CLARITY for Home Health Agencies

In COVID-19, News by Lisa Selman-Holman8 Comments

Annette Lee, RN, MS, COS-C from Provider Insights, Inc. has provided more clarity for home health agencies during this time. Read the full summary below.

So, last night, CMS published a "Fact Sheet" of additional blanket waivers and flexibilities provided to the home health industry.  Immediately, we all heard different interpretations. Today, like many of us, I spent the day reading the actual rule (starting on page 64 for HH ) and attending CMS, NAHC and NHPCO calls to sift through the details and gain some clarity.  Early in the day, even leaders across the nation were in conflict - but thankfully, by the end of the day, we have some real clarity - Information is Power - So, here is what we know, and I put them in order of what I think was most impactful! Please share this information freely!
1.) Home health agencies can obtain certifications and orders from NP's and PA's from a federal standpoint now for home health services!  This is already enacted!!  
So, how did this happen?  Last Friday, the CARES Act changed the Social Security Act.  Once the Act was changed, it paved the way- and we all thought we were in a holding pattern until CMS was able to update the regulation within 60 days (that is what I wrote to you last week, right!?)   BUT-  on 3/30/20, CMS announced that they were going to have a "Policy of non-enforcement" regarding the regulation which still currently states that Home Health orders must be received from an MD, DO, or DPM.  Only caveat- check with your state if it is within the NP/PA scope.
2.) CMS is encouraging HHAs to PLEASE be creative in how we manage patients in this emergency - and part of this is encouraging telehealth, remote monitoring, and other technology.
This does NOT mean we document these on our SN notes that flow to our claim as if we performed a visit... These remote encounters are not billable under the HH benefit.  So, why all the fuss?  Because the "fact sheet" stated "HHAs can provide more service by telehealth"- and could be easily assumed this meant our VISITS could now be remote.  What does it really mean?
CMS is encouraging HHAs to review every patient's plans of care-- determine which visits contain "hands on" components that are essential, such as a complex wound care, IV, injection.  Planned/ordered visits that are not necessarily needing that in person encounter should be considered for a remote encounter.  The plan of care must be updated appropriately and distinguish which visits are to be in person, and which can be remote.  Some examples of visits that may be appropriate for telehealth are: some observation and assessment, teaching, therapies following up on plan established. This is all to reduce the exposure and risk to your team and your patients.
Where to document? This is not defined by CMS - but they are clear that we do NEED to document these encounters.  So, it may be in a communication note, a coordination of care note, or a SN note that can be "non-billable".  We just must be careful to ensure that the documentation doesn't automatically flow to the home health claim.
Still feel uneasy?  Read it in the full context on page 72 of the interim rule URL at the beginning of the email.
3.) The HHA can certainly assist in facilitating the Face to Face to qualify the patient for home health.
Real life situation- you have your first COVID-19 referral. The patient had been tested, but has not seen their physician.  The physician was made aware of their results and made a referral to your HHA to assist the patient as they sheltered at home during their recovery.  You know you must still have a FTF to qualify for HH Medicare benefit- so you call the Dr's office and coordinate a time when you will be at the patient home- and using your front-facing, two way communication platform with video, such as Facetime, you are able to provide the physician with the ability to do a true "Telehealth visit".  This visit will be documented by the physician (how perfect as you can help guide the Dr with what you are seeing and finding as needs!) and billed by the physician- and now, you have your FTF completed!  Boom!
4.) 65+?  Comorbids?  HOMEBOUND!!
All patients who are high risk (over 65, or any age with chronic diseases such as COPD, cardiac disease or diabetes, etc) can be considered "homebound" during this crisis, because it is medically contraindicated for the patient to leave the home.  This is also true, of course, of any patient who is suspected or confirmed COVID-19 positive.  This should be the statement at the admission and ongoing used to support homebound.  The functional status, may certainly not be indicative of the "normal homebound limitations".  Look at your current census and see if you also may have patients that you are using their Medicaid benefit, because the patient wasn't homebound - Medicare should now be the payer - if they meet the other criteria.
5.) Assessment timeframes relaxed
The "initial assessment (484.55a) standard pertains to the 48 hour rule.  The HHA must typically have their first in-person visit within 48 hours to assess just two things: Immediate care needs and if the patient qualifies for home health.  This relaxation states the timeframe can be met by calling the patient and assessing/documenting these things within 48 hours.
The SOC comprehensive assessment timeframe was also relaxed-- up to 30 days to complete the SOC comprehensive assessment, and the 30 day submission rule from M0090 has been waived.  CMS has not indicated how long providers have to submit.  CMS also stated that there will be no penalties from late submissions during the emergency period.
6.) Supervisory visits - Now Remote!
A COP relaxation to decrease exposure available immediately!  The RN may simply call the patient or caregiver and discuss the care provided to ensure she/he can answer the appropriate questions required for a supervisory visit.  Document how this encounter was performed, and of course this is not a billed service.
7.) Payment changes- RAPs remain and 2% raise
Immediately, MACs were instructed to delay the autocancel of RAPs.  This is meant to ensure no further hardship to cashflow during the emergency when the end of episode claims may be late.  What does this mean? CMS will not take back the 20% provided at RAP, until the end of episode claim is submitted for the full amount.
Also beginning with 30-day episodes that begin on May 1st or after, you will see a 2% raise, due to that little thing called "sequestration" being lifted until 12/31/20.
8.) Iowa friends -  It was discussed by IME on 3/30/20 that there is intent to provide guidance that our HH visits WILL be billable to IME and MCOs here in IOWA!  Be watching for that IME email this week!
9.) All audits are to be halted.  

