Claim Denials

Common Areas of Home Health Agency Noncompliance with §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care

§484.60 Condition of participation: Care planning, coordination of services, and quality of care specifies the items that must be included on the home health plan of care. The original CMS 485 Plan of Care, which is still utilized in various formats by many home care agencies, includes prompts to address many of these items. However, with the revised Conditions of Participation (CoPs) that went into effect on January 13, 2018, several elements have not historically had prompts to address compliance. As a result, many agencies have been noncompliant with this revised CoP.

These areas of focus are:

  • 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 $484.60 (a) (2) (xii).

  • Patient and caregiver education and training to facilitate timely discharge $484.60 (a) (2) (xiii).

  • Information related to any advanced directives $484.60 (a) (2) (xv).

Risk for Emergency Department Visits and Hospital Re-admission

In respect to the patient’s risk for emergency department visits and hospital re-admission, the CoPs do not specify how the agency describes the patient’s risk. On the OASIS-D assessment, results of (M1033) Risk for Hospitalization can be used to guide this description:

“Patient is at risk for rehospitalization due to a history of 2 or more falls in the past year, 3 hospitalizations in the past 6 months, and currently taking 7 medications.”

Agencies may also use a standardized, validated risk assessment tool, such as the Probability of Repeated Admission (PRA) Instrument, which is distributed by the Johns Hopkins Bloomberg School of Public Health.

Patient and Caregiver Education and Training to Facilitate Timely Discharge

To support patient and caregiver education to facilitate timely discharge, the CoPs must ensure and document on the Plan of Care that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. The agency must provide training, as necessary, to ensure a timely discharge §484.60 (d) (5).

“Physical therapist will educate patient on home health plan of care, focusing on exercises to improve balance and gait to ensure a timely discharge.”

Information Related to Any Advanced Directives

§484.10 Condition of participation: Patient rights (c) (2) (ii) requires that the agency inform and distribute written information to the patient, in advance, concerning its policies on advance directives, including a description of applicable State law. The agency may furnish advance directives information to a patient at the time of the first home visit, as long as the information is furnished before care is provided.

If the patient has an advance directive, these details must be included on the Plan of Care or an addendum to the Plan of Care. To support compliance, agencies should also document the absence of an advance directive.

While MACS have not yet denied claims for noncompliance with the advance directive requirement, CERT auditors have denied these claims. If a claim was submitted as noncompliant with the requirement to include advance directive information on the Plan of Care, CMS has not yet issued guidance. The National Association for Home Care and Hospice (NAHC) recommends that agencies cancel non-compliant claims, obtain an addendum to the Plan of Care, and resubmit the claims. Agencies should contact their MAC for further guidance on the process or other policy guidance for correcting these claims.