Page 137 - Business Development Orientation Binder

 Primary disciplines: RN, PT, and ST (Note: VNSNY criteria are more
limiting and permit primary disciplines as RN and PT only—ST is not a
“stand alone” service)
 Secondary disciplines: MSW, OT, HHA (Note: as per VNSNY criteria ST is considered a
secondary discipline)
 Custodial care is NOT skilled (covered under special circumstances)
 A service is not considered skilled merely because a nurse performs it
3. Physician Generated Orders: 485/POC
4. F2F Encounter Form signed by MD
5. PECOS Enrolled MD
6. Part Time and Intermittent:
 Skilled visit must be made at least every 60 days
 Any number of days per week, up to 28 hrs/week of combined RN and HHA service
(an RN visit is considered 1 hour)
 Daily visits must be time limited (give an end date in “Protocols”)
 Homecare needs are predictable and finite
7. Service is Medically Reasonable and Necessary:
 Care is consistent with nature and severity of illness/injury
 Home care is required
 Care follows accepted standards of medical practice
 Ask yourself: Does the OASIS assessment reflect a need for homecare?
 Maintenance therapy is covered under special circumstances

 How is Medicare Reimbursement Determined?
 Payment is “per episode” (ONE “Cert” period). Payment is the same whether a patient
is discharged in 2 weeks or in 9!
 Medicare payment is determined by the HHRG (Home Health Resource Group) score,
which is generated by the OASIS assessment.
 Skilled service is narrowly defined as restorative care and skilled tasks
 Medicare generally covers service for a LIMITED TIME PERIOD.
 Limited personal care is covered. This type of care must be in support of and as
adjunct to skilled professional service.
 For patients who are “dually eligible”, (have both Medicare and Medicaid), service
not covered by Medicare may be billed to Medicaid by “split billing”. This entails:
1. Determining what services are not covered by Medicare (e.g. long HHA
hrs)
2. Complete Advance Benificary Notice (ABN)
3. Complete Coordination of Benefits (COB) screen in Fiscals, (if
applicable)
8. Medicare Bundle PaymentModel (BP3)
 Pre-determined dollar amount to manage patient for 90 days by preventing re-
hosptialization and un-necessay ER visits (Risk Program)

Reimbursement 06-27-2017 Page 2 of 4