Medical Reviews – Be One step ahead

CMS published new guidance to contractors and Medicare Reviewers in CR9189 last month which took effect on August 11th.   One thing that agencies must be aware of is that no regulations have been modified, adjusted or added.  CR9189 is updating the medical necessity reviewer guidance on physician certification, recerts, and to determine if the patient is actually eligible for home health services.


The new guidance was issued as part of the final rule that took effect on January 1, 2015 and ties into requirements set by the Affordable Care Act (ObamaCare).  Face to Face encounters are at the center of the new guidance.  Reviewers are going to be looking for specific information that qualifies that patient for home health services.  Your standard Face to Face form is a starting point, but additional information will also be required to pass these new review standards.


The use of a signed plan of care (485) is also not going to be allowed to substantiate care. Instead, your agency must be able to provide documentation from the physician stating following requirements be met:

  • Patient requires intermittent skilled nursing, physical therapy, or speech services.
  • Homebound – the patient is unable to leave the home without taxing effort.
  • The physician will establish and review a plan of care for the patient.
  • The patient is under the care of a physician.
  • Face to Face encounter is documented as occurred and meets all requirements.


To make the process easier, CMS is allowing a patient’s medical records from an acute or post-acute facility if being referred to home health. Using this documentation should be done when available and received from the facility as quickly as possible.  This information can almost always be found in notes and discharge paperwork from the facility. If you go this route for patients discharged from a hospital or nursing facility, please make sure it has documented:

  • Face to Face encounter with a physician.
  • The patient is indeed homebound.
  • The patient does need skilled services.


Medicare reviewers are going to be checking all of this documentation. If their track records hold true, you can expect them to miss a few items that are submitted.  Remember, the patients are going to be evaluated to see if they meet medical necessity and whether or not services should have been continued (for recerts).  Appeals will be necessary and very likely.  As the adjudication process is still years behind, using the appeal process will work in your agency’s benefit in order to reduce take backs and potential cash flow issues.