* = Required Information

To be filled out by the home care agency.

QUALIFYING ENCOUNTER TYPE FOR HOME CARE SERVICES (check all that apply)

Acute Post-acute (physician who conducted the face-to-face encounter during an inpatient stay)
Face-to face encounter was conducted within 90 days prior to SOC within 30 days after SOC
Yes No
Face-to-face was provided later than 30 days after initial SOC

To be filled out by physician conducting the initial certification for homecare admission.

PHYSICIAN ATTESTATION

I certify that this patient is under my care and that I or an allowed NPP (a nurse practitioner, or a clinical nurse specialist, or a physician's assistant) working with me, had a face-to-face encounter that meets the physician faceto-face encounter requirements on: Date:. I have initiated the establishment of the plan of care.

Based on the clinical findings, I certify the patient is homebound and that the following intermittent home care services are medically necessary: (Check all that apply)

Nursing Therapy PT SLP/SP
OT Social Worker Home Health Aide

I have provided the home care agency with the following documentation to support the patientís medical necessity and substantiate their homebound status. (Check all that apply)

Encounter visit clinical note Physician progress notes Discharge summary History and physical
Reports (therapy, operative, etc.)

Choose one:

I am the certifying physician, and I will periodically review the patients plan of care. The encounter findings were communicated to the patients community based physician
who will be assuming the patient's home health needs and periodically reviewing the plan of care.

Physician, please sign, and return this form within 2 days and attach copies of documentation. Lack of supporting documentation could adversely affect the patient's ability to receive home care services. See reverse side to review examples of required content.

Physician, please sign, and return this form within 2 days and attach copies of documentation. Lack of supporting documentation could adversely affect the patient's ability to receive home care services. See reverse side to review examples of required content.

PART 1 - To Physician (For Signature) PART 2 - Clinical Record (Temporary Copy)

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expect home health agencies to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient's eligibility for Medicare home health services. The encounter and documentation are a condition of payment.

DEFINITIONS AND DIRECTIONS: (This information is not all-inclusive)

Describe the patient's condition and symptoms, not just a list of diagnoses. Explain if this is a new problem or an exacerbation of a previous problem.

DEFINITIONS AND DIRECTIONS: (This information is not all-inclusive)

If this is a post-operative patient, for example:

  • How long ago was the surgery?
  • Were there any complications?
  • If the patient has pain, how severe is the pain?

Skilled Services Need:

Is there evidence that skilled therapy service (PT, OT, SLP) is needed? For example:

  • Assessment of functional deficits and home safety evaluation
  • Therapeutic exercises
  • Restore joint function for post joint replacement
  • Gait training
  • ADL training
  • Therapeutic exercise to improve swallowing
  • Therapeutic exercise to improve language function
  • Therapeutic exercise to improve cognitive function

Is there evidence that Nursing is needed?

  • Complex wound assessment and care
  • Management of new/changed medications

Homebound Status:

Description should not be limited to weakness, considerable and taxing effort, poor endurance. Include a description of the patient's condition and symptoms, not just a diagnosis and not just the need for an assistive device. Patient does not have to be bedridden.

For example:

If shortness of breath is applicable, describe the severity (severe at rest, with minimal exertion, etc.)
Patient is homebound due to a psychiatric condition/symptoms

The physician must certify that:
1. The home health services are needed because the patient is confined to the home (homebound).
2. The patient needs 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 patients 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 must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
3. A plan of care has been established and is periodically reviewed by a physician;
4. The services are or were furnished while the patient is or was under the care of a physician;
5. For episodes with starts of care beginning January 1, 2011 and later, prior to initially certifying the home health patient's eligibility, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) had a face-to-face.

"I certify that in my estimation continued services will be required for (a) more than 60days (b) more than 120 days" where (a) and (b) will be check marks.

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