Home Health Review Tool Step 1 (Face-to-Face Encounter Requirement)

Home Health Review Tool Step 1 (Face-to-Face Encounter Requirement) 1 Is a Face-to-Face Encounter note* present? No NO YES Yes 1.1 Was the Face-to-Face Encounter note signed and dated by an allowed provider type**? No NO YES Note Deny/ Non-Affirm reason (continue to step 2) Yes 1.2 No Was the Face-to-Face Encounter performed by an allowed physician or NPP**? YES NO Yes 1.3 Does the Face-to-Face Encounter progress note indicate the reason for the encounter was related to the need for home health services? No . YES NO Yes 1.4 Is the Face-to-Face encounter note dated between 90 before or 30 days after the start of home health services? YES No NO Yes F2F Encounter Requirement ARE MET. Proceed to Step 2 (Plan of Care requirements) * Face-to-face encounter note can include progress notes, discharge summary, etc. . **Please refer to 42 CFR 424.22(a)(1)(v)(A) for detailed information on who can perform the face-toface encounter.

Step 2 (Plan of Care Requirement) 2 No Is Plan of Care present? YES NO Yes 2.1 No Is the plan of care signed and dated by the certifying physician? YES NO Yes 2.2 Does the Plan of Care address all pertinent details as described in 42 CFR §484.18(a) including: Diagnoses; Mental status, Types of services and equipment required Frequency of visits, Prognosis, Rehab potential Functional limitations Activities permitted Yes Nutritional requirements Medications and treatments Safety measures to protect against injury Instructions for timely discharge or referral, Any other appropriate items No . YES NO Yes 2.3b 2.3a Yes Does the Plan of Care include therapy services? YES NO No Does the Plan of Care address; Specific procedures and modalities, Measurable therapy treatment goals, Frequency and duration of services YES NO Yes Plan of Care Requirements ARE MET. Proceed to Step 3 (Homebound) . Note Deny/ Non-Affirm reason (continue to step 3)

Step 3 Homebound Requirement 3 No Was any certifying physician and/or acute or post-acute care facility documentation NO YES submitted? Yes 3.1 (Criteria ONE) 3.1a Does the physician/facility documentation indicate that the patient requires a: mobility assist device or special transportation or assistance of another person to leave the home or has a condition that leaving home is medically contraindicated? YES Yes 3.1b Is the HHA info signed/dated by the certifying physician ? YES NO NO No Yes 3.1c Yes Is the HHA info corroborated by the certifying physician and/or acute or post-acute care facility documentation? YES NO Yes 3.2 (Criteria TWO)* Does the physician/facility documentation support that the patient has a normal inability to leave the home AND requires a Yes considerable and taxing effort to leave the home? YES NO No Do the HHA medical records or plan of care satisfy the homebound criteria ONE requirements? NO YES No . Note Deny/ Non-Affirm reason (continue to step 4) No 3.2a Do the HHA medical records or plan of care satisfy the homebound criteria TWO requirements? YES NO No Yes 3.2b Yes Is the HHA info signed/dated by the certifying physician ? NO YES HomeBound Requirement IS MET. Proceed Step 4 (Need for Skilled Care) No No Yes 3.2c Yes Is the HHA info corroborated by the certifying physician and/or acute or post-acute care facility documentation? YES NO . No Note Deny/ Non-Affirm reason (continue to step 4) *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.

Step 4 (Need for Skilled Care Requirement) 4 No Was any certifying physician and/or acute or post-acute care facility documentation submitted? YES NO Yes 4.1a 4.1 Is skilled need (skilled nursing care, PT, SLP, or OT) supported by the certifying physician, acute care facility, or post-acute care facility documentation? YES NO No Do the HHA medical records or plan of care support the the need for skilled services? YES NO No Yes 4.1b Is the HHA medical record or plan of care signed/dated by the physician? YES NO Yes No Yes Note Deny/ Non-Affirm reason (continue to step 5) 4.1c . Is the HHA medical record or plan of care corroborated by the certifying physician and/or acute or post-acute care facility documentation? Yes YES NO No Yes Skilled Need Requirement IS MET. Proceed Step 5 (Certification) . *Skilled need may be substantiated through an examination of all submitted medical record documentation from the certifying physician, 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.

Step 5 (Certification Requirement) 5 No Is a certification statement(s)* present? YES NO Yes 5.1 No Does the physician certify that the patient requires skilled care**? NO YES Yes 5.2 No Does the physician certify that the patient is homebound? YES NO Yes 5.3 Does the physician certify that a POC has been established by a physician who does not have a financial relationship with the HHA? YES Deny/ NonAffirm No NO (note all denial reasons from steps 1-5) Yes . 5.4 No Does the physician certify that the patient is under the care of a physician? YES NO Yes 5.5b 5.5a Did the certifying physician conduct and sign the face to face encounter note provided? YES NOYes Yes No Does the physician certify that the patient had a face to face encounter and did the physician document the date of the encounter? YES No NO Yes All Requirements ARE MET. Mark the case AFFIRMED or PAYABLE * A certification statement may appear in a progress note, plan or care, or any other part of the patient's medical record. It may be on any form and in any format. ** "skilled care" means skilled nursing care, PT, SLP, or a continuing need OT after the need for skilled nursing, PT or SLP have ceased. .