This content was originally published on Month June 14, 2018 

Is the new Plan of Care (POC) Requirement reason for alarm? 

On January 9, the National Association for Home Care & Hospice (NAHC) made some waves when it issued a special alert related to content of the home health plan of care. In the alert, they indicate that “Effective January 13, 2018, the “Plan of Care” (POC) Condition of Participation under 42 CFR 484.60 also became a Condition of Payment under the home health benefit, 42 CFR 409.43. This means that all the elements must be in the POC or Medicare payment will be denied.” 

Why the alarm now? 

This Plan of Care (POC) Requirement alert’s basis was that the home health Comprehensive Error Rate Testing (CERT) contractor was finding “significant noncompliance with this new requirement.” The specific non-compliance area was lack of information related to any patient advance directives. 

However, while this alert did bring up a possible billing and compliance issue for home health agencies, it is hardly new requirement. Let’s look at a few regulations that apply. 

42 CFR 409.41 Requirement for payment.  

In order for home health services to qualify for payment under the Medicare program the following requirements must be met: 

  • (a) The services must be furnished to an eligible beneficiary by, or under arrangements with, an HHA that— 
  • (1) Meets the conditions of participation for HHAs at part 484 of this chapter… 
  • (c) All requirements contained in §§ 409.42 through 409.47. 

This requirement dates from December 20, 1994 and shows that even prior to January 2018 that for payment to be made the patient must meet qualifications for coverage that includes a plan of care. These are shown at: 

  • 409.42 Beneficiary qualifications for coverage of services.

To qualify for Medicare coverage of home health services, a beneficiary must meet each of the following requirements: 

  • …(d)Under a plan of care. The beneficiary must be under a plan of care that meets the requirements for plans of care specified in § 409.43. 

This requirement was last revised on November 4, 2011 and shows that there must be a plan of care that is defined in: 

  • 409.43 Plan of care requirements.

Link to an amendment published at 83 FR 56627, Nov. 13, 2018. 

    • (a)Contents. The plan of care must contain those items listed in § 484.60(a) of this chapter that specify the standards relating to a plan of care that an HHA must meet in order to participate in the Medicare program. 

This was first published in December 1994, amended in July 2000, November 2009, November 2015, and January 2017. 

That was then, this is now. 

So now we see that even before January 13, 2018 for payment to be made that the Plan of Care had to include the components of the Conditions of Participation now found in 42 CR 484.60. A few years ago this was a major issue in Palmetto GBA’s Medicare Administrative Contractor (MAC) and multiple Zone Program Integrity Contractor (ZPIC) jurisdictions that especially found that Rehabilitation Potential and Discharge Plan were missing from agency Plans of Care. This is a similar issue now—but not a crisis. 

Prior to 2018, the Conditions of Participation requirements for content of the Plan of Care were: 

  • 484.18(a) Standard: Plan of care

The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. 

What does this all mean? 

To bring this into perspective, the only difference is that now (as of January 2018) advance directive information and two other items are required to be addressed in the Plan of Care. This is not a change in payment requirements for the vast majority of the plan of care content. 42 CFR 484.60 (that replaces 484.18) identifies these items that the CERT has found deficient on the plans of care: 

(2) The individualized plan of care must include the following: 

  • (i) All pertinent diagnoses; [no change from old CoP] 
  • (ii) The patient’s mental, psychosocial, and cognitive status; [minimal change from old CoP] 
  • (iii) The types of services, supplies, and equipment required; [minimal change from old CoP] 
  • (iv) The frequency and duration of visits to be made; [minimal change from old CoP] 
  • (v) Prognosis; [no change from old CoP] 
  • (vi) Rehabilitation potential; [no change from old CoP] 
  • (vii) Functional limitations; [no change from old CoP] 
  • (viii) Activities permitted; [no change from old CoP] 
  • (ix) Nutritional requirements; [no change from old CoP] 
  • (x) All medications and treatments; [minimal change from old CoP] 
  • (xi) Safety measures to protect against injury; [minimal change from old CoP] 
  • (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. [NEW] 
  • (xiii) Patient and caregiver education and training to facilitate timely discharge; [minimal change from old CoP] 
  • (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; [NEW] 
  • (xv) Information related to any advanced directives; [NEW] and 
  • (xvi) Any additional items the HHA or physician may choose to include. [minimal change from old CoP] 

We see that the requirement for advance directives is “Information related to any advanced directives”. The home health interpretive guidelines do not provide any clarification what level of detail must be incorporated in the plan of care related to advance directives. However, if other parts of the record do indicate the presence of an advance directive, this must be included on the Plan of Care to be compliant for Conditions of Participation to allow billing. 

How to CERT-ainly Maintain Payment Compliance 

We have also seen an agency receive a CERT denial for the Plan of Care lacking risk for emergency department visits and hospital readmission, along with the necessary interventions to address the underlying risk factors. This was another of the three added items for Plan of Care content. 

So the only thing “new” that went into effect from January 2018 is that advance directive information, risk for emergency department visits and rehospitalization, and patient-specific goals must now be addressed in the Plan of Care (PoC) Requirement. Agencies should simply add a check of these items during their PoC generation process. To accomplish this, compare admission documents that contain advance directive information to the Plan of Care information that will be sent to the physician for review and signature, and review of the comprehensive assessment for the other new items. 

What’s the “fix”? 

It’s an easy compliance fix. Your chosen electronic medical records (EMR) system should assist you in compliance: if it does not, seek to change it or customize it to include these required items. 

A Plan of Care review checklist can assist in full compliance with this issue that is simply adding a few new items to an old requirement. Let’s keep this in perspective. Check the PoC content when it is generated and you’ll sail right through these CERT and other Medicare reviews. 

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