Frequently Asked Questions

For the 2025 HHVBP measure “Home Health Within Stay Potentially Preventable Hospitalization (PPH)”, the number of risk-adjusted potentially preventable hospitalizations OR potentially preventable observation stays that occur within a home health stay for all eligible stays at the agency will be calculated.

• Planned admissions are not counted (for example planned hip replacements, planned knee replacements)
• Whether or not the hospitalization or observations are preventable or not will be determined by the codes the hospital places on their claim

The measure-specific exclusions for this measure are:

• HH stays that begin with a LUPA claim
• Stays in which the patient receives service from multiple agencies during the home health stay
• Patients not continuously enrolled in Medicare part A Fee for Service for the 12 months prior to the home health admission date through the end of the home health stay
• Patients less than 18 years old

Reference: Specifications for the Home Health Within-Stay Potentially Preventable Hospitalization Measure for the Home Health Quality Reporting Program

The implementation of mandatory all payer OASIS Collection and Submission is for all SOC OASIS 07/01/2025 and after. You will also be required to collect and submit all subsequent OASIS for these patients (Recert, TF, ROC, DAH, DC, Other Follow Up/SCIC etc).

The Final OASIS E1 Manual states the following:

OASIS data collection and submission are required for patients with any pay source who are not exempt from OASIS data collection, and who begin receiving home health care services with an OASIS SOC M0090 data on or after July 1, 2025. The requirement includes the SOC OASIS and any subsequent OASIS time point assessments relevant to the patient’s home health stay (that is, resumption of care, recertification, other follow-up, transfer, discharge, and death at home).

• Patients under the age of 18, patients receiving maternity services, and patients receiving only personal care, housekeeping and/or chore services continue to be excluded from OASIS data collection and submission requirements.

Reference: CMS Home Health OASIS All Payer Q&As

Yes. Per the Medicare Benefit Manual Chapter 7, the 30-day reassessment is still a requirement. The documentation states “At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements. The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.

See the following from the OASIS Guidance Manual, Chapter 3, Item M0104 – regarding Timely Initiation of Care, which states:

• A valid referral is considered received when the agency has received adequate information about a patient (such as name, address/contact info, and diagnosis and/or general home care needs) to initiate patient assessment and confirmed that the referring physician/allowed practitioner or another physician/allowed practitioner, will provide the plan of care and ongoing orders.
• In cases where home care is requested by a hospitalist who will not be providing an ongoing plan of care for the patient, the agency must contact an alternate or attending physician/allowed practitioner. The agency will note the date the alternate or attending physician/allowed practitioner agreed to follow the patient as the referral date (M0104) unless referral details are later updated or revised.
• Enter the date of the most recent/latest referral
• If Start of Care or Resumption of Care is delayed due to the patient’s condition or physician/allowed practitioner request (for example, extended hospitalization), the date the agency received the updated/revised referral for home care services would be considered the date of referral.

The Timely Initiation of Care quality measure, as well as the CoP, will be based on whether the initial assessment was conducted either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered SOC date. If you are pursuing a physician ordered SOC date, you must contact the referring provider and get that order date within the 48-hour period, or you will be out of compliance.

Surveyors will count 48 hours from the time that the referral is received whether a physician has been verified to cover the patient or not. If there is a question as to being able to obtain the physician confirmation of home health coverage, the agency should seek documentation of a specific SOC date in the referral order.

The short answer is No, CMS does not mandate that you always discharge (and readmit if a referral is received). The rationale is a bit more complex as the decision to transfer/resume vs. discharge and readmit has to be evaluated on a case-by-case basis, and the decision to DC vs TRN based on impact to payment and quality measures.

However, IF a patient is in a facility (SNF, Acute Care Hospital/ACH, Swing Bed, etc.) on the 60th day of the certification period, the patient SHOULD be discharged.

