a diabetic who has recently
become insulin dependent. The physician has ordered teaching of self-injection and
management of insulin, signs, and symptoms of insulin shock, and actions to take in
emergencies. The education is reasonable and necessary to the treatment of the illness or
injury, and the teaching services and the patient/caregiver responses must be documented.

EXAMPLE 2:
A physician has ordered skilled nursing care to teach a patient to follow a new
medication regimen in which there is a significant probability of adverse drug reactions
due to the nature of the drug and the patient's condition, to recognize signs and symptoms
of adverse reactions to new medications, and to follow the necessary dietary restrictions.
After it becomes apparent that the patient remains unable to take the medications
properly, cannot demonstrate awareness of potential adverse reactions, and is not
following the necessary dietary restrictions, skilled nursing care for further teaching
would not be reasonable and necessary, since the patient has demonstrated an inability to
be taught. The documentation must thoroughly describe all efforts that have been made
to educate the patient/caregiver, and their responses. The health record should also
describe the reason for the failure of the educational attempts.
EXAMPLE 3:
A physician has ordered skilled nursing visits to teach self-administration of insulin to a
patient who has been self-injecting insulin for 10 years and there is no change in the
patient's physical or mental status that would require re-teaching. The skilled nursing
visits would not be considered reasonable and necessary since the patient has a
longstanding history of being able to perform the service.
EXAMPLE 4:
A physician has ordered skilled nursing visits to teach self-administration of insulin to a
patient who has been self-injecting insulin for 10 years because the patient has recently
lost the use of the dominant hand and must be retrained to use the other hand. Skilled
nursing visits to re-teach self-administration of the insulin would be reasonable and
necessary. The patient’s response to teaching must be documented at each home health
visit, until the patient has learned how to self-administer.
EXAMPLE 5:
A patient recovering from pneumonia is being sent home requiring I.V. infusion of
antibiotics four times per day. The patient's spouse has been shown how to administer
the drug during the hospitalization and has been told the signs and symptoms of infection.
The physician has ordered home health services for a nurse to teach the administration of
the drug and the signs and symptoms requiring immediate medical attention.
EXAMPLE 6:
A spouse who has been taught to perform a dressing change for a post-surgical patient
may need to be re-taught wound care if the spouse demonstrates improper performance of
wound care. The medical record should document the reason that the re-teaching or
retraining is required and the patient/caregiver response to the education.

NOTE: There is no requirement that the patient, family or other caregiver be taught to
provide a service if they cannot or choose not to provide the care.
Teaching and training activities that require the skills of a licensed nurse include, but are
not limited to, the following:
1. 	Teaching the self-administration of injectable medications, or a complex range
of medications;
2. 	Teaching a newly diagnosed diabetic or caregiver all aspects of diabetes
management, including how to prepare and to administer insulin injections, to
prepare and follow a diabetic diet, to observe foot-care precautions, and to
observe for and understand signs of hyperglycemia and hypoglycemia;
3. 	Teaching self-administration of medical gases;
4. 	Teaching wound care where the complexity of the wound, the overall condition
of the patient or the ability of the caregiver makes teaching necessary;
5. 	Teaching care for a recent ostomy or where reinforcement of ostomy care is
needed;
6. 	Teaching self-catheterization;
7. 	Teaching self-administration of gastrostomy or enteral feedings;
8. 	Teaching care for and maintenance of peripheral and central venous lines and
administration of intravenous medications through such lines;
9. 	Teaching bowel or bladder training when bowel or bladder dysfunction exists;
10. 	Teaching how to perform the activities of daily living when the patient or
caregiver must use special techniques and adaptive devices due to a loss of
function;
11. 	Teaching transfer techniques, e.g., from bed to chair, that are needed for safe
transfer;
12. 	Teaching proper body alignment and positioning, and timing techniques of a
bed-bound patient;
13. 	Teaching ambulation with prescribed assistive devices (such as crutches,
walker, cane, etc.) that are needed due to a recent functional loss;
14. 	Teaching prosthesis care and gait training;

15. 	Teaching the use and care of braces, splints and orthotics and associated skin
care;
16. 	Teaching the preparation and maintenance of a therapeutic diet; and
17. 	Teaching proper administration of oral medication, including signs of side-
effects and avoidance of interaction with other medications and food.
18. 	Teaching the proper care and application of any special dressings or skin
treatments, (for example, dressings or treatments needed by patients with severe
or widespread fungal infections, active and severe psoriasis or eczema, or due to
skin deterioration due to radiation treatments)
40.1.2.4 - Administration of Medications
(Rev. 1, 10-01-03)
A3-3118.1.B.4, HHA-205.1.B.4
Although drugs and biologicals are specifically excluded from coverage by the statute
(§1861(m)(5) of the Act, the services of a nurse that are required to administer the
medications safely and effectively may be covered if they are reasonable and necessary to
the treatment of the illness or injury.
A. Injections
Intravenous, intramuscular, or subcutaneous injections and infusions, and
hypodermoclysis or intravenous feedings require the skills of a licensed nurse to be
performed (or taught) safely and effectively. Where these services are reasonable and
necessary to treat the illness or injury, they may be covered. For these services to be
reasonable and necessary, the medication being administered must be accepted as safe
and effective treatment of the patient's illness or injury, and there must be a medical
reason that the medication cannot be taken orally. Moreover, the frequency and duration
of the administration of the medication must be within accepted standards of medical
practice, or there must be a valid explanation regarding the extenuating circumstances to
justify the need for the additional injections.
1. Vitamin B-12 injections are considered specific therapy only for the following
conditions:
• 	Specified anemias: pernicious anemia, megaloblastic anemias, macrocytic
anemias, fish tapeworm anemia;
• 	Specified gastrointestinal disorders: gastrectomy, malabsorption syndromes
such as sprue and idiopathic steatorrhea, surgical and mechanical disorders
such as resection of the small intestine, strictures, anastomosis and blind loop
syndrome, and

• 	Certain neuropathies: posterolateral sclerosis, other neuropathies associated
with pernicious anemia, during the acute phase or acute exacerbation of a
neuropathy due to malnutrition and alcoholism.
For a patient with pernicious anemia caused by a B-12 deficiency, intramuscular or
subcutaneous injection of vitamin B-12 at a dose of from 100 to 1000 micrograms no
more frequently than once monthly is the accepted reasonable and necessary dosage
schedule for maintenance treatment. More frequent injections would be appropriate
in the initial or acute phase of the disease until it has been determined through
laboratory tests that the patient can be sustained on a maintenance dose.
2. Insulin Injections
Insulin is customarily self-injected by patients or is injected by their families.
However, where a patient is either physically or mentally unable to self-inject
insulin and there is no other person who is able and willing to inject the patient,
the injections would be considered a reasonable and necessary skilled nursing
service.
EXAMPLE: A patient who requires an injection of insulin once per day for treatment of
diabetes mellitus, also has multiple sclerosis with loss of muscle control in the arms and
hands, occasional tremors, and vision loss that causes inability to fill syringes or self-
inject insulin. If there weren't an able and willing caregiver to inject her insulin, skilled
nursing care would be reasonable and necessary for the injection of the insulin.
The prefilling of syringes with insulin (or other medication that is self-injected) does not
require the skills of a licensed nurse and, therefore, is not considered to be a skilled
nursing service. If the patient needs someone only to prefill syringes (and therefore
needs no skilled nursing care on an intermittent basis, physical therapy, or speech-
language pathology services), the patient, therefore, does not qualify for any Medicare
coverage of home health care. Prefilling of syringes for self-administration of insulin or
other medications is considered to be assistance with medications that are ordinarily self-
administered and is an appropriate home health aide service. (See §50.2.) However,
where State law requires that a licensed nurse prefill syringes, a skilled nursing visit to
prefill syringes is paid as a skilled nursing visit (if the patient otherwise needs skilled
nursing care, physical therapy, or speech-language pathology services), but is not
considered to be a skilled nursing service.
B. Oral Medications
The administration of oral medications by a nurse is not reasonable and necessary skilled
nursing care except in the specific situation in which the complexity of the patient's
condition, the nature of the drugs prescribed, and the number of drugs prescribed require
the skills of a licensed nurse to detect and evaluate side effects or reactions. The medical
record must document the specific circumstances that cause administration of an oral
medication to require skilled observation and assessment.

C. Eye Drops and Topical Ointments
The administration of eye drops and topical ointments does not require the skills of a
nurse. Therefore, even if the administration of eye drops or ointments is necessary to the
treatment of an illness or injury and the patient cannot self-administer the drops, and
there is no one available to administer them, the visits cannot be covered as a skilled
nursing service. This section does not eliminate coverage for skilled nursing visits for
observation and assessment of the patient's condition. (See §40.2.1.)
EXAMPLE 1:
A physician has ordered skilled nursing visits to administer eye drops and ointments for a
patient with glaucoma. The administration of eye drops and ointments does not require
the skills of a nurse. Therefore, the skilled nursing visits cannot be covered as skilled
nursing care, notwithstanding the importance of the administration of the drops as
ordered.
EXAMPLE 2:
A physician has ordered skilled nursing visits for a patient with a reddened area under the
breast. The physician instructs the patient to wash, rinse, and dry the area daily and apply
vitamin A and D ointment. Skilled nursing care is not needed to provide this treatment
and related services safely and effectively.
40.1.2.5 - Tube Feedings
(Rev. 1, 10-01-03)
A3-3118.1.B.5, HHA-205.1.B.5
Nasogastric tube, and percutaneous tube feedings (including gastrostomy and
jejunostomy tubes), and replacement, adjustment, stabilization. and suctioning of the
tubes are skilled nursing services, and if the feedings are required to treat the patient's
illness or injury, the feedings and replacement or adjustment of the tubes would be
covered as skilled nursing services.
40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration
(Rev. 1, 10-01-03)
A3-4118.1.B.6, HHA-205.1.B.6
Nasopharyngeal and tracheostomy aspiration are skilled nursing services and, if required
to treat the patient's illness or injury, would be covered as skilled nursing services.
40.1.2.7 - Catheters
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.1.B.7, HHA-205.1.B.7
Insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter,
and in selected patients, urethral catheters, are considered to be skilled nursing services.

Where the catheter is necessitated by a permanent or temporary loss of bladder control,
skilled nursing services that are provided at a frequency appropriate to the type of
catheter in use would be considered reasonable and necessary. Absent complications,
Foley catheters generally require skilled care once approximately every 30 days and
silicone catheters generally require skilled care once every 60-90 days and this frequency
of service would be considered reasonable and necessary. However, where there are
complications that require more frequent skilled care related to the catheter, such care
would, with adequate documentation, be covered.
EXAMPLE: A patient who has a Foley catheter due to loss of bladder control because
of multiple sclerosis has a history of frequent plugging of the catheter and urinary tract
infections. The physician has ordered skilled nursing visits once per month to change the
catheter, and has left a "PRN" order for up to three additional visits per month for skilled
observation and evaluation and/or catheter changes if the patient or caregiver reports
signs and symptoms of a urinary tract infection or a plugged catheter. During the
certification period, the patient's family contacts the HHA because the patient has an
elevated temperature, abdominal pain, and scant urine output. The nurse visits the patient
and determines that the catheter is plugged and there are symptoms of a urinary tract
infection. The nurse changes the catheter and contacts the physician to report findings
and discuss treatment. The skilled nursing visit to change the catheter and to evaluate the
patient would be reasonable and necessary to the treatment of the illness or injury. The
need for the skilled services must be documented.
40.1.2.8 - Wound Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical
sites, fistulas, tube sites, and tumor erosion sites) when the skills of a licensed nurse are
needed to provide safely and effectively the services necessary to treat the illness or
injury, is considered to be a skilled nursing service. For skilled nursing care to be
reasonable and necessary to treat a wound, the size, depth, nature of drainage (color,
odor, consistency, and quantity), and condition and appearance of the skin surrounding
the wound must be documented in the clinical findings so that an assessment of the need
for skilled nursing care can be made. This includes whether wound care is performed via
dressing changes, NPWT using conventional DME systems or NPWT using a disposable
device. Coverage or denial of skilled nursing visits for wound care may not be based
solely on the stage classification of the wound, but rather must be based on all of the
documented clinical findings. Moreover, the plan of care must contain the specific
instructions for the treatment of the wound. Where the physician or allowed practitioner
has ordered appropriate active treatment (e.g., sterile or complex dressings, NPWT,
administration of prescription medications, etc.) of wounds with the following
characteristics, the skills of a licensed nurse are usually reasonable and necessary:
• 	Open wounds which are draining purulent or colored exudate or have a foul odor
present or for which the patient is receiving antibiotic therapy;

