The “Typical” Home Health Patient

There really is no “typical” home health patient. Besides the very specific medical needs of each patient, one must also consider the patients’ unique family and support situation and individual home environment.

The following are common family situations that may require home health care services.

  • Recent discharge from the hospital or extended care facility.
  • Multiple diagnoses or medical complications.
  • High risk disorders.
  • Frequent hospitalization or emergency room visits.
  • Acute episode of chronic illness.
  • Multiple medications requiring instruction.
  • Pain management.
  • IV Therapy.
  • On-going treatment: catheters, tube feeding, ostomy.
  • Acute impaction requiring enema, disimpaction and bowel program.
  • Wound care requiring treatment, suture removal.
  • Nutritional deficiencies requiring diet instruction.
  • Unstable vital signs.
  • New diagnosis requiring instruction.
  • Terminal illness.

Patients must be HOMEBOUND (leaving the home would require a considerable and taxing effort)


Physician Payment for Home Care Cert/Recerts

Finally, Physicians, get paid for what you already do.

Rates and Information

On January 1, 2001, the Center for Medicare and Medicaid Services (“CMS”) began to pay physicians for “Cert” and “Recert” of Medicare home health care patients. The payments average $72 for certification and $60 for recertification, depending on location.

HCPCS Codes for Physician Home Care Certification/Recertification:

GO180 = Initial Certification of Medicare Home Health Care
Average Pyment = $71.67*
Applies only to new orders for Medicare skilled home health care.
One bill per patient per 60-day episode of care.

GO179 = Recertification of medicare Home Health Care
Average payment = $60.45*
In prolonged episodes, will typically occur every 60 days.
Not for “change orders.”

Both GO180 “Cert” and GO179 “Recert” are…

  1. Billable only by the physician who authorizes home health care. (Nurse Practitioners may not bill.)
  2. Not for Medicaid services, DME or outpatient physical therapy.
  3. Billed under Medicare Part B, which requires physician to bill co-pay.

Best of all, they do NOT require additional documentation to “Back-Up” your claim. 485 Plan of Care and verbal orders are already provided to the physician for signature.

GO181 = Home Health Care Supervision
Average Payment = $121.63*
In Prolonged episodes, will typically occur every 60 days.
Not for “change orders”.


Physician Payment Rates For Care Plan Oversight

Home Care Cert/Recerts/Supervision

The table below shows Medicare’s 89 carrier localities in each of the markets where HHHS offers home health care services, and the corresponding year 2001 Medicare allowables for physicians for home health care cert/recert, based on the RBRVS conversion factor and relative values published 11/1/00 by HCFA.


Overview – Medicare Home Health Benefit

Basic Medicare Guidelines for Home Health Care:

Medicare will pay for health care services provided in a patients residence ONLY if all four of these conditions are met:

  • Patient must need intermittent skilled nursing care, physical therapy, speech therapy or occupational therapy.
  • Patient must be home bound.
  • Patient is under the care of a physician who: determines the need for home care is medically necessary & medically reasonable; sets up a home health Plan of Care; periodically reviews the Plan of Care
  • The home health agency serving the patient is approved for payment by the Medicare program.

Definition of Homebound

A. Homebound = one who requires considerable effort and assistance to leave home, AND needs care on an intermittent basis. Patients may be considered homebound if absences from the home are infrequent or for periods of relatively short duration or attributable to the need to receive medical treatment. Generally speaking, a beneficiary will be considered to be homebound if he/she:

  • Has a condition due to an illness or injury which restricts the ability to leave home except with the aid of supportive device (crutch, cane, wheelchair, walker), needs special transportation, or another person

B. Has a condition which is such that leaving the home is medically indicated.


Occupational Therapy Indicators

Activities of Daily Living

  • Feeding Skills: not feeding self, squirrels or pockets food, decreased suck and swallowing, no lip closure, none or decreased chewing pattern, drooling is present, facial droop, unable to hold utensils or use appropriately.
  • Dressing Skills: unable to dress self secondary to orthopedic or neurological problem, not able to manage fasteners (buttons, snaps, zippers, etc.], confused on how to put on clothing.
  • Hygiene Skills: patient is not able to wash face independently from a basin while in bed, requires assistance with oral hygeine, assistance required on/off toilet, including hygiene when using toilet, requires assistance with grooming skills.

Upper Extremity Functioning

  • Unable to maintain upright sitting posture.
  • Decreased upper extremity coordination – unable to use arms during bed mobility
  • No muscle control in extremities with decreased positioning.
  • Unable to grasp
  • Decreased muscle/tone strength in one or both extremities.
  • Decreased joint mobility
  • Edema/pain upon movement pressure in either/both extremities in combination with above upper extremity dysfunction.
Visual/Perceptual Defects

  • Visual deficits present: Decreased peripheral vision, poor visual orientaiton, tunnel vision.
  • Observations: Does patient only eat 1/2 of food on plate?
  • Cannot locate utensils on tray? Misjudges by over or under shooting when trying to bring food to mouth?
  • Unable to identify body parts?
  • Sensory Defects:
  • No response to hot or cold.
  • Unilateral neglect.
  • Unable to determine joint position without using vision.
  • Unable to discriminate touch.
  • Patient complains of numbness or tingling in extremities.


Speech Therapy Indicators

Commonly Referred:

  • Strokes
  • Traumatic Brain Injury
  • Multiple Sclerosis
  • Parkinson’s
  • History of Falls
  • Anoxia

Cognitive Deficits:

  • Unable to maintain attention.
  • Disoriented to Time, Place or Person.
  • Difficulty in completing daily tasks / remembering.
  • Confused or shows poor judgement

Swallowing Deficits:

  • History of Aspiration; Drools
  • Coughs after swallowing; Difficulty eating

Speech Deficits:

  • Speech distorted/slurred; Difficult to understand

Language Deficits:

  • Difficulty expresing wants & needs
  • Speaks in Jargon