In other cases, the decision to TRN and Resume vs DC and Readmit would be based on:

• Facility Setting (PAC vs. Acute Care) and/or
• Impact to PDGM Payment, if applicable.
• In cases where a patient is discharged to a facility – regardless of type – Medicare is now applying the regulation, to claims processing, that if the patient returns/resumes within the same 30-day period the discharge will be nonallowed for billing purposes and the claim RTP for correction
• If the patient is discharged to a facility - regardless of type – and has a new SOC on day 31 or later of the episode – the agency can receive institutional credit on that new claim if the discharge happened within the prior 14 days (this is the only way to get the credit for a SNF, LTCH, Rehab or Psych readmission)
• Note: if the patient is admitted to an acute care hospital and resumed in the last 14 days of a period the next 30-day claim will get institutional credit.

The Discharge to Community measure that was based on OASIS responses is no longer utilized in the HHVBP measure calculations. It has been replaced by the Discharge to Community Post Acute Care measure (DCT-PAC). The measure is the risk-adjusted prediction of the number of HH stays resulting in a discharge to the community (Patient discharge code 01 or 81) without an unplanned admission to an Acute Care Hospital or LTCH or death in the 31 days post-discharge observation window. This is a measure that will cover two years of data and it will be derived from hospital claims. See the model guide at this link for more information.

For a Start of Care, OASIS Guidance states that the assessing clinician has 5 days to continue to gather needed information to complete the Comprehensive Assessment. When additional time is needed to gather information during this 5-day window, the clinician is to note the last date that information was received to complete the assessment in M0090, Date Assessment Completed.

NOTE: the 5-day assessment window does not apply to other types of assessments. The 5-day window is also not just to complete the documentation of information already received at the SOC visit; the window is to get additional clarification from the provider, the family, or the care team such as the PT who is evaluating within the 5-day window, for example.

OASIS Assessments must be submitted and accepted to iQIES within 30 days of the recorded M0090 date.

The window for the new cycle selection for Ohio, North Carolina & Florida opened on April 1 and will close on April 14, 2025. Oklahoma's ended in March, Illinois & Texas are in July.

The options to choose from are #1 Pre-Claim Review, #2 Post Payment Review. If you were 90% successful with affirmations or approval under one of those two options, review in the subsequent selection period you may select: #1 Pre-Claim Review, #3 Selective Post Payment Review or #4 Spot Check Review.

Your question was specifically about Spot Check, which includes that 5% of your claims will be chosen for ADR REVIEW and this is PRE-PAYMENT.....meaning as you bill the claim they will be selected for ADR review and the chart will have to be submitted for medical review and that can take 60+ days to get the results and if approved you will then be paid. If you have an agency that bills 1,000 claims per month this means that you will have 6,000 in 6 months and 300 of them will be pulled for medical review. You are not only looking at delayed payment of 300 claims, but you are facing the possibility of denials that would require a lengthy appeal process and possibly being referred to additional medical reviews such as UPIC if the denials are significant.

I also want to reiterate that that if you select #3 there is no clear answer as to the calculation of identifying a Statistically Valid Sample of charts, not to mention the fact that if you select this one you are stuck there until 2029.

In our experience, being under Pre-Claim review, while it might seem tedious, has become a way for agencies to ensure that, at least initially, the certification passes medical review scrutiny and does NOT subject the entire chart to medical review nor does it delay cash flow.

Thank you for your questions regarding OASIS items and their use. Each item used in the OASIS data set is used in some capacity, but they are not all used for the same purpose. This makes it difficult to select only those used for reimbursement or outcomes measures.

For example, The M1800 items plus M1033 are used to calculate the functional domain in PDGM payment, which impacts your Medicare payments. However, the GG Items (GG0130 and GG0170) are used to determine the patient’s functional status for the Discharge Function Score in Home Health Value Based Purchasing.

M1021, Primary Diagnosis and M1023, Secondary diagnoses, are used for risk adjusting the Potentially Preventable Hospitalization measure for HHVBP (as well as M1021 and the M1700 items).

For a list of all the OASIS Items used in Home Health Quality Reporting program, this link to HHQRP Outcomes Measures will open a table with all the measures and the items used to calculate them.

This link opens a table with all the process measures used in HHVBP; some of these are also used in reports your surveyor pulls prior to on-site survey, such as the Potentially Avoidable Events reports.