• 	Wounds with a drain or T-tube that require shortening or movement of such
drains;
• 	Wounds which require irrigation or instillation of a sterile cleansing or medicated
solution into several layers of tissue and skin and/or packing with sterile gauze;
• 	Recently debrided ulcers;
• 	Pressure sores (decubitus ulcers) with the following characteristics:
o 	There is partial tissue loss with signs of infection such as foul odor or
purulent drainage; or
o 	There is full thickness tissue loss that involves exposure of fat or invasion
of other tissue such as muscle or bone.
NOTE: Wounds or ulcers that show redness, edema, and induration, at
times with epidermal blistering or desquamation do not ordinarily require
skilled nursing care.
• 	Wounds with exposed internal vessels or a mass that may have a proclivity for
hemorrhage when a dressing is changed (e.g., post radical neck surgery, cancer of
the vulva);
• 	Open wounds or widespread skin complications following radiation therapy, or
which result from immune deficiencies or vascular insufficiencies;
• 	Post-operative wounds where there are complications such as infection or allergic
reaction or where there is an underlying disease that has a reasonable potential to
adversely affect healing (e.g., diabetes);
• 	Third degree burns, and second degree burns where the size of the burn or
presence of complications causes skilled nursing care to be needed;
• 	Skin conditions that require application of nitrogen mustard or other
chemotherapeutic medication that present a significant risk to the patient;
• 	Other open or complex wounds that require treatment that can only be provided
safely and effectively by a licensed nurse.
EXAMPLE 1:
A patient has a second-degree burn with full thickness skin damage on the back. The
wound is cleansed, followed by an application of Sulfamylon. While the wound requires
skilled monitoring for signs and symptoms of infection or complications, the dressing

change requires skilled nursing services. The home health record at each visit must
document the need for the skilled nursing services.
EXAMPLE 2:
A patient experiences a decubitus ulcer where the full thickness tissue loss extends
through the dermis to involve subcutaneous tissue. The wound involves necrotic tissue
with a physician's order to apply a covering of a debriding ointment following vigorous
irrigation. The wound is then packed loosely with wet to dry dressings or continuous
moist dressing and covered with dry sterile gauze. Skilled nursing care is necessary for
proper treatment. The home health record at each visit must document the need for the
skilled nursing services.
NOTE: This section relates to the direct, hands on skilled nursing care provided to
patients with wounds, including any necessary dressing changes on those wounds. While
a wound might not require this skilled nursing care, the wound may still require skilled
monitoring for signs and symptoms of infection or complication (see §40.1.2.1) or for
skilled teaching of wound care to the patient or the patient's family (see §40.1.2.3). For
an example of when wound care is provided separately from the furnishing of NPWT
using a disposable device, see §50.4.4.
40.1.2.9 - Ostomy Care
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.1.B.9, HHA-205.1.B.9
Ostomy care during the post-operative period and in the presence of associated
complications where the need for skilled nursing care is clearly documented is a skilled
nursing service. Teaching ostomy care remains skilled nursing care regardless of the
presence of complications. The teaching services and the patient/caregiver responses
must be documented.
40.1.2.10 - Heat Treatments
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Heat treatments that have been specifically ordered by a physician or allowed practitioner
as part of active treatment of an illness or injury and require observation by a licensed
nurse to adequately evaluate the patient's progress would be considered a skilled nursing
service.
40.1.2.11 - Medical Gases
(Rev. 1, 10-01-03)
A3-3118.1.B.11, HHA-205.1.B.11
Initial phases of a regimen involving the administration of medical gases that are
necessary to the treatment of the patient's illness or injury, would require skilled nursing
care for skilled observation and evaluation of the patient's reaction to the gases, and to

teach the patient and family when and how to properly manage the administration of the
gases.
40.1.2.12 - Rehabilitation Nursing
(Rev. 1, 10-01-03)
A3-3118.1.B.12, HHA-205.1.B.12
Rehabilitation nursing procedures, including the related teaching and adaptive aspects of
nursing that are part of active treatment (e.g., the institution and supervision of bowel and
bladder training programs) would constitute skilled nursing services.
40.1.2.13 - Venipuncture
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Effective February 5, 1998, venipuncture for the purposes of obtaining a blood sample
can no longer be the sole reason for Medicare home health eligibility. However, if a
beneficiary qualifies for home health eligibility based on a skilled need other than solely
venipuncture (e.g., eligibility based on the skilled nursing service of wound care and
meets all other Medicare home health eligibility criteria), medically reasonable and
necessary venipuncture coverage may continue under a home health plan of care.
Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act specifically exclude venipuncture,
as a basis for qualifying for Medicare home health services if this is the sole skilled
service the beneficiary requires. However, the Medicare home health benefit will
continue to pay for a blood draw if the beneficiary has a need for another qualified skilled
service and meets all home health eligibility criteria. This specific requirement applies to
home health services furnished on or after February 5, 1998.
For venipuncture to be reasonable and necessary:
1. The physician or allowed practitioner order for the venipuncture for a laboratory
test should be associated with a specific symptom or diagnosis, or the
documentation should clarify the need for the test when it is not diagnosis/illness
specific. In addition, the treatment must be recognized (in the Physician's Desk
Reference, or other authoritative source) as being reasonable and necessary to the
treatment of the illness or injury for venipuncture and monitoring the treatment
must also be reasonable and necessary.
2. The frequency of testing should be consistent with accepted standards of medical
practice for continued monitoring of a diagnosis, medical problem, or treatment
regimen. Even where the laboratory results are consistently stable, periodic
venipuncture may be reasonable and necessary because of the nature of the
treatment.
3. The home health record must document the rationale for the blood draw as well as
the results.

Examples of reasonable and necessary venipuncture for stabilized patients
include, but are not limited to those described below.
a. 	Captopril may cause side effects such as leukopenia and agranulocytosis
and it is standard medical practice to monitor the white blood cell count
and differential count on a routine basis (every 3 months) when the results
are stable and the patient is asymptomatic.
b. 	In monitoring phenytoin (e.g., Dilantin) administration, the difference
between a therapeutic and a toxic level of phenytoin in the blood is very
slight and it is therefore appropriate to monitor the level on a routine basis
(every 3 months) when the results are stable and the patient is
asymptomatic.
c. 	Venipuncture for fasting blood sugar (FBS)
• 	An unstable insulin dependent or noninsulin dependent diabetic would
require FBS more frequently than once per month if ordered by the
physician or allowed practitioner.
• 	Where there is a new diagnosis or where there has been a recent
exacerbation, but the patient is not unstable, monitoring once per month
would be reasonable and necessary.
• 	A stable insulin or noninsulin dependent diabetic would require
monitoring every 2-3 months.
d. 	Venipuncture for prothrombin
• 	Where the documentation shows that the dosage is being adjusted,
monitoring would be reasonable and necessary as ordered by the
physician or allowed practitioner.
• 	Where the results are stable within the therapeutic ranges, monthly
monitoring would be reasonable and necessary.
• 	Where the results remain within nontherapeutic ranges, there must be
specific documentation of the factors that indicate why continued
monitoring is reasonable and necessary.
EXAMPLE: A patient with coronary artery disease was hospitalized with atrial
fibrillation and subsequently discharged to the HHA with orders for anticoagulation
therapy as well as other skilled nursing care. If indicated, monthly venipuncture to report
prothrombin (protime) levels to the physician or allowed practitioner would be
reasonable and necessary even though the patient's prothrombin time tests indicate
essential stability. The home health record must document the rationale for the blood
draw as well as the results.

40.1.2.14 - Student Nurse Visits
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.1.B.14, HHA-205.1.B.14
Visits made by a student nurse may be covered as skilled nursing care when the HHA
participates in training programs that utilize student nurses enrolled in a school of nursing
to perform skilled nursing services in a home setting. To be covered, the services must
be reasonable and necessary skilled nursing care and must be performed under the
general supervision of a registered or licensed nurse. The supervising nurse need not
accompany the student nurse on each visit. All documentation requirements must be
fulfilled by student nurses.
40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching
(Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24)
The evaluation, psychotherapy, and teaching needed by a patient suffering from a
diagnosed psychiatric disorder that requires active treatment by a psychiatrically trained
nurse and the costs of the psychiatric nurse's services may be covered as a skilled nursing
service. Psychiatrically trained nurses are nurses who have special training and/or
experience beyond the standard curriculum required for a registered nurse. The services
of the psychiatric nurse are to be provided under a plan of care established and reviewed
by a physician or allowed practitioner.
Because the law precludes agencies that primarily provide care and treatment of mental
diseases from participating as HHAs, psychiatric nursing must be furnished by an agency
that does not primarily provide care and treatment of mental diseases. If a substantial
number of an HHA's patients attend partial hospitalization or intensive outpatient
programs or receive other outpatient mental health services, the Medicare contractor will
verify whether the patients meet the eligibility requirements specified in §30 and whether
the HHA is primarily engaged in care and treatment of mental disease.
Services of a psychiatric nurse would not be considered reasonable and necessary to
assess or monitor use of psychoactive drugs that are being used for non-psychiatric
diagnoses or to monitor the condition of a patient with a known psychiatric illness who is
on treatment but is considered stable. A person on treatment would be considered stable
if their symptoms were absent or minimal or if symptoms were present but were
relatively stable and did not create a significant disruption in the patient's normal living
situation.
EXAMPLE 1:
A patient is homebound for medical conditions, but has a psychiatric condition for which
he has been receiving medication. The patient's psychiatric condition has not required a
change in medication or hospitalization for over 2 years. During a visit by the nurse, the
patient's spouse indicates that the patient is awake and pacing most of the night and has
begun ruminating about perceived failures in life. The nurse observes that the patient

does not exhibit an appropriate level of hygiene and is dressed inappropriately for the
season. The nurse comments to the patient about her observations and tries to solicit
information about the patient's general medical condition and mental status. The nurse
advises the physician about the patient's general medical condition and the new
symptoms and changes in the patient's behavior. The physician orders the nurse to check
blood levels of medication used to treat the patient's medical and psychiatric conditions.
The physician then orders the psychiatric nursing service to evaluate the patient's mental
health and communicate with the physician about whether additional intervention to deal
with the patient's symptoms and behaviors is warranted. The home health record at each
visit should document the need for the psychiatric skilled nursing services and treatment.
The home health record must also reflect the patient/caregiver response to any
interventions provided.
EXAMPLE 2:
A patient is homebound after discharge following hip replacement surgery and is
receiving skilled therapy services for range of motion exercise and gait training. In the
past, the patient had been diagnosed with clinical depression and was successfully
stabilized on medication. There has been no change in her symptoms. The fact that the
patient is taking an antidepressant does not indicate a need for psychiatric nursing
services.
EXAMPLE 3:
A patient was discharged after 2 weeks in a psychiatric hospital with a new diagnosis of
major depression. The patient remains withdrawn; in bed most of the day, and refusing
to leave home. The patient has a depressed affect and continues to have thoughts of
suicide, but is not considered to be suicidal. Psychiatric skilled nursing services are
necessary for supportive interventions until antidepressant blood levels are reached and
the suicidal thoughts are diminished further, to monitor suicide ideation, ensure
medication compliance and patient safety, perform suicidal assessment, and teach crisis
management and symptom management to family members. The home health record at
each visit should document the need for the psychiatric skilled nursing services and
treatment. The home health record must also reflect the patient/caregiver response to any
interventions provided.
40.1.3 - Intermittent Skilled Nursing Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The law, at §1861(m) of the Act defines intermittent, for the purposes of §§1814(a)(2)
and 1835(a)(2)(A), as skilled nursing care that is either provided or needed on fewer than
7 days each week, or less than 8 hours each day for periods of 21 days or less (with
extensions in exceptional circumstances when the need for additional care is finite and
predictable.)

To meet the requirement for "intermittent" skilled nursing care, a patient must have a
medically predictable recurring need for skilled nursing services. In most instances, this
definition will be met if a patient requires a skilled nursing service at least once every 60
days. The exception to the intermittent requirement is daily skilled nursing services for
diabetics unable to administer their insulin (when there is no able and willing caregiver).
Since the need for "intermittent" skilled nursing care makes the patient eligible for other
covered home health services, the Medicare contractor should evaluate each claim
involving skilled nursing services furnished less frequently than once every 60 days. In
such cases, payment should be made only if documentation justifies a recurring need for
reasonable, necessary, and medically predictable skilled nursing services. The following
are examples of the need for infrequent, yet intermittent, skilled nursing services:
1. 	The patient with an indwelling silicone catheter who generally needs a catheter
change only at 90-day intervals;
2. 	The patient who experiences a fecal impaction (i.e., loss of bowel tone, restrictive
mobility, and a breakdown in good health habits) and must receive care to
manually relieve the impaction. Although these impactions are likely to recur, it
is not possible to pinpoint a specific timeframe; or
3. 	The blind diabetic who self-injects insulin may have a medically predictable
recurring need for a skilled nursing visit at least every 90 days. These visits, for
example, would be to observe and determine the need for changes in the level and
type of care which have been prescribed thus supplementing the physician or
allowed practitioner's contacts with the patient.
There is a possibility that a physician or allowed practitioner may order a skilled visit less
frequently than once every 60 days for an eligible beneficiary if there exists an
extraordinary circumstance of anticipated patient need that is documented in the patient's
plan of care in accordance with 42 CFR 409.43(b). A skilled visit frequency of less than
once every 60 days would only be covered if it is specifically ordered by a physician or
allowed practitioner in the patient's plan of care and is considered to be a reasonable,
necessary, and medically predictable skilled need for the patient in the individual
circumstance.
Where the need for "intermittent" skilled nursing visits is medically predictable but a
situation arises after the first visit making additional visits unnecessary, e.g., the patient is
institutionalized or dies, the one visit would be paid at the wage-adjusted LUPA amount
for that discipline type. However, a one-time order; e.g., to give gamma globulin
following exposure to hepatitis, would not be considered a need for "intermittent" skilled
nursing care since a recurrence of the problem that would require this service is not
medically predictable.
Although most patients require services no more frequently than several times a week,
Medicare will pay for part-time (as defined in §50.7) medically reasonable and necessary
skilled nursing care 7 days a week for a short period of time (2 to 3 weeks). There may

also be a few cases involving unusual circumstances where the patient's prognosis
indicates the medical need for daily skilled services will extend beyond 3 weeks. As
soon as the patient's physician makes this judgment, which usually should be made
before the end of the 3-week period, the HHA must forward medical documentation
justifying the need for such additional services and include an estimate of how much
longer daily skilled services will be required.
A person expected to need more or less full-time skilled nursing care over an extended
period of time, i.e., a patient who requires institutionalization, would usually not qualify
for home health benefits.
40.2 - Skilled Therapy Services
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.2, HHA-205.2
To be covered as skilled therapy, the services must require the skills of a qualified
therapist and must be reasonable and necessary for the treatment of the patient’s illness or
injury as discussed below. Coverage does not turn on the presence or absence of an
individual’s potential for improvement, but rather on the beneficiary’s need for skilled
care.
40.2.1 - General Principles Governing Reasonable and Necessary
Physical Therapy, Speech-Language Pathology Services, and
Occupational Therapy
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
The service of a physical therapist, speech-language pathologist, or occupational therapist
is a skilled therapy service if the inherent complexity of the service is such that it can be
performed safely and/or effectively only by or under the general supervision of a skilled
therapist. To be covered, assuming all other eligibility and coverage criteria have been
met, the skilled services must also be reasonable and necessary to the treatment of the
patient's illness or injury or to the restoration or maintenance of function affected by the
patient's illness or injury. It is necessary to determine whether individual therapy
services are skilled and whether, in view of the patient's overall condition, skilled
management of the services provided is needed.
The development, implementation, management, and evaluation of a patient care plan
based on the physician or allowed practitioner's orders constitute skilled therapy services
when, because of the patient's clinical condition, those activities require the specialized
skills, knowledge, and judgment of a qualified therapist to ensure the effectiveness of the
treatment goals and ensure medical safety. Where the specialized skills, knowledge, and
judgment of a therapist are needed to manage and periodically reevaluate the
appropriateness of a maintenance program, such services would be covered, even if the
skills of a therapist were not needed to carry out the activities performed as part of the
maintenance program.

