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Medicare Home Health Billing Requirements

May 25, 2021

Clear Defined Patient PoliciesDo you offer home health services to patients? Unfortunately, billing Medicare is a lot more complicated than it might seem when it comes to this type of treatment. That’s why it is incredibly vital that every visit is properly documented and meets certain requirements to ensure the payment process goes as smoothly as possible.

In this guide, we’ll go over a few of the basics you need to know about various medicare requirements for home health billing. Then we’ll take a look at a few coverage restrictions and why they are important to remember. Finally, we’ll look at why you might need an outside team to help you with the process.

Ready to get started? Let’s go.

What Are the Medicare Requirements for Home Health Billing?

In order for Medicare to pay for home health services, specific criteria must be met in relation to the patient’s needs. To put it simply, not everyone is a good candidate for this type of in-home medical care.

Why? Medicare has specific guidelines when it comes to what they’ll pay for and what they’ll deny when a physician or certified nurse practitioner sees a person at their residence or another similar location.

Generally, these guidelines are used to ensure only those with a specific level of medical need receive the additional care and associated cost of home health treatment. By knowing the patient guidelines, you can easily help determine if a Medicare patient is a good candidate for this type of service. Here are the three key criteria that the patient must meet.

1. Home Confinement

Perhaps the most important aspect of home health qualification is that the patient is confined to his or her home. What this means in terms of Medicare is that the individual has a condition that makes it very difficult to leave their residence. This can be because of a need for special medical equipment like a wheelchair, oxygen tank, crutches, or other similar requirements.

Likewise, patients who have a difficult time leaving due to a taxing medical condition, such as a terminal illness, serious disability, or other situation when the health condition makes travel contraindicated. Infrequent trips like the need to travel to specific one-time events like family funerals, religious services, and other common errands are not considered disqualifiers for the home confinement guidelines.

2. Need for Skilled Services

To receive home health care, the patient must also be in need of skilled services. According to the Medicare guidelines, there must be a documented requirement for either intermittent skilled nursing care for under eight hours per day or a special service, such as a physical therapist, occupational therapist, speech-language pathologist, or other similar providers. Furthermore, the requested services must be reasonable and follow basic guidelines for the recommended number of visits appropriate for the patient’s needs.

3. Physician Involvement

In addition to the two criteria above, patients must also be under the care of a physician and recommended for home health by a physician. In order for this to take place, the patient must have a face-to-face encounter with the recommending physician somewhere between sixty days before or thirty days after the start of home health care. In addition, the treating home health physician and the recommending physician cannot be the same and must have no financial link between them. This is an incredibly important piece of information when it comes to home health billing and should always be followed accordingly.

Required Documentation

As expected, proper documentation is essential when it comes to billing Medicare for home health services. In order for a claim to be paid, there must be full evidence in the patient’s medical file corroborating their homebound status, plus information on the reason for the physician’s recommendation for services.

In this case, having detailed chart notes with the reasoning for the request and any additional information that would back up the need for home health care is paramount to proving medical necessity. For example, documenting the patient’s medical condition that makes it impossible to leave home for treatment and using similar notes on the recertification should help prove they meet the three criteria points listed above.

How Many Hours Does Medicare Cover for Home Health Care?

In general, there is a limit to the number of hours in which Medicare will pay for home health care once a patient has qualified using the criteria we previously mentioned. The exact amount listed in the requirements is that patients cannot receive more than twenty-eight hours per week with a maximum of no more than eight hours per day. If necessary, Medicare can provide an additional thirty-five hours a week of care, which is determined on a case-by-case basis.

Furthermore, the patient’s plan of care must be recertified by the physician once every sixty days. This means that, even if you’re using the maximum number of hours for care, there will still need to be a documented medical necessity every two months to continue at the same level.

What is the Maximum Number of Visits Medicare Will Cover?

The interesting thing about Medicare and home health is that there is no specific set number of maximum visits. However, it is marked by hours, which is detailed above. These visits can happen seven days per week, with the only guideline being that the maximum number of hours cannot be exceeded. Again, this treatment plan certification must be renewed every sixty days to stay in compliance.

Why Working with a Medical Billing Expert is Important

If your practice offers or recommends home health services to patients, it is incredibly vital that you work with an expert in medical billing. By doing this, you can ensure your billing practices and recordkeeping always meets Medicare requirements.

At M-Scribe Medical Billing, we offer our clients expert advice and service to ensure the entire process goes as smoothly as possible. While dealing with Medicare, Medicaid, and other similar organizations can be difficult, our team works hard to ensure they’re always up to date with the latest guidelines and recommendations. Please contact us today for more information.


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