Because of the comprehensive nature of the OASIS and its use, we strongly encourage agencies to review ALL the OASIS items and provide education to staff on the OASIS data set regularly. Should you need assistance with either, please let us know - we can help!

The OASIS E-1 Guidance Manual states that:

“Agencies may have the comprehensive assessment including OASIS, if applicable, completed by one clinician. If collaboration with other health care personnel and/or agency staff is utilized, the agency is responsible for establishing policies and practices related to collaborative efforts, including how assessment information from multiple clinicians will be documented within the clinical record, ensuring compliance with applicable requirements, and accepted standards of practice.”

The manual also states that “Any differences between OASIS coding should be discussed jointly by the assessing clinician and auditor to determine the reasons for the differences and to ensure that assessing clinicians fully understand the OASIS items and related guidance.”

Given this guidance, best practice would reflect that a discussion between the reviewer and the assessing clinician occurred, whether verbally or in writing, and that the clinician who is responsible for the comprehensive assessment agrees with the changes made. Agency policy would dictate how this is documented; some agencies document on a care coordination note with the assessing clinician re-signing and “locking” the comprehensive assessment after review to reflect this agreement and to affix the clinician signature to the legal document in the software platform.

Yes, if Medicare is listed as a pay source for home health, the data is used in Home Health Quality Reporting Program OASIS-based measures.

The Home Health Quality Reporting Program Quality Measures User’s Manual, Version 3.0 states:

“The OASIS-based quality measures in the Home Health Quality Reporting Program will continue to report only data for Medicare fee-for-service, Medicare Advantage (Medicare managed care), Medicaid, and Medicaid managed care.”

It also states in Chapter 3 of this manual that quality episodes [for use in HHQRP] are not created for patients who meet OASIS measure exclusions or who do not have Medicare Traditional fee-for-service, Medicare HMO/Managed Care/Advantage plans, Medicaid Traditional or Medicaid HMO/Managed Care plans, or are receiving only personal care, homemaker, or chore services.

The HHVBP adjustment should be applied prior to sequestration. There are two resources for your review and use regarding the VBP adjustment and sequestration. Question 5008 of the HHVBP FAQs states: Through the expanded HHVBP Model, CMS will adjust each HH PPS final claim payment amount to a home health agency (HHA) with a “through date” in the HHVBP payment year by an amount up to or down to the maximum applicable percent. Applying the sequestration adjustment is the final step in processing a claim.

• Home Health Value Based Purchasing Newsletter, March 2025. - See Page 4 of 6.
• Home Health Value based Purchasing Frequently Asked Questions, CMS, March 2025. - See Page 8 of 70, Question 5008.

Medically necessary skilled care is defined in section 40 of the Medicare Benefit Policy Manual, Home Health Chapter 7. This layer of coverage is in addition to beneficiary eligibility criteria covered in sections 20 and 30 of this manual. Additionally, CGS, your Home Health Medicare Administrative Contractor (MAC) provides information on coverage on their website. Keep in mind that some Medicare Advantage plans cover things that Traditional Medicare does not. You will need to check with the specific MA plan to determine.

Whether or not Medicaid covers long-term medication management is dependent on the individual Medicaid insurance policy’s coverage guidelines. Please refer to the Medicaid payer’s insurance contract and/or coverage criteria for information as to whether long-term medication management is a covered billable service.

No. According to CMS’ Home Health Conditions of Participation, the Home Health Agency must provide skilled nursing services and at least one other therapeutic service. The therapeutic services include PT, OT, S-LP, MSW or HH Aide services. So, CMS does not require aide services; please confirm that the State you are providing care in also does not require this. If you list that you provide home health aide services, you will need to have other qualified staff members provide the aide services (such as your LVNs, or RNs). You may also provide the aide services “indirectly”, meaning contracted staffing services. If you decide you are no longer going to provide home health aide services, you will need to update your service line listing with the state, CMS and on your website and marketing brochures and other public facing information. You will also need to update your Acceptance to Service Policy, which is the new CoP mandated policy effective this January 1, 2025.