While a patient's particular medical condition is a valid factor in deciding if skilled
therapy services are needed, a patient's diagnosis or prognosis should never be the sole
factor in deciding that a service is or is not skilled. The key issue is whether the skills of
a therapist are needed to treat the illness or injury, or whether the services can be carried
out by unskilled personnel.
A service that is ordinarily considered unskilled could be considered a skilled therapy
service in cases where there is clear documentation that, because of special medical
complications, skilled rehabilitation personnel are required to perform the service.
However, the importance of a particular service to a patient or the frequency with which
it must be performed does not, by itself, make an unskilled service into a skilled service.
Assuming all other eligibility and coverage criteria have been met, the skilled therapy
services must be reasonable and necessary to the treatment of the patient's illness or
injury within the context of the patient's unique medical condition. To be considered
reasonable and necessary for the treatment of the illness or injury:
a. 	The services must be consistent with the nature and severity of the illness or
injury, the patient's particular medical needs, including the requirement that the
amount, frequency, and duration of the services must be reasonable; and
b. 	The services must be considered, under accepted standards of medical practice, to
be specific, safe, and effective treatment for the patient's condition, meeting the
standards noted below. The home health record must specify the purpose of the
skilled service provided.
To ensure therapy services are effective, at defined points during a course of
treatment, for each therapy discipline for which services are provided, a qualified
therapist (instead of an assistant) must perform the ordered therapy service. During
this visit, the therapist must assess the patient using a method which allows for
objective measurement of function and successive comparison of measurements. The
therapist must document the measurement results in the clinical record. Specifically:
i. 	Initial Therapy Assessment
• 	For each therapy discipline for which services are provided, a qualified
therapist (instead of an assistant) must assess the patient’s function using a
method which objectively measures activities of daily living such as, but
not limited to, eating, swallowing, bathing, dressing, toileting, walking,
climbing stairs, using assistive devices, and mental and cognitive factors.
The measurement results must be documented in the clinical record.
• 	Where more than one discipline of therapy is being provided, a qualified
therapist from each of the disciplines must functionally assess the patient.
The therapist must document the measurement results which correspond to
the therapist’s discipline and care plan goals in the clinical record.

ii. 	Reassessment at least every 30 days (performed in conjunction with an
ordered therapy service)
• 	At least once every 30 days, for each therapy discipline for which services
are provided, a qualified therapist (instead of an assistant) must provide
the ordered therapy service, functionally reassess the patient, and compare
the resultant measurement to prior assessment measurements. The
therapist must document in the clinical record the measurement results
along with the therapist’s determination of the effectiveness of therapy, or
lack thereof.
• 	For multi-discipline therapy cases, a qualified therapist from each of the
disciplines must functionally reassess the patient. The therapist must
document the measurement results which correspond to the therapist’s
discipline and care plan goals in the clinical record.
• 	The 30-day clock begins with the first therapy service (of that discipline)
and the clock resets with each therapist’s
visit/assessment/measurement/documentation (of that discipline).
c. 	Services involving activities for the general welfare of any patient, e.g., general
exercises to promote overall fitness or flexibility and activities to provide diversion or
general motivation do not constitute skilled therapy. Unskilled individuals without
the supervision of a therapist can perform those services.
d. 	Assuming all other eligibility and coverage requirements have been met, in order
for therapy services to be covered, one of the following three conditions must be met:
1. 	The skills of a qualified therapist, or by a qualified therapist assistant under
the supervision of a qualified therapist, are needed to restore patient function:
• 	To meet this coverage condition, therapy services must be provided with
the expectation, based on the assessment made by the physician or allowed
practitioner of the patient's restorative potential that the condition of the
patient will improve materially in a reasonable and generally predictable
period of time. Improvement is evidenced by objective successive
measurements.
• 	Therapy is not considered reasonable and necessary under this condition if
the patient’s expected restorative potential would be insignificant in
relation to the extent and duration of therapy services required to reach
such potential.
• 	Therapy is not required to effect improvement or restoration of function
where a patient suffers a transient or easily reversible loss of function
(such as temporary weakness following surgery) which could reasonably
be expected to improve spontaneously as the patient gradually resumes

normal activities. Therapy in such cases is not considered reasonable and
necessary to treat the patient’s illness or injury, under this condition.
However, if the criteria for maintenance therapy described in (3) below is
met, therapy could be covered under that condition.
2. The patient’s clinical condition requires the specialized skills, knowledge, and
judgment of a qualified therapist to establish or design a maintenance
program, related to the patient’s illness or injury, in order to ensure the safety
of the patient and the effectiveness of the program, to the extent provided by
regulation,
• 	For patients receiving rehabilitative/restorative therapy services, if the
specialized skills, knowledge, and judgment of a qualified therapist are
required to develop a maintenance program, the expectation is that the
development of that maintenance program would occur during the last
visit(s) for rehabilitative/restorative treatment. The goals of a maintenance
program would be to maintain the patient’s current functional status or to
prevent or slow further deterioration.
• 	Necessary periodic reevaluations by a qualified therapist of the beneficiary
and maintenance program are covered if the specialized skills, knowledge,
and judgment of a qualified therapist are required.
• 	Where a maintenance program is not established until after the
rehabilitative/restorative therapy program has been completed, or where
there was no rehabilitative/restorative therapy program, and the
specialized skills, knowledge, and judgment of a qualified therapist are
required to develop a maintenance program, such services would be
considered reasonable and necessary for the treatment of the patient’s
condition in order to ensure the effectiveness of the treatment goals and
ensure medical safety. When the development of a maintenance program
could not be accomplished during the last visits(s) of
rehabilitative/restorative treatment, the therapist must document why the
maintenance program could not be developed during those last
rehabilitative/restorative treatment visit(s).
• 	When designing or establishing a maintenance program, the qualified
therapist must teach the patient or the patient's family or caregiver’s
necessary techniques, exercises or precautions as necessary to treat the
illness or injury. The instruction of the beneficiary or appropriate
caregiver by a qualified therapist regarding a maintenance program is
covered if the specialized skills, knowledge, and judgment of a qualified
therapist are required. However, visits made by skilled therapists to a
patient's home solely to train other HHA staff (e.g., home health aides) are
not billable as visits since the HHA is responsible for ensuring that its staff
is properly trained to perform any service it furnishes. The cost of a

skilled therapist's visit for the purpose of training HHA staff is an
administrative cost to the agency.
3. 	The skills of a qualified therapist or by a qualified therapist assistant under the
supervision of a qualified therapist are needed to perform maintenance
therapy:
• 	Coverage of therapy services to perform a maintenance program is not
determined solely on the presence or absence of a beneficiary’s potential
for improvement from the therapy, but rather on the beneficiary’s need for
skilled care. Assuming all other eligibility and coverage requirements are
met, skilled therapy services are covered when an individualized
assessment of the patient’s clinical condition demonstrates that the
specialized judgment, knowledge, and skills of a qualified therapist or by a
qualified therapist assistant under the supervision of a qualified therapist
(“skilled care”) are necessary for the performance of a safe and effective
maintenance program. Such a maintenance program to maintain the
patient’s current condition or to prevent or slow further deterioration is
covered so long as the beneficiary requires skilled care for the safe and
effective performance of the program. When, however, the individualized
assessment does not demonstrate such a necessity for skilled care,
including when the performance of a maintenance program does not
require the skills of a therapist or by a qualified therapist assistant under
the supervision of a qualified therapist because it could safely and
effectively be accomplished by the patient or with the assistance of non-
therapists, including unskilled caregivers, such maintenance services will
not be covered.
• 	Further, under the standard set forth in the previous paragraph, skilled care
is necessary for the performance of a safe and effective maintenance
program only when (a) the particular patient’s special medical
complications require the skills of a qualified therapist or by a qualified
therapist assistant under the supervision of a qualified therapist to perform
a therapy service that would otherwise be considered non-skilled; or (b)
the needed therapy procedures are of such complexity that the skills of a
qualified therapist are required to perform the procedure.
e. 	The amount, frequency, and duration of the services must be reasonable.
As is outlined in home health regulations, as part of the home health agency (HHA)
Conditions of Participation (CoPs), the clinical record of the patient must contain
progress and clinical notes. Additionally, in Pub. 100-04, Medicare Claims
Processing Manual, Chapter 10; “Home Health Agency Billing”, instructions specify
that for each claim, HHAs are required to report all services provided to the
beneficiary during each 30-day period, this includes reporting each visit in line-item
detail. As such, it is expected that the home health records for every visit will reflect
the need for the skilled medical care provided. These clinical notes are also expected
to provide important communication among all members of the home care team

regarding the development, course and outcomes of the skilled observations,
assessments, treatment and training performed. Taken as a whole then, the clinical
notes are expected to tell the story of the patient’s achievement towards his/her goals
as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a
skilled service is needed.
Therefore the home health clinical notes must document as appropriate:
• 	the history and physical exam pertinent to the day’s visit , (including the
response or changes in behavior to previously administered skilled services)
and
• 	the skilled services applied on the current visit, and
• 	the patient/caregiver’s immediate response to the skilled services provided,
and
• 	the plan for the next visit based on the rationale of prior results.
Clinical notes should be written such that they adequately describe the reaction of a
patient to his/her skilled care. Clinical notes should also provide a clear picture of the
treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the
patient’s care should not be used. For example terminology such as the following
would not adequately describe the need for skilled care:
• 	Patient tolerated treatment well
• 	Caregiver instructed in medication management
• 	Continue with POC
Objective measurements of physical outcomes of treatment should be provided and/or
a clear description of the changed behaviors due to education programs should be
recorded in order that all concerned can follow the results of the applied services.
When the skilled service is being provided to either maintain the patient’s condition
or prevent or slow further deterioration, the clinical notes must also describe:
• 	A detailed rationale that explains the need for the skilled service in light of the
patient’s overall medical condition and experiences,
• 	the complexity of the service to be performed, and
• 	any other pertinent characteristics of the beneficiary or home.
40.2.2 - Application of the Principles to Physical Therapy Services
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)

The following discussion of skilled physical therapy services applies the principles in
§40.2.1 to specific physical therapy services about which questions are most frequently
raised.
A. Assessment
Assuming all other eligibility and coverage requirements have been met, the skills of a
physical therapist to assess and periodically reassess a patient's rehabilitation needs and
potential or to develop and/or implement a physical therapy program are covered when
they are reasonable and necessary because of the patient's condition. Skilled
rehabilitation services concurrent with the management of a patient's care plan include
objective tests and measurements such as, but not limited to, range of motion, strength,
balance, coordination, endurance, or functional ability.
As described in section 40.2.1(b), at defined points during a course of therapy, the
qualified physical therapist (instead of an assistant) must perform the ordered therapy
service visit, assess the patient’s function using a method which allows for objective
measurement of function and comparison of successive measurements, and document the
results of the assessments, corresponding measurements, and effectiveness of the therapy
in the patient’s clinical record. Refer to §40.2.1(b) for specific timing and documentation
requirements associated with these requirements.
B. Therapeutic Exercises
Therapeutic exercises, which require the skills of a qualified physical therapist to ensure
the safety of the beneficiary and the effectiveness of the treatment constitute skilled
physical therapy, when the criteria in §40.2.1(d) above are met.
C. Gait Training
Gait evaluation and training furnished to a patient whose ability to walk has been
impaired by neurological, muscular or skeletal abnormality require the skills of a
qualified physical therapist and constitute skilled physical therapy and are considered
reasonable and necessary if they can be expected to materially improve or maintain the
patient's ability to walk or prevent or slow further deterioration of the patient’s ability to
walk. Gait evaluation and training which is furnished to a patient whose ability to walk
has been impaired by a condition other than a neurological, muscular, or skeletal
abnormality would nevertheless be covered where physical therapy is reasonable and
necessary to restore or maintain function or to prevent or slow further deterioration. Refer
to §40.2.1(d)(1) for the reasonable and necessary coverage criteria associated with
restoring patient function.
EXAMPLE 1:
A physician has ordered gait evaluation and training for a patient whose gait has been
materially impaired by scar tissue resulting from burns. Physical therapy services to
evaluate the beneficiary's gait, establish a gait training program, and provide the skilled

