Refer a Patient to VNH

Make a referral

Medicare requires that a patient have a skilled need and be homebound.  Most other insurances have similar requirements for adult home health care. A skilled need is medically necessary care that can only be delivered under the direction of a skilled or licensed clinician.

Examples of need

Homebound definition

Face-to-face requirement

Valid reimbursable diagnosis

Examples of need

Homebound definition

Requires a taxing effort because of illness or injury and may include the use of a supportive device (i.e. walker, cane, wheelchair, special transportation, etc.)

• Is medically contraindicated due to a specific condition
• Is infrequent, or of short duration for healthcare purposes. (Additional infrequent absences for a short duration may not indicate that the patient is not homebound and can be discussed with the VNH care team)

The following are some (but not all) examples of situations that may render a patient homebound.

• Vision impairment
• Cognitive impairment/dementia
• Cardiac or pulmonary disease, causing fatigue and shortness of breath
• Post-op patients on pain medications
• Inability to bend and twist as required to enter/exit car
• Bedbound or wheelchair-bound
• Paralysis or hemiparesis
• Inability to open doors or use handrails
• Activity restrictions

Face-to-face requirement

Medicare requires documentation of a completed, valid, and signed face-to-face encounter for a patient to be eligible for home health services. The face-to-face encounter is a Medicare requirement; however, most insurances have followed Medicare and also require a valid face-to-face. The encounter must be completed by a PECOS enrolled physician or other approved non-physician practitioner, which can include nurse practitioners, clinical nurse specialists, and physician assistants. The face-to-face encounter must be performed by the provider following the patient during the home health episode unless a patient is referred directly from an inpatient facility.

Required components of a face-to-face encounter document:

• A clinical note performed and signed and dated by an allowed provider type. A handwritten signature must have a handwritten date and an electronic signature and date must be clearly identified as being an electronic signature.  If the encounter is performed by a resident, the encounter note must be co-signed by the supervising attending who will follow the patient during the home health episode.
• Encounter may be up to 90 days prior to the home health start of care or may take place within 30 days after the start of care.
• The encounter must be related to the reason for the referral and admission to home health. The not must include the clinical diagnosis, assessment and plan for the treatment of the issue.
• The encounter or related documentation from the facility or provider must include documentation supporting that the patient is homebound.

Valid face-to-face encounter documentation can be found in an office visit note, progress note, emergency department notes and discharge summaries.  Please note that not all discharge summaries include a valid assessment/clinical findings. If it only includes patient instructions, medication list, nursing or therapy notes, it is not a valid face-to-face.

Please reach out to the Intake team at 800-300-8853, Option 1 with any questions related to the face-to-face documentation. We are here to assist you and help make the referral process go as smoothly as possible.

Valid reimbursable diagnoses

Medicare reimbursement is determined based on the patient’s diagnoses.  The primary diagnosis must be as specific as possible and there are a number of diagnoses that are excluded from payment.  Many of these excluded diagnoses are unspecified diagnoses or symptoms, such as weakness, debility, abnormal gait, dizziness, and fatigue.  They can also include diagnoses that do not specify whether the injury, surgery or wound is on the right or left side of the body.

The home health primary diagnosis should reflect the underlying cause for the patient symptoms and be as specific as possible. Some examples may include:

Muscle weakness, Generalized weakness

Consider: What is the reason the patient is presenting with muscle weakness? Did the patient have surgery, an injury, cardiac or respiratory condition? Did the patient have an infection? Identify what caused the weakness.

Debility

Same as weakness guidance. Old age is not a valid diagnosis under PDGM.

Abnormal gait

What is the abnormal gait related to? Is there an underlying neurological cause? Even variations of abnormal gait such as ataxic gait, difficulty in walking, etc. are not allowed as a primary diagnosis by Medicare.

Superficial injury codes

Superficial injury codes, most used to capture skin tears and abrasions, are NOT allowed as a valid primary diagnosis by Medicare. Consider a laceration code, if more appropriate. Why did the patient receive a skin tear? Falling? Loss of balance? Identify the cause rather than the symptoms.

Please reach out to the Intake team at 800-300-8853, Option 1 with any questions related to the appropriate diagnosis. We are here to assist you and help make the referral process go as smoothly as possible.