The home health quality 30 day readmission measure was retired and was replaced by the new measure “Home Health Within Stay Potentially Preventable Hospitalization” or PPH measure.

This is a claims-based measure that is risk adjusted. The measure calculates potentially preventable hospitalization or potentially preventable observation stays that occur within a home health “stay” for all eligible patients at each agency.

A “stay” is a sequence of HH payment episodes separated from other HH payment episodes by at least two (2) days.

For HHVBP, only the Medicare fee-for service (traditional) patients are included in this measure.

Exclusions include:

• Home health stays that begin with a LUPA claim adjustment
• Stays in which the patient receives service from multiple agencies during the home health stay
• For patients not continually enrolled in Traditional Medicare for the 12 months prior to the home health admission date through the end of the home health stay

Whether a Hospitalization or Observation stay is preventable or not is based on the diagnosis listed on the hospital claim. To clarify, planned admissions are not included in the calculations unless the planned stay includes one of the acute diagnoses from this designated list; in that case it would be reclassified as unplanned.

To view details of the PPH Measure, click here.

For Medicare HMO or Advantage Plans, be sure to note M0063, Medicare Number is answered properly. The OASIS manual states that the patient’s Medicare Beneficiary Identifier should be entered if available, even if the patient is a member of a Medicare HMO, Another Medicare Advantage Plan, or Medicare Part C. If the Medicare MBI is not available, mark “NA – No Medicare”.

Do not enter the HMO ID number. The Medicare number (if known) should be entered even if Medicare FFS is not the primary payment source for this episode of care.

If these items are answered correctly, and your OASIS continues to be rejected, contact the Home Health Quality Help Desk at homehealthqualityquestions@cms.hhs.govor the iQIES help desk atiqies@cms.hhs.gov

OASIS guidance states that an OASIS transfer should be completed when the patient is admitted for 24 hours or longer for a reason(s) other than diagnostic testing. If the patient does not meet these requirements, then no OASIS TF should be performed. If the patient does not meet TF assessment criteria, your agency policy would dictate if you would complete an Other Follow-Up Assessment/ Significant Change In Condition (SCIC) comprehensive assessment following the patients return home from the hospital for observation stays or emergency department visits.

Traditional Medicare Fee for Service patients who are re-admitted or held in observation status while on home health services are counted in the claims-based measure “Home Health Within Stay Potentially Preventable Hospitalization” or PPH measure. You can find additional information on this outcomes measure, which is a HHQRP and HHVBP here.

For individuals under a home health plan of care, payment for all services (Nursing, therapy, home health aides and medical social services) and routine and non-routine medical supplies, with the exception of certain injectable osteoporosis drugs, DME, and furnishing negative pressure wound therapy (NPWT) using a disposable device is included in the HHPPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services.

The Consolidated Billing List under Home Health PPS can be downloaded here: Home Health Consolidated Billing Master Code List

The guidelines for documentation for medical necessity as stated in Publication 100-2, Chapter 7 Medicare Benefit Policy Manual – Home Health. In section 40.1 CMS defines skilled, medically necessary nursing services coverage and documentation. Additionally, in section 40.2, CMS defines the same criteria as required for coverage in Skilled Therapy Services notes. In part these sections read:

“As is outlined in home health regulations, as part of the home health agency (HHA) Conditions of Participation (CoPs), the clinical record of the patient must contain progress and clinical notes. Additionally, in Pub. 100-04, Medicare Claims Processing Manual, Chapter 10; “Home Health Agency Billing”, instructions specify that for each claim, HHAs are required to report all services provided to the beneficiary during each 30-day period, which includes reporting each visit in line-item detail. As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided. These clinical notes are also expected to provide important communication among all members of the home care team regarding the development, course and outcomes of the skilled observations, assessments, treatment and training performed. Taken as a whole then, the clinical notes are expected to tell the story of the patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a skilled service is needed.”