services necessary to implement the program would be covered. The patient’s response to
therapy must be documented. At appropriate intervals (see above), the qualified therapist
must assess the patient with objective measurements of function.
EXAMPLE 2:
A patient who has had a total hip replacement is ambulatory but demonstrates weakness
and is unable to climb stairs safely. Physical therapy would be reasonable and necessary
to teach the patient to climb and descend stairs safely. Once the patient has reached the
goal of climbing and descending stairs safely, additional therapy services are no longer
required, and thus would not be covered.
EXAMPLE 3:
A patient who has received gait training has reached their maximum restoration potential,
and the physical therapist is teaching the patient and family how to safely perform the
activities that are a part of the maintenance program. The visits by the physical therapist
to demonstrate and teach the activities (which by themselves do not require the skills of a
therapist) would be covered since they are needed to establish the program (refer to
§40.2.1(d)(2)). The patient’s and caregiver’s understanding and implementation of the
maintenance program must be documented. After the establishment of the maintenance
program, any further visits would need to document why the skilled services of a physical
therapist are still required.
D. Range of Motion
Only a qualified physical therapist may perform range of motion tests and, therefore,
such tests are skilled physical therapy.
Range of motion exercises constitute skilled physical therapy only if they are part of an
active treatment for a specific disease state, illness, or injury that has resulted in a loss or
restriction of mobility (as evidenced by physical therapy notes showing the degree of
motion lost and the degree to be restored). Unskilled individuals may provide range of
motion exercises unrelated to the restoration of a specific loss of function often safely and
effectively. Passive exercises to maintain range of motion in paralyzed extremities that
can be carried out by unskilled persons do not constitute skilled physical therapy.
However, if the criteria in §40.2.1(d)(3) are met, where there is clear documentation that,
because of special medical complications (e.g., susceptible to pathological bone
fractures), the skills of a therapist are needed to provide services which ordinarily do not
need the skills of a therapist, and then the services would be covered.
E. Maintenance Therapy
Where services that are required to maintain the patient’s current function or to prevent or
slow further deterioration are of such complexity and sophistication that the skills of a
qualified therapist are required to perform the procedure safely and effectively, the

services would be covered physical therapy services. Further, where the particular
patient’s special medical complications require the skills of a qualified therapist to
perform a therapy service safely and effectively that would otherwise be considered
unskilled, such services would be covered physical therapy services. Refer to
§40.2.1(d)(3).
EXAMPLE 4:
Where there is an unhealed, unstable fracture that requires regular exercise to maintain
function until the fracture heals, the skills of a physical therapist would be needed to
ensure that the fractured extremity is maintained in proper position and alignment during
maintenance range of motion exercises.
EXAMPLE 5:
A Parkinson's patient or a patient with rheumatoid arthritis who has not been under a
restorative physical therapy program may require the services of a physical therapist to
determine what type of exercises are required to maintain the patient's present level of
function or to prevent or slow further deterioration. The initial evaluation of the patient's
needs, the designing of a maintenance program appropriate to the patient’s capacity and
tolerance and to the treatment objectives of the physician, the instruction of the patient,
family or caregivers to carry out the program safely and effectively, and such
reevaluations as may be required by the patient's condition, would constitute skilled
physical therapy. Each component of this process must be documented in the home
health record.
While a patient is under a restorative physical therapy program, the physical therapist
should regularly reevaluate the patient's condition and adjust any exercise program the
patient is expected to carry out alone or with the aid of supportive personnel to maintain
the function being restored. Consequently, by the time it is determined that no further
restoration is possible (i.e., by the end of the last restorative session) the physical
therapist will already have designed the maintenance program required and instructed the
patient or caregivers in carrying out the program.
F. Ultrasound, Shortwave, and Microwave Diathermy Treatments
These treatments must always be performed by or under the supervision of a qualified
physical therapist and are skilled therapy.
G. Hot Packs, Infra-Red Treatments, Paraffin Baths and Whirlpool Baths
Heat treatments and baths of this type ordinarily do not require the skills of a qualified
physical therapist. However, the skills, knowledge, and judgment of a qualified physical
therapist might be required in the giving of such treatments or baths in a particular case,
e.g., where the patient's condition is complicated by circulatory deficiency, areas of
desensitization, open wounds, fractures, or other complications. There must be clear

documentation in the home health record, of the special medical complications that
describe the need for the skilled services provided by the therapist.
H. Wound Care Provided Within Scope of State Practice Acts
If wound care falls within the auspice of a physical therapist's State Practice Act, then the
physical therapist may provide the specific type of wound care services defined in the
State Practice Act. However, such visits in this specific situation would be a covered
therapy service when there is documentation in the home health record that the skills of a
therapist are required to perform the service. The patient’s response to therapy must be
documented.
40.2.3 - Application of the General Principles to Speech-Language
Pathology Services
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
The following discussion of skilled speech-language pathology services applies the
principles to specific speech-language pathology services about which questions are most
frequently raised. Coverage of speech-language pathology services is not determined
solely on the presence or absence of a beneficiary’s potential for improvement from the
therapy, but rather on the beneficiary’s need for skilled care. Assuming all other
eligibility and coverage requirements have been met, skilled speech-language pathology
services are covered when the individualized assessment of the patient’s clinical
condition demonstrates that the specialized judgment, knowledge, and skills of a
qualified speech-language pathologist are necessary.
As described in §40.2.1(b), at defined points during a course of therapy, the qualified
speech-language pathologist must perform the ordered therapy service visit, assess the
patient’s function using a method which allows for objective measurement of function
and comparison of successive measurements, and document the results of the
assessments, corresponding measurements, and effectiveness of therapy in the patient’s
clinical record. Refer to §40.2.1(b) for specific timing and documentation requirements
associated with these requirements.
1. The skills of a speech-language pathologist are required for the assessment of a
patient's rehabilitation needs (including the causal factors and the severity of the
speech and language disorders), and rehabilitation potential. Reevaluation would be
considered reasonable and necessary only if the patient exhibited:
• 	A change in functional speech or motivation;
• 	Clearing of confusion; or
• 	The remission of some other medical condition that previously contraindicated
speech-language pathology services.

Where a patient is undergoing restorative speech-language pathology services, routine
reevaluations are considered to be a part of the therapy and cannot be billed as a
separate visit.
2. The services of a speech-language pathologist would be covered if they are needed as
a result of an illness or injury and are directed towards specific speech/voice
production.
3. Speech-language pathology would be covered where a skilled service can only be
provided by a speech-language pathologist and where it is reasonably expected that
the skilled service will improve, maintain, or prevent or slow further deterioration in
the patient’s ability to carry out communication or feeding activities.
4. The services of a speech-language pathologist to establish a hierarchy of speech-
voice-language communication tasks and cueing that directs a patient toward speech-
language communication goals in the plan of care would be covered speech-language
pathology.
5. The services of a speech-language pathologist to train the patient, family, or other
caregivers to augment the speech-language communication, treatment, to establish an
effective maintenance program, or carry out a safe and effective maintenance
program when the particular patient’s special medical complications require the skills
of a qualified therapist (not an assistant) to perform a therapy service that would
otherwise be considered unskilled or the needed therapy procedures are of such
complexity that the skills of a qualified therapist are required to perform the
procedures, would be covered speech-language pathology services.
6. The services of a speech-language pathologist to assist patients with aphasia in
rehabilitation of speech and language skills are covered when needed by a patient.
7. The services of a speech-language pathologist to assist patients with voice disorders to
develop proper control of the vocal and respiratory systems for correct voice
production are covered when needed by a patient.
40.2.4 - Application of the General Principles to Occupational Therapy
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.2.D, HHA-205.2.D
The following discussion of skilled occupational therapy services applies the principles to
specific occupational therapy services about which questions are most frequently raised.
Coverage of occupational therapy services is not determined solely on the presence or
absence of a beneficiary’s potential for improvement from the therapy, but rather on the
beneficiary’s need for skilled care. Assuming all other eligibility and coverage
requirements have been met, skilled occupational therapy services are covered when the
individualized assessment of the patient’s clinical condition demonstrates that the
specialized judgment, knowledge, and skills of a qualified occupational therapist are
necessary.

40.2.4.1 - Assessment
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
Assuming all other eligibility and coverage requirements are met, the skills of an
occupational therapist to assess and reassess a patient's rehabilitation needs and potential
or to develop and/or implement an occupational therapy program are covered when they
are reasonable and necessary because of the patient's condition.
As described in §40.2.1(b), at defined points during a course of therapy, the qualified
occupational therapist (instead of an assistant) must perform the ordered therapy service
visit, assess the patient’s function using a method which allows for objective
measurement of function and comparison of successive measurements, and document the
results of the assessments, corresponding measurements, and effectiveness of therapy in
the patient’s clinical record. Refer to §40.2.1(b) for specific timing and documentation
requirements associated with these requirements.
40.2.4.2 - Planning, Implementing, and Supervision of Therapeutic
Programs
(Rev. 1, 10-01-03)
A3-3118.2.D.2, HHA-205.2.D.2
The planning, implementing, and supervision of therapeutic programs including, but not
limited to those listed below are skilled occupational therapy services, and if reasonable
and necessary to the treatment of the patient's illness or injury would be covered.
A. Selecting and Teaching Task Oriented Therapeutic Activities Designed to
Restore Physical Function.
EXAMPLE: Use of woodworking activities on an inclined table to restore shoulder,
elbow, and wrist range of motion lost as a result of burns.
B. Planning, Implementing, and Supervising Therapeutic Tasks and Activities
Designed to Restore Sensory-Integrative Function.
EXAMPLE: 	Providing motor and tactile activities to increase sensory output and
improve response for a stroke patient with functional loss resulting in a distorted body
image.
C. Planning, Implementing, and Supervising of Individualized Therapeutic Activity
Programs as Part of an Overall "Active Treatment" Program for a Patient With a
Diagnosed Psychiatric Illness.
EXAMPLE: Use of sewing activities that require following a pattern to reduce
confusion and restore reality orientation in a schizophrenic patient.

D. Teaching Compensatory Techniques to Improve the Level of Independence in
the Activities of Daily Living.
EXAMPLE: Teaching a patient who has lost use of an arm how to pare potatoes and
chop vegetables with one hand.
EXAMPLE: Teaching a stroke patient new techniques to enable them to perform
feeding, dressing, and other activities of daily living as independently as possible.
E. The Designing, Fabricating, and Fitting of Orthotic and Self-Help Devices.
EXAMPLE: Construction of a device which would enable a patient to hold a utensil and
feed themselves independently.
EXAMPLE: Construction of a hand splint for a patient with rheumatoid arthritis to
maintain the hand in a functional position.
F. Vocational and Prevocational Assessment and Training
Vocational and prevocational assessment and training that is directed toward the
restoration of function in the activities of daily living lost due to illness or injury would
be covered. Where vocational or prevocational assessment and training is related solely
to specific employment opportunities, work skills, or work settings, such services would
not be covered because they would not be directed toward the treatment of an illness or
injury.
40.2.4.3 - Illustration of Covered Services
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A3-3118.2.D.3, HHA-205.2.D.3
EXAMPLE 1:
A physician orders occupational therapy for a patient who is recovering from a fractured
hip and who needs to be taught compensatory and safety techniques with regard to lower
extremity dressing, hygiene, toileting, and bathing. The occupational therapist will
establish goals for the patient's rehabilitation (to be approved by the physician), and will
undertake teaching techniques necessary for the patient to reach the goals. Occupational
therapy services would be covered at a duration and intensity appropriate to the severity
of the impairment and the patient's response to treatment. Such visits would be
considered covered when the skills of a therapist are required to perform the services.
The patient’s needs in response to therapy must be documented.
EXAMPLE 2:
A physician has ordered occupational therapy for a patient who is recovering from a
CVA. The patient has decreased range of motion, strength, and sensation in both the
upper and lower extremities on the right side. In addition, the patient has perceptual and

cognitive deficits resulting from the CVA. The patient's condition has resulted in
decreased function in activities of daily living (specifically bathing, dressing, grooming,
hygiene, and toileting). The loss of function requires assistive devices to enable the
patient to compensate for the loss of function and maximize safety and independence.
The patient also needs equipment such as himi-slings to prevent shoulder subluxation and
a hand splint to prevent joint contracture and deformity in the right hand. The services of
an occupational therapist would be necessary to:
• 	Assess the patient's needs;
• 	Develop goals (to be approved by the physician);
• 	Manufacture or adapt the needed equipment to the patient's use;
• 	Teach compensatory techniques;
• 	Strengthen the patient as necessary to permit use of compensatory techniques; and
• 	Provide activities that are directed towards meeting the goals governing increased
perceptual and cognitive function.
Occupational therapy services would be covered at a duration and intensity appropriate to
the severity of the impairment and the patient's response to treatment. Such visits would
be considered covered therapy services when the skills of a therapist are required to
perform the services. The patient’s needs, course of therapy and response to therapy
must be documented.
50 - Coverage of Other Home Health Services
(Rev. 1, 10-01-03)
A3-3119, HHA-206
50.1 - Skilled Nursing, Physical Therapy, Speech-Language Pathology
Services, and Occupational Therapy
(Rev. 1, 10-01-03)
A3-3119.1, HHA-206.1
Where the patient meets the qualifying criteria in §30, Medicare covers skilled nursing
services that meet the requirements of §§40.1 and 50.7, physical therapy that meets the
requirements of §40.2, speech-language pathology services that meets the requirements
of §40.2, and occupational therapy that meets the requirements of §40.2.
Home health coverage is not available for services furnished to a qualified patient who is
no longer in need of one of the qualifying skilled services specified in §30. Therefore,
dependent services furnished after the final qualifying skilled service are not covered
under the home health benefit, except when the dependent service was followed by a
qualifying skilled service as a result of the unexpected inpatient admission or death of the
patient or due to some other unanticipated event.