That's right - you should not be getting any ADR, RAC, UPIC, etc audit at this time!  Notify me if you do- and I can help you talk with that auditing entity!   If you are in IL, OH or TX, CMS agrees to "PAUSE" Review choice demonstration.  If your agency is doing Pre-Claim Review (PCR), you may want to STRONGLY (hint, hint!) consider continuing to send in your information to Palmetto as PCR.  If you do not, your claims will pay in full, but then after the emergency there will be "some type" of post-pay audit, or TPE, etc to look at the claims that were paid during the emergency.  It is by far riskier to have a full audit, rather than just the documentation needed at the front end for PCR.  Also, a CMS representative stated today that this post pay audit could even include extrapolation ... a word dirtier than any four letters!

10.) There is help...MAC hotlines for advanced payments.  Agencies can request up to three months projected claims income upfront.  In 120 days after payment, the monies will be recouped by the MAC by withholding the billing amounts going forward until paid (expected within 90 days, by day 210) 
If there is one thing that I want to leave you with - and be very clear about is CMS' intent - and our reaction during this period of crisis - we are to be led by clinical judgement and ethical decision making.  Not everything will be perfect - it is OK - do NOT focus your efforts and resources on perfection with COPs at this time - we will not be surveyed under this emergency unless you have an immediate jeopardy situation.   Do your best, document, keep your patients and your team safe.  That is the best you can do.  If we can do that - we will get through this!  Hang in there friends!  Can't wait to see you all again!

All of the information mentioned above was provided by Annette Lee at Provider Insights.


  1. 2 Questions please ma’am….
    1. Are ADR’s paused for Medicare replacement plans such as Humana, Aetna, and BCBS?
    2. Can telehealth visits be counted towards LUPA rates? I believe NAHC said no, but it was stated they could count on the TAHCH conf call yesterday.

  2. Annette,

    I appreciate your articles clarifying the drastic changes we are currently facing. They are incredibly helpful and well written. I’m hoping you can assist in clarifying NPP orders. Do you know if this is a temporary or permanent change? I understood this to be permanent. After Monday’s announcement I ask Lisa to clarify and she stated it is not temporary. As we look to update policy I need to be certain and am coming up short on answers. I appreciate any guidance you can offer. Thank you kindly, Susan

  3. Thank you for this summation. It was very succinct and helpful in this time of information overload.

  4. Thank you for the info, very helpful!
    I was wondering if there was any documentation what the LUPA threshold is for a positive COVID-19 patient with the primary dx of U07.1?

  5. Good Morning,

    On #5… it says the time frame can be met by calling the patient and assessing/documenting within 48hrs. Is there anything specific we must document on the welcome call.. HB Status/skilled need? Thank you!

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