Written by Carissa McKenna, Clinical Consulting Director, and Catherine Bella, Clinical Consulting Manager

The primary objective of the Medicare Home Health Start of Care visit is to confirm the patient is eligible for the benefit.

Does the patient meet Medicare’s Homebound Criteria?

This is an assessment, not an agreement that the patient will remain at home. The first thing to assess is whether the patient requires a supportive device, the use of special transportation and/or the assistance of another person to leave home. If the patient’s provider documents that the patient has a condition (temporary or permanent) which makes leaving the home medically contraindicated this will fulfill the first criterion. Secondly, the documentation must support the patient’s normal inability to leave home and clearly and consistently describe the taxing effort required to leave home.

Does the patient require a professional to provide “reasonable and necessary” skilled therapy or intermittent skilled nursing services?

This is not limited to “tasks” like wound care or therapeutic exercises. Teaching regarding the management of medication, disease processes and effective techniques to manage chronic conditions that can keep patients safely at home are other examples of skilled services which may be provided.

The Medicare Benefit Policy Manual Chapter 7 – Home Health Services, is a great resource providing more guidance on eligibility, going into detail regarding where services can be provided, the provider’s responsibilities and examples of allowable absences from the home. Home Health Agency staff should be knowledgeable in Medicare Policies.

What are some precarious situations that a home health start of care clinician might encounter?

  • Patient is unstable on clinician’s arrival
  • Patient becomes unstable at some point during the visit
  • Patient is NOT in the “Green Zone” on a “stop light” tool
  • Patient is unsafe to be home alone but has no willing/able caregiver to provide 24/7 assistance

Call 911, if the patient needs emergency services. The clinical supervisor and the provider both need to be notified of any unusual situations as soon as possible.

Given the situations above, should the clinician complete the comprehensive assessment and OASIS to be submitted for payment? What are the options and what are the potential impacts to the agency?

If the patient is sent to the hospital and admitted as an inpatient:

  • The agency may transfer the patient and complete a resumption of care (ROC), if the LUPA threshold for the 30-day period is met, the acute care hospitalization (ACH) will impact both the Care Compare scores as well as the Home Health Value Based Purchasing scores for the agency.
  • The agency may transfer the patient and discharge from the agency. This will result in a Low Utilization Payment Adjustment (LUPA) which will likely not cover the costs of the SOC visit.

The agency may choose not to bill for the SOC visit. This will result in no data being transmitted to Medicare and no reimbursement at all for the SOC visit.

  • One instance where the agency may need to non-bill the SOC visit is when the patient is sent to the hospital before completing all elements of the SOC Comprehensive Assessment and is kept in the hospital under observation. If the patient does not return to the agency within the necessary timeframe for completion of the comprehensive assessment (within five days of the SOC), then the agency will not be able to bill the SOC visit since the comprehensive assessment is incomplete.

In both cases, the agency must consider the impact that the hospitalization and/or the emergency department visit may have on Value Based Purchasing payment adjustments.

One final, but important, consideration is the time the clinician has spent with the patient. If the field clinicians are paid per visit, this may incentivize them to just proceed with completing and submitting the SOC because they are paid based on the visits made. Another factor is productivity. Completing the SOC visit will help clinicians to ensure they meet their required productivity. Consider these motivators and establish agency policies that respect the time and effort the clinical staff spend doing the right thing for the patient rather than only providing incentives for making visits.


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