50.2 - Home Health Aide Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
For home health aide services to be covered:
• 	The patient must meet the qualifying criteria as specified in §30;
• 	The services provided by the home health aide must be part-time or intermittent
as discussed in §50.7;
• 	The services must meet the definition of home health aide services of this section;
and
• 	The services must be reasonable and necessary to the treatment of the patient's
illness or injury.
NOTE: A home health aide must be certified consistent the competency evaluation
requirements.
The reason for the visits by the home health aide must be to provide hands-on personal
care of the patient or services needed to maintain the patient's health or to facilitate
treatment of the patient's illness or injury.
The physician or allowed practitioner's order should indicate the frequency of the home
health aide services required by the patient. These services may include but are not
limited to:
A. Personal Care
Personal care means:
1. 	Bathing, dressing, grooming, caring for hair, nail, and oral hygiene which are
needed to facilitate treatment or to prevent deterioration of the patient's health,
changing the bed linens of an incontinent patient, shaving, deodorant application,
skin care with lotions and/or powder, foot care, and ear care; and
2. 	Feeding, assistance with elimination (including enemas unless the skills of a
licensed nurse are required due to the patient's condition, routine catheter care and
routine colostomy care), assistance with ambulation, changing position in bed,
assistance with transfers.
EXAMPLE 1:

A physician has ordered home health aide visits to assist the patient in personal care
because the patient is recovering from a stroke and continues to have significant right
side weakness that causes the patient to be unable to bathe, dress or perform hair and oral
care. The plan of care established by the HHA nurse sets forth the specific tasks with
which the patient needs assistance. Home health aide visits at an appropriate frequency
would be reasonable and necessary to assist in these tasks.
EXAMPLE 2:
A physician ordered four home health aide visits per week for personal care for a
multiple sclerosis patient who is unable to perform these functions because of increasing
debilitation. The home health aide gave the patient a bath twice per week and washed
hair on the other two visits each week. Only two visits are reasonable and necessary
since the services could have been provided in the course of two visits.
EXAMPLE 3:
A physician ordered seven home health aide visits per week for personal care for a bed-
bound, incontinent patient. All visits are reasonable and necessary because the patient
has extensive personal care needs.
EXAMPLE 4:
A patient with a well-established colostomy forgets to change the bag regularly and has
difficulty changing the bag. Home health aide services at an appropriate frequency to
change the bag would be considered reasonable and necessary to the treatment of the
illness or injury.
B. Simple Dressing Changes That Do Not Require the Skills of a Licensed Nurse
EXAMPLE 5:
A patient who is confined to the bed has developed a small reddened area on the
buttocks. The physician has ordered home health aide visits for more frequent
repositioning, bathing and the application of a topical ointment and a gauze 4x4. Home
health aide visits at an appropriate frequency would be reasonable and necessary.
C. Assistance With Medications Which Are Ordinarily Self-Administered and Do
Not Require the Skills of a Licensed Nurse to Be Provided Safely and Effectively
NOTE: Prefilling of insulin syringes is ordinarily performed by the diabetic as part of
the self-administration of the insulin and, unlike the injection of the insulin, does not
require the skill of a licensed nurse to be performed properly. Therefore, if HHA staff
performs the prefilling of insulin syringes, it is considered to be a home health aide
service. However, where State law precludes the provision of this service by other than a
licensed nurse or physician, Medicare will make payment for this service, when covered,
as though it were a skilled nursing service. Where the patient needs only prefilling of

insulin syringes and does not need skilled nursing care on an intermittent basis, physical
therapy, speech-language pathology services, or have a continuing need for occupational
therapy, then Medicare cannot cover any home health services to the patient (even if
State law requires that the insulin syringes be filled by a licensed nurse).
Home health aide services are those services ordered in the plan of care that the aide is
permitted to perform under State law. Medicare coverage of the administration of insulin
by a home health aide will depend on whether or not the agency is in compliance with all
Federal and State laws and regulations related to this task. However, when the task of
insulin administration has been delegated to the home health aide, the task must be
considered and billed as a Medicare home health aide service. By a State allowing the
delegation of insulin administration to home health aides, the State has extended the role
of aides, not equated aide services with the services of a registered nurse.
D. Assistance With Activities which Are Directly Supportive of Skilled Therapy
Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively
Performed Such as Routine Maintenance Exercises and Repetitive Practice of
Functional Communication Skills to Support Speech-Language Pathology Services
E. Provision of Services Incidental to Personal Care Services not Care of Prosthetic
and Orthotic Devices
When a home health aide visits a patient to provide a health related service as discussed
above, the home health aide may also perform some incidental services which do not
meet the definition of a home health aide service (e.g., light cleaning, preparation of a
meal, taking out the trash, shopping, etc.) However, the purpose of a home health aide
visit may not be to provide these incidental services since they are not health related
services, but rather are necessary household tasks that must be performed by anyone to
maintain a home.
EXAMPLE 1:
A home health aide visits a recovering stroke patient whose right side weakness and poor
endurance cause her to be able to leave the bed and chair only with extreme difficulty.
The physician has ordered physical therapy and speech-language pathology services for
the patient and home health aide services three or four times per week for personal care,
assistance with ambulation as mobility increases, and assistance with repetitive speech
exercises as her impaired speech improves. The home health aide also provides
incidental household services such as preparation of meals, light cleaning and taking out
the trash. The patient lives with an elderly frail sister who is disabled and who cannot
perform either the personal care or the incidental tasks. The home health aide visits at a
frequency appropriate to the performance of the health related services would be covered,
notwithstanding the incidental provision of noncovered services (i.e., the household
services) in the course of the visits.
EXAMPLE 2:

A physician orders home health aide visits three times per week. The only services
provided are light housecleaning, meal preparation and trash removal. The home health
aide visits cannot be covered, notwithstanding their importance to the patient, because the
services provided do not meet Medicare's definition of "home health aide services."
50.3 - Medical Social Services
(Rev. 1, 10-01-03)
A3-3119.3, HHA-206.3
Medical social services that are provided by a qualified medical social worker or a social
work assistant under the supervision of a qualified medical social worker may be covered
as home health services where the beneficiary meets the qualifying criteria specified in
§30, and:
1. 	The services of these professionals are necessary to resolve social or emotional
problems that are or are expected to be an impediment to the effective treatment
of the patient's medical condition or rate of recovery; and
2. 	The plan of care indicates how the services which are required necessitate the
skills of a qualified social worker or a social work assistant under the supervision
of a qualified medical social worker to be performed safely and effectively.
Where both of these requirements for coverage are met, services of these professionals
which may be covered include, but are not limited to:
1. 	Assessment of the social and emotional factors related to the patient's illness, need
for care, response to treatment and adjustment to care;
2. 	Assessment of the relationship of the patient's medical and nursing requirements
to the patient's home situation, financial resources and availability of community
resources;
3. 	Appropriate action to obtain available community resources to assist in resolving
the patient's problem (NOTE: Medicare does not cover the services of a medical
social worker to complete or assist in the completion of an application for
Medicaid because Federal regulations require the State to provide assistance in
completing the application to anyone who chooses to apply for Medicaid.);
4. 	Counseling services that are required by the patient; and
5. 	Medical social services furnished to the patient's family member or caregiver on a
short-term basis when the HHA can demonstrate that a brief intervention (that is,
two or three visits) by a medical social worker is necessary to remove a clear and
direct impediment to the effective treatment of the patient's medical condition or
to the patient's rate of recovery. To be considered "clear and direct," the behavior
or actions of the family member or caregiver must plainly obstruct, contravene, or
prevent the patient's medical treatment or rate of recovery. Medical social

services to address general problems that do not clearly and directly impede
treatment or recovery as well as long-term social services furnished to family
members, such as ongoing alcohol counseling, are not covered.
NOTE: Participating in the development of the plan of care, preparing clinical and
progress notes, participating in discharge planning and in-service programs, and acting as
a consultant to other agency personnel are appropriate administrative costs to the HHA.
EXAMPLE 1:
The physician has ordered a medical social worker assessment of a diabetic patient who
has recently become insulin dependent and is not yet stabilized. The nurse, who is
providing skilled observation and evaluation to try to restabilize the patient notices during
her visits that the supplies left in the home for the patient's use appear to be frequently
missing, and the patient is not compliant with the regimen although she refuses to discuss
the matter. The assessment by a medical social worker would be reasonable and
necessary to determine if there are underlying social or emotional problems impeding the
patient's treatment.
EXAMPLE 2:
A physician ordered an assessment by a medical social worker for a multiple sclerosis
patient who was unable to move anything but her head and who had an indwelling
catheter. The patient had experienced recurring urinary tract infections and multiple
infected ulcers. The physician ordered medical social services after the HHA indicated to
him that the home was not well cared for, the patient appeared to be neglected much of
the time, and the relationship between the patient and family was very poor. The
physician and HHA were concerned that social problems created by family caregivers
were impeding the treatment of the recurring infections and ulcers. The assessment and
follow-up for counseling both the patient and the family by a medical social worker were
reasonable and necessary.
EXAMPLE 3:
A physician is aware that a patient with atherosclerosis and hypertension is not taking
medications as ordered and adhering to dietary restrictions because he is unable to afford
the medication and is unable to cook. The physician orders several visits by a medical
social worker to assist in resolving these problems. The visits by the medical social
worker to review the patient's financial status, discuss options, and make appropriate
contacts with social services agencies or other community resources to arrange for
medications and meals would be a reasonable and necessary medical social service.
EXAMPLE 4:
A physician has ordered counseling by a medical social worker for a patient with
cirrhosis of the liver who has recently been discharged from a 28-day inpatient alcohol
treatment program to her home which she shares with an alcoholic and neglectful adult

child. The physician has ordered counseling several times per week to assist the patient
in remaining free of alcohol and in dealing with the adult child. The services of the
medical social worker would be covered until the patient's social situation ceased to
impact on her recovery and/or treatment.
EXAMPLE 5:
A physician has ordered medical social services for a patient who is worried about his
financial arrangements and payment for medical care. The services ordered are to
arrange Medicaid if possible and resolve unpaid medical bills. There is no evidence that
the patient's concerns are adversely impacting recovery or treatment of his illness or
injury. Medical social services cannot be covered.
EXAMPLE 6:
A physician has ordered medical social services for a patient of extremely limited income
who has incurred large unpaid hospital and other medical bills following a significant
illness. The patient's recovery is adversely affected because the patient is not maintaining
a proper therapeutic diet, and cannot leave the home to acquire the medication necessary
to treat their illness. The medical social worker reviews the patient's financial status,
arranges meal service to resolve the dietary problem, arranges for home delivered
medications, gathers the information necessary for application to Medicaid to acquire
coverage for the medications the patient needs, files the application on behalf of the
patient, and follows up repeatedly with the Medicaid State agency.
The medical social services that are necessary to review the financial status of the patient,
arrange for meal service and delivery of medications to the home, and arrange for the
Medicaid State agency to assist the patient with the application for Medicaid are covered.
The services related to the assistance in filing the application for Medicaid and the
follow-up on the application are not covered since they must be provided by the State
agency free of charge, and hence the patient has no obligation to pay for such assistance.
EXAMPLE 7:
A physician has ordered medical social services for an insulin dependent diabetic whose
blood sugar is elevated because she has run out of syringes and missed her insulin dose
for two days. Upon making the assessment visit, the medical social worker learns that
the patient's daughter, who is also an insulin dependent diabetic, has come to live with the
patient because she is out of work. The daughter is now financially dependent on the
patient for all of her financial needs and has been using the patient's insulin syringes. The
social worker assesses the patient's financial resources and determines that they are
adequate to support the patient and meet her own medical needs, but are not sufficient to
support the daughter. She also counsels the daughter and helps her access community
resources. These visits would be covered, but only to the extent that the services are
necessary to prevent interference with the patient's treatment plan.
EXAMPLE 8:

A wife is caring for her husband who is an Alzheimer's patient. The nurse learns that the
wife has not been giving the patient his medication correctly and seems distracted and
forgetful about various aspects of the patient's care. In a conversation with the nurse, the
wife relates that she is feeling depressed and overwhelmed by the patient's illness. The
nurse contacts the patient's physician who orders a social work evaluation. In her
assessment visit, the social worker learns that the patient's wife is so distraught over her
situation that she cannot provide adequate care to the patient. While there, the social
worker counsels the wife and assists her with referrals to a support group and her private
physician for evaluation of her depression. The services would be covered.
EXAMPLE 9:
The parent of a dependent disabled child has been discharged from the hospital following
a hip replacement. Although arrangements for care of the disabled child during the
hospitalization were made, the child has returned to the home. During a visit to the
patient, the nurse observes that the patient is transferring the child from bed to a
wheelchair. In an effort to avoid impeding the patient's recovery, the nurse contacts the
patient's physician to order a visit by a social worker to mobilize family members or
otherwise arrange for temporary care of the disabled child. The services would be
covered.
50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than
Covered Osteoporosis Drugs), the Use of Durable Medical Equipment
and Furnishing Negative Pressure Wound Therapy Using a Disposable
Device
(Rev. 233, Issued: 02-24-17, Effective: 01-01-17, Implementation: 03-27-17)
50.4.1 - Medical Supplies
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are
essential in enabling HHA personnel to conduct home visits or to carry out effectively the
care the physician has ordered for the treatment or diagnosis of the patient's illness or
injury. All supplies which would have been covered under the cost-based reimbursement
system are bundled under home health PPS. Payment for the cost of supplies has been
incorporated into the per visit and 30-day period payment rates. Supplies fit into two
categories. They are classified as:
• 	Routine - because they are used in small quantities for patients during the usual
course of most home visits; or
• 	Nonroutine - because they are needed to treat a patient's specific illness or injury
in accordance with the physician or allowed practitioner's plan of care and meet
further conditions discussed in more detail below.

All HHAs are expected to separately identify in their records the cost of medical and
surgical supplies that are not routinely furnished in conjunction with patient care visits
and the use of which are directly identifiable to an individual patient.
50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and the
Patient's Plan of Care
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A. The Law
The Medicare law governing the home health PPS is specific to the type of items and
services bundled to the HHA and the time the services are bundled. Medical supplies are
bundled while the patient is under a home health plan of care. If a patient is admitted for
a condition which is related to a chronic condition that requires a medical supply (e.g.,
ostomy patient) the HHA is required to provide the medical supply while the patient is
under a home health plan of care during a 30-day period of care. The physician or
allowed practitioner’s orders in the plan of care must reflect all nonroutine medical
supplies provided and used while the patient is under a home health plan of care. The
consolidated billing requirement is not superseded by the exclusion of certain medical
supplies from the plan of care and then distinguishing between medical supplies that are
related and unrelated to the plan of care. Failure to include medical supplies on the plan
of care does not relieve HHAs from the obligation to comply with the consolidated
billing requirements. The comprehensive nature of the current patient assessment and
plan of care requirements looks at the totality of patient needs. However, there could be a
circumstance where a physician or allowed practitioner could be uncomfortable with
writing orders for a preexisting condition unrelated to the reason for home health care. In
those circumstances, PRN orders for such supplies may be used in the plan of care by a
physician or allowed practitioner.
Thus, all medical supplies are bundled while the patient is under a home health plan of
care. This includes, but is not limited to, the above listed medical supplies as well as the
Part B items provided in the final PPS rule. The latter item lists are subsequently updated
in accordance with the current process governing the deletion, replacement and revision
of Medicare Part B codes. Parenteral and enteral nutrition, prosthetics, orthotics, DME
and DME supplies are not considered medical supplies and therefore not subject to
bundling while the patient is under a home health plan of care. However, §1834(h)(4)(c)
of the Act specifically excludes from the term "orthotics and prosthetics" medical
supplies including catheters, catheter supplies, ostomy bags and supplies related to
ostomy care furnished by an HHA under §1861(m) of the Act. Therefore, these items are
bundled while a patient is under a home health plan of care.
B. Relationship Between Patient Choice and Veterans Benefits
For veterans, both Medicare and Veteran's Administration (VA) benefits are primary.
Therefore, the beneficiary who is a veteran has some choices in cases where the benefits
overlap. The beneficiary, however, must select one or the other program as primary
when obtaining active care. If the VA is selected as primary for home health care, then
Medicare becomes a secondary payer. An HHA must provide the medical supplies a

Medicare beneficiary needs no matter the payer; it is not obligated to provide medical
supplies that are not needed. If a patient has medical supplies provided by the VA
because of the patient's preference, then the HHA must not duplicate the supplies under
Medicare. The beneficiary's choice is controlling. The HHA may not require the
beneficiary to obtain or use medical supplies covered by the primary payer from any
other source, including the VA.
C. Medical Supplies Purchased by the Patient Prior to the Start of Care
A patient may have acquired medical supplies prior to his/her Medicare home health start
of care date. If a patient prefers to use his or her own medical supplies after having been
offered appropriate supplies by the HHA and it is determined by the HHA that the
patient's medical supplies are clinically appropriate, then the patient's choice is
controlling. The HHA is not required to duplicate the medical supplies if the patient
elects to use his or her own medical supplies. However, if the patient prefers to have the
HHA provide medical supplies while the patient is under a Medicare home health plan of
care, then the HHA must provide the medical supplies. The HHA may not require that
the patient obtain or use medical supplies from any other source. Given the possibility of
subsequent misunderstandings arising between the HHA and the patient on this issue, the
HHA should document the beneficiary's decision to decline HHA furnished medical
supplies and use their own resources.
50.4.1.2 - Routine Supplies (Nonreportable)
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Routine supplies are supplies that are customarily used in small quantities during the
course of most home care visits. They are usually included in the staff's supplies and not
designated for a specific patient. These supplies are included in the cost per visit of home
health care services. Routine supplies would not include those supplies that are
specifically ordered by the physician or allowed practitioner or are essential to HHA
personnel in order to effectuate the plan of care.
Examples of supplies which are usually considered routine include, but are not limited to:
A. Dressings and Skin Care
• 	Swabs, alcohol preps, and skin prep pads;
• 	Tape removal pads;
• 	Cotton balls;
• 	Adhesive and paper tape;
• 	Nonsterile applicators; and
• 	4 x 4's.
B. Infection Control Protection

• 	Nonsterile gloves;
• 	Aprons;
• 	Masks; and
• 	Gowns.
C. Blood Drawing Supplies
• 	Specimen containers.
D. Incontinence Supplies
• 	Incontinence briefs and Chux Covered in the normal course of a visit. For
example, if a home health aide in the course of a bathing visit to a patient
determines the patient requires an incontinence brief change, the incontinence
brief in this example would be covered as a routine medical supply.
E. Other
• 	Thermometers; and
• 	Tongue depressors.
There are occasions when the supplies listed in the above examples would be considered
nonroutine and thus would be considered a billable supply, i.e., if they are required in
quantity, for recurring need, and are included in the plan of care. Examples include, but
are not limited to, tape, and 4x4s for major dressings.

50.4.1.3 - Nonroutine Supplies (Reportable)
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Nonroutine supplies are identified by the following conditions:
1. The HHA follows a consistent charging practice for Medicare and other patients
receiving the item;
2. The item is directly identifiable to an individual patient;
3. The cost of the item can be identified and accumulated in a separate cost center;
and
4. The item is furnished at the direction of the patient's physician or allowed
practitioner and is specifically identified in the plan of care.
All nonroutine supplies must be specifically ordered by the physician or allowed
practitioner or the physician or allowed practitioner's order for services must require the
use of the specific supplies to be effectively furnished.
The charge for nonroutine supplies is excluded from the per visit costs.
Examples of supplies that can be considered nonroutine include, but are not limited to:
1. Dressings/Wound Care
• 	Sterile dressings;
• 	Sterile gauze and toppers;
• 	Kling and Kerlix rolls;
• 	Telfa pads;
• 	Eye pads;
• 	Sterile solutions, ointments;
• 	Sterile applicators; and
• 	Sterile gloves.
2. I.V. Supplies
3. Ostomy Supplies
4. Catheters and Catheter Supplies
• 	Foley catheters; and
• 	Drainage bags, irrigation trays.

5. Enemas and Douches
6. Syringes and Needles
7. Home Testing
• 	Blood glucose monitoring strips; and
• 	Urine monitoring strips.
Consider other items that are often used by persons who are not ill or injured to be
medical supplies only where:
• 	The item is recognized as having the capacity to serve a therapeutic or diagnostic
purpose in a specific situation; and
• 	The item is required as a part of the actual physician or allowed practitioner
prescribed treatment of a patient's existing illness or injury.
For example, items that generally serve a routine hygienic purpose, e.g., soaps and
shampoos and items that generally serve as skin conditioners, e.g., baby lotion, baby oil,
skin softeners, powders, lotions, are not considered medical supplies unless the particular
item is recognized as serving a specific therapeutic purpose in the physician or allowed
practitioner's prescribed treatment of the patient's existing skin (scalp) disease or injury.
Limited amounts of medical supplies may be left in the home between visits where
repeated applications are required and rendered by the patient or other caregivers. These
items must be part of the plan of care in which the home health staff is actively involved.
For example, the patient is independent in insulin injections but the nurse visits once a
day to change wound dressings. The wound dressings/irrigation solution may be left in
the home between visits. Supplies such as needles, syringes, and catheters that require
administration by a nurse should not be left in the home between visits.
50.4.2 - Durable Medical Equipment
(Rev. 1, 10-01-03)
A3-3119.4.B, HHA-206.4.B
Durable medical equipment which meets the requirements of the Medicare Benefit Policy
Manuals, Chapter 6, "Hospital Services Covered Under Part B," §80, and Chapter 15,
“Covered Medical and Other Health Services” §110, is covered under the home health
benefit with the beneficiary responsible for payment of a 20 percent coinsurance.
50.4.3 – Covered Osteoporosis Drugs
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

Sections 1861(m) and 1861(kk) of the Act provide for coverage of FDA approved
injectable drugs for the treatment of osteoporosis. These drugs are expected to be
provided by an HHA to female beneficiaries who are currently receiving services under
an open home health plan of care, who meet existing coverage criteria for the home
health benefit and who meet the criteria listed below. These drugs are covered on a cost
basis when provided by an HHA under the circumstances listed below.
The home health visit (i.e., the skilled nurse's visit) to administer the drug is covered
under all fee-for-service Medicare (Part A or Part B) home health coverage rules (see
section 30 above). Coverage of the drug is limited to female beneficiaries who meet each
of the following criteria:
o 	The individual is eligible for Medicare Part B coverage of home health services
(the nursing visit to perform the injection may be the individual's qualifying
service);
o 	The individual sustained a bone fracture that a physician, or allowed practitioner,
or certified nurse midwife certifies was related to post-menopausal osteoporosis;
and
o 	The individual's physician, or allowed practitioner, or certified nurse midwife
certifies that she is unable to learn the skills needed to self-administer the drug or
is otherwise physically or mentally incapable of administering the drug, and that
her family or caregivers are unable or unwilling to administer the drug.
This drug is considered part of the home health benefit under Part B. Therefore, Part B
deductible and coinsurance apply regardless of whether home health visits for the
administration of the drug are covered under Part A or Part B.
For instructions on billing for covered osteoporosis drugs, see Pub. 100-04, Medicare
Claims Processing Manual, chapter 10, section 90.1.
50.4.4 - Negative Pressure Wound Therapy Using a Disposable Device
(Rev. 12382; Issued: 11-28-23; Effective: 01-01-24; Implementation:01-02-24)
For services furnished on or after January 1, 2017 and before January 1,
2024, sections 1834 and 1861(m)(5) of the Act required a separate
payment to an HHA for an applicable disposable device, to an individual
who received home health services for which payment was made under
the Medicare home health benefit. Section 1834 of the Act defines an
applicable device as a disposable NPWT device that is an integrated
system comprised of a non-manual vacuum pump, a receptacle for
collecting exudate, and dressings for the purposes of wound therapy used
in lieu of a conventional NPWT DME system. As required by §1834 of
the Act, the separate payment amount for a disposable NPWT device
was set equal to the amount of the payment that would be made under
the Medicare Hospital Outpatient Prospective Payment System (OPPS)

using the Level I HCPCS code, otherwise referred to as Current
Procedural Terminology (CPT) codes, for which the description for a
professional service includes the furnishing of such a device.
Payment for HH visits related to wound care, but not requiring the
furnishing of an entirely new disposable NPWT device, were covered by
the HH PPS period payment and were billed using the HH claim. Where
a home health visit was exclusively for the purpose of furnishing NPWT
using a disposable device, the HHA submitted only a type of claim that
was paid for separately outside the HH PPS (TOB 34x). Where,
however, the home health visit included the provision of other home
health services in addition to, and separate from, furnishing NPWT using
a disposable device, the HHA submitted both a home health claim and a
TOB 34x— the home health claim for other home health services and the
TOB 34x for furnishing NPWT using a disposable device.
EXAMPLE:
A patient requires dNPWT for the treatment of a wound. On Monday, a
nurse assesses a patient’s wound, applies a new disposable NPWT
device, and provides wound care education to the patient and family.
The nurse returns on Thursday for wound assessment and replaces the
fluid management system (or dressing) for the existing disposable
NPWT, but does not replace the entire device. The nurse returns the
following Monday, assesses the patient’s condition and the wound, and
replaces the device that had been applied on the previous Monday with a
new disposable NPWT device. In this scenario, the billing procedures
are as follows:
For both Monday visits, all the services provided by the nurse were
associated with furnishing NPWT using a disposable device. The nurse
did not provide any services that were not associated with furnishing
NPWT using a disposable device. Therefore, all the nursing services for
both Monday visits should be reported on TOB 34x with CPT code
97607 or 97608. None of the services should be reported on the HH
claim.
For the Thursday visit, the nurse checked the wound, but did not apply a
new disposable NPWT device, so even though the nurse provided care
related to the wound, those services would not be considered furnishing
NPWT using a disposable device. Therefore, the services should be
reported on bill type 32x and no services should be reported on bill type
34x.
For services furnished on or after January 1, 2024, Division FF, section
4136 of the Consolidated Appropriations Act of 2023 (CAA, 2023) (Pub.

L.117-328) requires that beginning in CY 2024, there will be a separate
payment amount for an applicable dNPWT device only and does not
include payment for the nursing and therapy services. Payment for the
device is equal to the supply price used to determine the relative value for
the service under the Medicare Physician Fee Schedule (as of January 1,
2022) for the applicable disposable device and updated by the consumer
price index for all urban consumers minus the productivity adjustment for
each future year.
Payment for nursing or therapy services, described in section 1861(m), to
apply a disposable NPWT device would now be made under the
prospective payment system established under section 1895, the HH PPS,
and is no longer separately billable. Additionally, beginning in CY 2024
and each subsequent year, claims for the separate payment amount of an
applicable dNPWT device would now be accepted and processed on
claims submitted using the type of bill that is most commonly used by
home health agencies to bill services under a home health plan of care
(TOB 032x). That is, claims with a date of service on or after January 1,
2024 for an applicable dNPWT device will no longer be submitted on
TOB 034x.
EXAMPLE:
A patient requires dNPWT for the treatment of a wound. On Monday, a nurse
assesses a patient’s wound, applies a new disposable NPWT device, and
provides wound care education to the patient and family. The nursing visit is
reported on the home health claim as a home health visit using the
appropriate G-code, revenue code and units of time on TOB 032x. Payment
for these services are included in the overall HH PPS payment rate for the
30-day period of care if the LUPA threshold has been met for the period. The
HHA would report the Healthcare Common Procedure Coding System
(HCPCS) code A9272 (for the device only) on the home health type of bill
TOB 032x. A separate payment is made for the device only. The nurse returns
on Thursday for follow up teaching and assessment of the device. The nurse
does not replace the dNPWT device at this visit. Only the nursing visit is
reported on the home health claim using TOB 032x. No separate reporting
for the device would be included on the claim since the device was not
replaced during this visit.
For instructions on billing for NPWT using a disposable device, see Pub.
100-04, Medicare Claims Processing Manual, chapter 10, Section 90.3 –
Billing Instructions for Disposable Negative Pressure Wound Therapy
Services.
50.5 - Services of Interns and Residents
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

Home health services include the medical services of interns and residents-in-training
under an approved hospital teaching program if the services are ordered by the physician
or allowed practitioner who is responsible for the plan of care and the HHA is affiliated
with or is under common control of a hospital furnishing the medical services. Approved
means:
• 	Approved by the Accreditation Council for Graduate Medical Education;
• 	In the case of an osteopathic hospital, approved by the Committee on Hospitals of
the Bureau of Professional Education of the American Osteopathic Association;
• 	In the case of an intern or resident-in-training in the field of dentistry, approved
by the Council on Dental Education of the American Dental Association; or
• 	In the case of an intern or resident-in-training in the field of podiatry, approved by
the Council on Podiatric Education of the American Podiatric Association.
50.6 - Outpatient Services
(Rev. 1, 10-01-03)
A3-3119.6, HHA-206.6
Outpatient services include any of the items or services described above which are
provided under arrangements on an outpatient basis at a hospital, skilled nursing facility,
rehabilitation center, or outpatient department affiliated with a medical school, and (1)
which require equipment which cannot readily be made available at the patient's place of
residence, or (2) which are furnished while the patient is at the facility to receive the
services described in (1). The hospital, skilled nursing facility, or outpatient department
affiliated with a medical school must all be qualified providers of services. However,
there are special provisions for the use of the facilities of rehabilitation centers. The cost
of transporting an individual to a facility cannot be reimbursed as home health services.
50.7 - Part-Time or Intermittent Home Health Aide and Skilled Nursing
Services
(Rev. 1, 10-01-03)
A3-3119.7, HHA-206.7, A3-3119.7A, HHA-206.7A, A3-3119.7.B, HHA-206.7.B
Where a patient is eligible for coverage of home health services, Medicare covers either
part-time or intermittent home health aide services or skilled nursing services subject to
the limits below. The law at §1861(m) of the Act clarified: "the term "part-time or
intermittent services" means skilled nursing and home health aide services furnished any
number of days per week as long as they are furnished (combined) less than 8 hours each
day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to
the need for care, less than 8 hours each day and 35 or fewer hours each week).

50.7.1 - Impact on Care Provided in Excess of "Intermittent" or "Part-
Time" Care
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)
Home health aide and/or skilled nursing care, in excess of the amounts of care that meet
the definition of part-time or intermittent, may be provided to a home care patient or
purchased by other payers without bearing on whether the home health aide and skilled
nursing care meets the Medicare definitions of part-time or intermittent.
EXAMPLE: A patient needs skilled nursing care monthly for a catheter change and the
home health agency also renders needed daily home health aide services 24 hours per day
that will be needed for a long and indefinite period of time. The HHA bills Medicare for
the skilled nursing and home health aide services, which were provided before the 35th
hour of service each week, and bills the beneficiary (or another payer) for the remainder
of the care. If the Medicare contractor determines that the 35 hours of care are
reasonable and necessary, Medicare would cover the 35 hours of skilled nursing and
home health aide visits.
50.7.2 - Application of this Policy Revision
(Rev. 1, 10-01-03)
A3-3119.7.D, HHA-206.7.D
Additional care covered by other payers discussed in §50.7.1 does not affect Medicare
coverage when the conditions listed below apply. A patient must meet the criteria for
Medicare coverage of home health services, before this policy revision becomes
applicable to skilled nursing services and/or home health aide services. The definition of
"intermittent" with respect to the need for skilled nursing care where the patient qualifies
for coverage based on the need for "skilled nursing care on an intermittent basis" remains
unchanged. Specifically:
1. This policy revision always applies to home health aide services when the patient
qualifies for coverage;
2. This policy revision applies to skilled nursing care only when the patient needs
physical therapy or speech-language pathology services or continued occupational
therapy, and also needs skilled nursing care; and
3. If the patient needs skilled nursing care but does not need physical therapy or
speech-language pathology services or occupational therapy, the patient must still
meet the longstanding and unchanged definition of "intermittent" skilled nursing
care in order to qualify for coverage of any home health services.
60 - Special Conditions for Coverage of Home Health Services Under
Hospital Insurance (Part A) and Supplementary Medical Insurance
(Part B)
(Rev. 1, 10-01-03)

A3-3122, HHA-212
60.1 - Post-Institutional Home Health Services Furnished During A
Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part
B
(Rev. 1, 10-01-03)
A3-3122.1, HHA-212.1, A3-3122.1, HHA-212.2, PMs A-97-12, A-97-16, A-98-49
Section 1812(a)(3) of the Act provides post-institutional home health services for
individuals enrolled in Part A and Part B and home health services for individuals who
are eligible for Part A only. For beneficiaries who are enrolled in Part A and Part B, Part
A finances post-institutional home health services furnished during a home health spell of
illness for up to 100 visits during a spell of illness.
Part A finances up to 100 visits furnished during a home health spell of illness if the
following criteria are met:
• 	Beneficiaries are enrolled in Part A and Part B and qualify to receive the
Medicare home health benefit;
• 	Beneficiaries must have at least a three consecutive day stay in a hospital or rural
primary care hospital; and
• 	Home health services must be initiated and the first covered home health visit
must be rendered within 14 days of discharge from a 3 consecutive day stay in a
hospital or rural primary care hospital or within 14 days of discharge from a
skilled nursing facility in which the individual was provided post-hospital
extended care services. If the first home health visit is not initiated within 14 days
of discharge, then home health services are financed under Part B.
After an individual exhausts 100 visits of Part A post-institutional home health services,
Part B finances the balance of the home health spell of illness. A home health spell of
illness is a period of consecutive days beginning with the first day not included in a
previous home health spell of illness on which the individual is furnished post-
institutional home health services which occurs in a month the individual is entitled to
Part A. The home health spell of illness ends with the close of the first period of 60
consecutive days in which the individual is neither an inpatient of a hospital or rural
primary care hospital nor an inpatient of a skilled nursing facility (in which the individual
was furnished post-hospital extended care services) nor provided home health services.
EXAMPLE 1:
An individual is enrolled in Part A and Part B, qualifies for the Medicare home health
benefit, has a three consecutive day stay in a hospital, and is discharged on May 1. On
May 5, the individual receives the first skilled nursing visit under the plan of care.
Therefore, post-institutional home health services have been initiated within 14 days of
discharge. The individual is later hospitalized on June 2. Prior to the June 2

hospitalization, the individual received 12 home health visits. The individual stays in the
hospital for four consecutive days, is discharged and receives home health services. That
individual continues the May 5 home health spell of illness and would have 88 visits left
under that home health spell of illness under Part A. That individual could not start
another home health spell of illness (100 visits under Part A) until a 60-day consecutive
period in which the individual was not an inpatient of a hospital, rural primary care
hospital, an inpatient of a skilled nursing facility (in which the individual was furnished
post-hospital extended care services), or provided home health services had passed.
EXAMPLE 2:
An individual is enrolled in Part A and Part B, qualifies for the Medicare home health
benefit, has a three consecutive day stay in a hospital, and home health is initiated within
14 days of discharge. The individual exhausts the 100 visits under Part A post-
institutional home health services, continues to need home health services, and receives
home health services under Part B. The individual is then hospitalized for 4 consecutive
days. The individual is again discharged and receives home health services. The
individual cannot begin a new home health spell of illness because 60 days did not pass
in which the individual was not an inpatient of a hospital or rural primary care hospital or
an inpatient of a skilled nursing facility in which the individual was furnished post-
hospital extended care services. The individual would be discharged and Part B would
continue to finance the home health services.
60.2 - Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not
Meet Threshold for Post-Institutional Home Health Services
(Rev. 1, 10-01-03)
A3-3122.1, HHA-212.3
If beneficiaries are enrolled in Part A and Part B and are eligible for the Medicare home
health benefit, but do not meet the three consecutive day stay requirement or the 14 day
initiation of care requirement, then all of their home health services would be financed
under Part B. For example, this situation would include, but is not limited to,
beneficiaries enrolled in Part A and Part B who are coming from the community to a
home health agency in need of home health services or who stay less than three
consecutive days in a hospital and are discharged. Any home health services received
after discharge would be financed under Part B.
60.3 - Beneficiaries Who Are Part A Only or Part B Only
(Rev. 1, 10-01-03)
A3-3122.1, HHA-212.4
If a beneficiary is enrolled only in Part A and qualifies for the Medicare home health
benefit, then all of the home health services are financed under Part A. The 100-visit
limit does not apply to beneficiaries who are only enrolled in Part A. If a beneficiary is
enrolled only in Part B and qualifies for the Medicare home health benefit, then all of the
home health services are financed under Part B. There is no 100-visit limit under Part B.
The new definition of post-institutional home health services provided during a home

health spell of illness only applies to those beneficiaries who are enrolled in both Part A
and Part B and qualify for the Medicare home health benefit.
60.4 - Coinsurance, Copayments, and Deductibles
(Rev. 233, Issued: 02-24-17, Effective: 01-01-17, Implementation: 03-27-17)
There is no coinsurance, copayment, or deductible for home health services and supplies
other than the following:
• 	coinsurance required for durable medical equipment (DME) and furnishing
NPWT using a disposable device covered as a home health service; and
• 	deductible and coinsurance for the osteoporosis drug, which is part of the home
health benefit only paid under Part B.
The coinsurance liability of the beneficiary for DME and the osteoporosis drug furnished
as a home health service is 20 percent of the fee schedule amount for the services.
Coinsurance for furnishing NPWT using a disposable device as a home health service is
20 percent of the payment amount.
70 - Duration of Home Health Services
(Rev. 1, 10-01-03)
A3-3123, HHA-215, A3-3123.1, HHA-215.1
70.1 - Number of Home Health Visits Under Supplementary Medical
Insurance (Part B)
(Rev. 1, 10-01-03)
A3-3123.2, HHA-215.2
To the extent that all coverage requirements are met, payment may be made on behalf of
eligible beneficiaries under Part B for an unlimited number of covered home health visits.
The determination of Part A or Part B Trust Fund financing and coverage is made in
accordance with the financing shift required by the BBA described above in §60.
70.2 - Counting Visits Under the Hospital and Medical Plans
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A. Visit Defined
A visit is an episode of personal contact with the patient by staff of the HHA, or others
under arrangements with the HHA, for the purpose of providing a covered home health
service. Though visits are provided under the HH benefit as part of 30-day periods, and
periods are unlimited, each visit must be uniquely billed as a separate line item on a
Medicare HH claim, and data on visit charges is still used in formulating payment rates.
B. Counting Visits

Generally, one visit may be covered each time an HHA employee, or someone providing
home health services under arrangements with the HHA, enters the patient's home and
provides a covered service to a patient who meets the criteria in §30.
If the HHA furnishes services in an outpatient facility under arrangements with the
facility, one visit may be covered for each type of service provided.
If two individuals are needed to provide a service, two visits may be covered. If two
individuals are present, but only one is needed to provide the care, only one visit may be
covered.
A visit is initiated with the delivery of covered home health services and ends at the
conclusion of delivery of covered home health services. In those circumstances in which
all reasonable and necessary home health services cannot be provided in the course of a
single visit, HHA staff or others providing services under arrangements with the HHA
may remain at the patient's home between visits (e.g., to provide noncovered services).
However, if all covered services could be provided in the course of one visit, only one
visit may be covered.
EXAMPLES:
1. 	If an occupational therapist and an occupational therapy assistant visit the patient
together to provide therapy and the therapist is there to supervise the assistant,
one visit is counted.
2. 	If a nurse visits the patient in the morning to dress a wound and later must return
to replace a catheter, two visits are counted.
3. 	If the therapist visits the patient for treatment in the morning and the patient is
later visited by the assistant for additional treatment, two visits are counted.
4. 	If an individual is taken to a hospital to receive outpatient therapy that could not
be furnished in their own home (e.g., hydrotherapy) and, while at the hospital
receives speech-language pathology services and other services, two or more
visits would be charged.
5. 	Many home health agencies provide home health aide services on an hourly basis
(ranging from 1 to 8 hours a day). However, in order to allocate visits properly
against a patient's maximum allowable visits, home health aide services are to be
counted in terms of visits. Thus, regardless of the number of continuous hours a
home health aide spends in a patient's home on any given day, one "visit" is
counted for each such day. If, in a rare situation, a home health aide visits a
patient for an hour or two in the morning, and again for an hour or two in the
afternoon, two visits are counted.
C. Evaluation Visits

The HHAs are required by regulations to have written policies concerning the acceptance
of patients by the agency. These include consideration of the physical facilities available
in the patient's place of residence, the homebound status, and the attitudes of family
members for the purpose of evaluating the feasibility of meeting the patient's medical
needs in the home health setting. When personnel of the agency make such an initial
evaluation visit, the cost of the visit is considered an administrative cost of the agency
and is not chargeable as a visit since at this point the patient has not been accepted for
care. If, however, during the course of this initial evaluation visit, the patient is
determined suitable for home health care by the agency, and is also furnished the first
skilled service as ordered under the physician or allowed practitioner's plan of care, the
visit would become the first billable visit in the 30-day period.
The Medicare contractor will cover an observation and evaluation (or reevaluation) visit
made by a nurse (see §40.1.2.1 for a further discussion of skilled nursing observation and
evaluation visits) or other appropriate personnel, ordered by the physician or allowed
practitioner for the purpose of evaluating the patient's condition and continuing need for
skilled services, as a skilled visit.
A supervisory visit made by a nurse or other appropriate personnel (as required by the
conditions of participation) to evaluate the specific personal care needs of the patient or
to review the manner in which the personal care needs of the patient are being met by the
aide is an administrative function, not a skilled visit.
80 - Specific Exclusions From Coverage as Home Health Services
(Rev. 1, 10-01-03)
A3-3125, HHA-230.A
In addition to the general exclusions from coverage under health insurance listed in the
Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," the
following are also excluded from coverage as home health services:
80.1 - Drugs and Biologicals
(Rev. 1, 10-01-03)
A3-3125.A, HHA-230.A
Drugs and biologicals are excluded from payment under the Medicare home health
benefit.
A drug is any chemical compound that may be used on or administered to humans or
animals as an aid in the diagnosis, treatment, prevention of disease or other condition, for
the relief of pain or suffering, or to control or improve any physiological pathologic
condition.
A biological is any medicinal preparation made from living organisms and their products
including, but not limited to, serums, vaccines, antigens, and antitoxins. The one drug

exception is the osteoporosis drug, which is part of the home health benefit, and home
health agencies may provide services such as vaccines outside the home health benefit.
80.2 - Transportation
(Rev. 1, 10-01-03)
A3-3125.B, HHA-230.B
The transportation of a patient, whether to receive covered care or for other purposes, is
excluded from home health coverage. Costs of transportation of equipment, materials,
supplies, or staff may be allowable as administrative costs, but no separate payment is
made.
80.3 - Services That Would Not Be Covered as Inpatient Services
(Rev. 1, 10-01-03)
A3-3125C, HHA-230.C
Services that would not be covered if furnished as inpatient hospital services are excluded
from home health coverage.
80.4 - Housekeeping Services
(Rev. 1, 10-01-03)
A3-3125D, HHA-230D
Services for which the sole purpose is to enable the patient to continue residing in their
home (e.g., cooking, shopping, Meals on Wheels, cleaning, laundry) are excluded from
home health coverage.
80.5 - Services Covered Under the End Stage Renal Disease (ESRD)
Program
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)
Renal dialysis services that are covered and paid for under the ESRD PPS, which include
any item or service furnished to an ESRD beneficiary that is directly related to that
individual's dialysis, are excluded from coverage under the Medicare home health
benefit. However, to the extent that other requirements for coverage are met, an item or
service that is not directly related to a patient's dialysis would be covered (e.g., a skilled
nursing visit to furnish wound care for an abandoned shunt site). Within these
restrictions, beneficiaries may simultaneously receive items and services under the ESRD
PPS through their ESRD facility at home at the same time as receiving items and services
under the home health benefit that are not related to ESRD.
80.6 - Prosthetic Devices
(Rev. 1, 10-01-03)
A3-3125F, HHA-230F

Prosthetic items are excluded from home health coverage. However, catheters, catheter
supplies, ostomy bags, and supplies related to ostomy care are not considered prosthetic
devices if furnished under a home health plan of care and are not subject to this exclusion
from coverage but are bundled while a patient is under a HH plan of care.
80.7 - Medical Social Services Furnished to Family Members
(Rev. 1, 10-01-03)
A3-3125G, HHA-230G
Except as provided in §50.3, medical social services furnished solely to members of the
patient's family and that are not incidental to covered medical social services being
furnished to the patient are not covered.
80.8 - Respiratory Care Services
(Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)
If a respiratory therapist is used to furnish overall training or consultative advice to HHA
staff and incidentally furnishes respiratory therapy services to patients in their homes, the
costs of the respiratory therapist's services are allowable only as administrative costs to
the HHA. Visits by a respiratory therapist to a patient's home are not separately billable
during a HH period of care when a HH plan of care is in effect. However, respiratory
therapy services furnished as part of a plan of care other than a home health plan of care
by a licensed nurse or physical therapist and that constitute skilled care may be covered
and separately billed as skilled visits when the beneficiary is not in a home health period
of care. Note that Medicare billing does not recognize respiratory therapy as a separate
discipline, but rather sees the services in accordance with the revenue code used on the
claims (i.e. 042x).
80.9 - Dietary and Nutrition Personnel
(Rev. 1, 10-01-03)
A3-3125.I, HHA-230.I
If dieticians or nutritionists are used to furnish overall training or consultative advice to
HHA staff and incidentally furnish dietetic or nutritional services to patients in their
homes, the costs of these professional services are allowable only as administrative costs.
Visits by a dietician or nutritionist to a patient's home are not separately billable.
80.10 - Telecommunications Technology
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Telecommunications technology (other than audio-only telephone calls) can include:
remote patient monitoring, defined as the collection of physiologic data (for example,
ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the
patient or caregiver or both to the home health agency; teletypewriter (TTY) technology;
and 2-way audio-video telecommunications technology that allows for real-time
interaction between the patient and clinician. Telecommunications technology can be

ordered as part of a home health plan of care but such services cannot be reported as a
visit without the provision of another skilled service. If telecommunications technologies
are used by the home health agency, the costs of any equipment, set-up, and service
related to the technology are allowable only as administrative costs. Visits to a
beneficiary's home for the sole purpose of supplying, connecting, or training the patient
on the technology, without the provision of a skilled service, are not separately billable.
However, HHAs may include the costs of telecommunications technology as an
allowable administrative cost (that is, operating expense), if the technology is used by the
HHA to augment the care planning process.
90 - Medical and Other Health Services Furnished by Home Health
Agencies
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Payment may be made by Medicare contractors to a home health agency which furnishes
either directly or under arrangements with others the following "medical and other health
services" to beneficiaries with Part B coverage in accordance with Part B billing and
payment rules other than when a home health plan of care is in effect.
1. Surgical dressings (for a patient who is not under a home health plan of care), and
splints, casts, and other devices used for reduction of fractures and dislocations;
2. Prosthetic (Except for items excluded from the term "orthotics and prosthetics" in
accordance with §1834(h)(4)(C) of the Act for patients who are under a home
health plan of care);
3. Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes and
adjustments to these items when ordered by a physician or allowed practitioner.
(See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15);
4. Outpatient physical therapy, outpatient occupational therapy, and outpatient
speech-language pathology services (for a patient not under a home health plan of
care). (See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15); and
5. Rental and purchase of durable medical equipment. (See Pub 100-02, Medicare
Benefit Policy Manual, Chapter 15.) If a beneficiary meets all of the criteria for
coverage of home health services and the HHA is providing home health care
under the Hospital Insurance Program (Part A), any DME provided and billed to
the Medicare contractor by the HHA to that patient must also be provided under
Part A. Where the patient meets the criteria for coverage of home health services
and the HHA is providing the home health care under the Supplementary Medical
Insurance Program (Part B) because the patient is not eligible for Part A, the
DME provided by the HHA may, at the beneficiary's option, be furnished under
the Part B home health benefit or as a medical and other health service.
Irrespective of how the DME is furnished, the beneficiary is responsible for a 20
percent coinsurance.

6. 	Ambulance service. (See Pub 100-02, Medicare Benefit Policy Manual, Chapter
10, Ambulance Services)
7. 	Hepatitis B Vaccine. Hepatitis B vaccine and its administration are covered under
Part B for patients who are at high or intermediate risk of contracting hepatitis B.
High risk groups currently identified include: end-stage renal disease (ESRD)
patients, hemophiliacs who receive factor VIII or IX concentrates, clients of
institutions for the mentally retarded, persons who live in the same household as a
hepatitis B virus carrier, homosexual men, illicit injectable drug users.
Intermediate risk groups currently identified include staff in institutions for the
mentally retarded, workers in health care professions who have frequent contact
with blood or blood-derived body fluids during routine work. Persons in the
above listed groups would not be considered at high or intermediate risk of
contracting hepatitis B, however, if there is laboratory evidence positive for
antibodies to hepatitis B. ESRD patients are routinely tested for hepatitis B
antibodies as part of their continuing monitoring and therapy. The vaccine may
be administered, upon the order of a doctor of medicine or osteopathy, by home
health agencies.
8. 	Hemophilia clotting factors. Blood clotting factors for hemophilia patients
competent to use such factors to control bleeding without medical or other
supervision and items related to the administration of such factors are covered
under Part B.
9. 	Pneumococcal and influenza vaccines. See Pub 100-02, Medicare Benefit Policy
Manual, Chapter 15, “Covered Medical and Other Health Services,” §50.4.2
“Immunizations.”
10. Splints, casts. See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15,
“Covered Medical and Other Health Services.”
11. Antigens. See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15,
“Covered Medical and Other Health Services.”
100 - Physician or Allowed Practitioner Certification for Medical and
Other Health Services Furnished by Home Health Agency (HHA)
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
A physician or allowed practitioner must certify that the medical and other health
services covered by medical insurance, which were provided by (or under arrangements
made by) the HHA, were medically required. This certification needs to be made only
once where the patient may require over a period of time the furnishing of the same item
or service related to one diagnosis. There is no requirement that the certification be
entered on any specific form or handled in any specific way as long as the approach
adopted by the HHA permits the Medicare contractor to determine that the certification

requirement is, in fact, met. A written physician or allowed practitioner's order
designating the services required would also be an acceptable certification.
110 - Use of Telehealth in Delivery of Home Health Services
(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
Section 1895(e) governs the home health prospective payment system (PPS) and provides
that telehealth services are outside the scope of the Medicare home health benefit and
home health PPS.
This provision does not provide coverage or payment for Medicare home health services
provided via a telecommunications system. The law does not permit the substitution or
use of a telecommunications system to provide any covered home health services paid
under the home health PPS, or any covered home health service paid outside of the home
health PPS. As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with
the beneficiary by staff of the home health agency (HHA), or others under arrangements
with the HHA for the purposes of providing a covered service. The provision clarifies
that there is nothing to preclude an HHA from adopting telemedicine or other
technologies that they believe promote efficiencies, but there is no separate
reimbursement for those technologies under the Medicare home health benefit. However,
Medicare does recognize services furnished via telecommunications technology (see
section 80.10) as an allowed administrative cost on Medicare cost reports if
telecommunications technology is used by the HHA to augment the care planning
process, and the technology is indicated on the plan of care.
This provision does not waive the current statutory requirement for a physician or
allowed practitioner certification of a home health plan of care under current
§§1814(a)(2)(C) or 1835(a)(2)(A) of the Act.
Transmittals Issued for this Chapter

Rev # 	Issue Date 	Subject 	Impl Date CR#
R12425BP 12/21/2023 	Enforcing Billing Requirements for
Intensive Outpatient Program (IOP) Services
with New Condition Code 92 - Additional
Publication Update
01/02/2024 13496
R12382BP 11/28/2023 	Separate Payment for Disposable Negative
Pressure Wound Therapy Devices on Home
Health Prospective Payment System Claims
01/02/2024 13244
R12291BP 10/05/2023 	Separate Payment for Disposable Negative
Pressure Wound Therapy Devices on Home
Health Prospective Payment System Claims
No Longer Sensitive - Rescinded and
Replaced by Transmittal 12382
01/02/2024 13244
07/20/2023 	Separate Payment for Disposable Negative
Pressure Wound Therapy Devices on Home
Health Prospective Payment System Claims
SENSITIVE/CONTROVERSIAL DO NOT
POST- Rescinded and Replaced by
Transmittal 12291
01/02/2024 13244
R11447BP 06/06/2022 	Update to Chapter 7, “Home Health
Services,” of the Medicare Benefit Policy
Manual (Pub 100-02)
05/26/2022 12615
R11386BP 04/27/2022 	Update to Chapter 7, “Home Health
Services,” of the Medicare Benefit Policy
Manual (Pub 100-02) - Rescinded and
replaced by Transmittal 11447
05/26/2022 12615
R11296BP 03/25/2022 	Update to Chapter 7, “Home Health
Services,” of the Medicare Benefit Policy
Manual (Pub 100-02) – Rescinded and
replaced by Transmittal 11386
05/26/2022 12615
R10738BP 05/07/2021 	Home Health Manual Update to Implement
Calendar Year 2021 Request for Anticipated
Payment Policies and Corrections to
Certification and Recertification for Home
Health Beneficiaries
08/09/2021 12218

R10438BP 11/06/2020 	Home Health Manual Update to Incorporate
Allowed Practitioners into Home Health
Policy
01/11/2121 12023
R265BP 	01/10/2020 	Manual Updates Related to Calendar Year
(CY) 2020 Home Health Payment Policy
Changes, Maintenance Therapy, and Remote
Patient Monitoring
02/11/2020 11577
R258BP 	03/22/2019 	Manual Updates Related to Home Health
Certification and Recertification Policy
Changes
04/22/2019 11104
R233BP 	02/24/2017 	Clarification of Payment Policy Changes for
Negative Pressure Wound Therapy (NPWT)
Using a Disposable Device and the Outlier
Payment Methodology for Home Health
Services
03/27/2017 9898
R208BP 	04/22/2015 	Manual Updates to Clarify Requirements for
Physician Certification and Recertification
of Patient Eligibility for Home Health
Services
05/11/2015 9119
R207BP 	04/10/2015 	Manual Updates to Clarify Requirements for
Physician Certification and Recertification
of Patient Eligibility for Home Health
Services – Rescinded and replaced by
Transmittal 208
05/11/2015 9119
R179BP 	01/14/2014 	Manual Updates to Clarify Skilled Nursing
Facility (SNF), Inpatient Rehabilitation
Facility (IRF), Home Health (HH), and
Outpatient (OPT) Coverage Pursuant to
Jimmo vs. Sebelius
01/07/2014 8458
R176BP 	12/13/2013 	Manual Updates to Clarify Skilled Nursing
Facility (SNF), Inpatient Rehabilitation
Facility (IRF), Home Health (HH), and
Outpatient (OPT) Coverage Pursuant to
Jimmo vs. Sebelius – Rescinded and
replaced by Transmittal 179
01/07/2014 8458

R172BP 	10/18/2013 	Home Health - Clarification to Benefit
Policy Manual Language on Confined to the
Home Definition
11/19/2013 8444
R144BP 	05/06/2011 	Home Health Therapy Services 	05/05/2011 7374
R142BP 	04/15/2011 	Home Health Therapy Services – Rescinded
and replaced by Transmittal 144
05/05/2011 7374
R139BP 	02/16/2011 	Clarifications for Home Health Face-to Face
Encounter Provisions
03/10/2011 7329
R37BP 	08/12/2005 	Conforming Changes for Change Request
3648 to Pub. 100-02
09/12/2005 3912
R26BP 	11/05/2004 	Inclusion of Forteo as a Covered
Osteoporosis Drug and Clarification of
Manual Instructions Regarding Osteoporosis
Drugs
04/04/2004 3524
R1BP 	10/01/2003 	Introduction to the Benefit Policy Manual 	N/A 	N/A
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