Therefore the home health clinical notes must document as appropriate:

• the history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and
• the patient/caregiver’s response to the skilled services provided, and
• the plan for the next visit based on the rationale of prior results,
• a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
• the complexity of the service to be performed, and
• any other pertinent characteristics of the beneficiary or home

Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:

• Patient tolerated treatment well
• Caregiver instructed in medication management
• Continue with POC

Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.

All skilled care patients, regardless of payer, must have OASIS data collected and submitted. Currently, OASIS data on non- Medicare or non-Medicaid payers is NOT USED for calculation of outcomes. However, if you are treating medication management patients as “skilled” then they are included in your outcomes data calculations (unless they meet exclusions per OASIS and outcomes specifications).

“Skilled” is defined by the Medicare Benefit Policy Manual for the purpose of the HHQRP and Outcomes. This manual says the following about medication management:

“The prefilling of syringes with insulin (or other medication that is self-injected) does not require the skills of a licensed nurse and, therefore, is not considered to be a skilled nursing service. If the patient needs someone only to prefill syringes (and therefore needs no skilled nursing care on an intermittent basis, physical therapy, or speech language pathology services), the patient, therefore, does not qualify for any Medicare coverage of home health care. Prefilling of syringes for self-administration of insulin or other medications is considered to be assistance with medications that are ordinarily self-administered and is an appropriate home health aide service. (See §50.2.) However, where State law requires that a licensed nurse prefill syringes, a skilled nursing visit to prefill syringes is paid as a skilled nursing visit (if the patient otherwise needs skilled nursing care, physical therapy, or speech-language pathology services), but is not considered to be a skilled nursing service.”

“The administration of oral medications by a nurse is not reasonable and necessary skilled nursing care except in the specific situation in which the complexity of the patient's condition, the nature of the drugs prescribed, and the number of drugs prescribed require the skills of a licensed nurse to detect and evaluate side effects or reactions. The medical record must document the specific circumstances that cause administration of an oral medication to require skilled observation and assessment.”

Filling medication dispensers/boxes or prefilling syringes is not a covered skill under the Medicare benefit. There are some exceptions when the patient has a medically complex regimen with frequent changes and the skills of a SN to teach and monitor on the new/changed/complex medications are needed. However, if the patient is unable to learn the teaching and training, once this is established, the teaching and training is no longer a covered skill.

So, unless the patient is not complex, then “medication management” is not a billable skill. If no skilled service is performed as described in the Medicare Benefit Policy Manual, then these visits should not be billed to Medicare. Management of medications under a VA program is covered in some contracts, and if so, OASIS may be required, but those patients would be excluded from outcomes measure calculations based on how the payer question on the OASIS is answered. Be sure you are ONLY marking the insurances that are paying for home health care, not all the payers the patient has to choose from.

For scenario 1, While you will not need a Plan of Care for billing as no signature will leave you not being able to bill, you would need one for treatment provided, assuming that you documented a verbal confirmation of the plan to provide care, you would be covered for care provided.

For Scenario 2, to support compliance with the Conditions of Participation, you should develop a Plan of Care and have it signed and dated by the physician despite not billing for the services.

Additional criteria that must be met to be compliant for billing and the Conditions of Participation is as follows:

For Home Health Benefits to be covered the following criteria must be met related to the Plan of Care:

According to Medicare Benefit Policy Manual Chapter 7- 30.2 - Services Are Provided Under a Plan of Care Established and Approved by a Physician or Allowed Practitioner (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

Surveyors do not evaluate whether services were billed or not billed.

According to the CoPs and Surveyor’s Guidance Manual for Home Health:

§ 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility.

§484.55(b)(3) When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician or allowed practitioner, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. For Medicare patients, the occupational therapist may complete the comprehensive assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility.

Since both PT and OT were ordered on the referral, OT can complete the SOC OASIS. OT must document the skilled need for PT during the SOC to establish Medicare eligibility during the SOC visit. There must be at least one skilled visit from PT to establish eligibility; this PT eval visit needs to happen “soon after the SOC”.

The order of visits does not matter.

Eligibility is stated as “confined to the home and has need for skilled nursing care (other than solely venipuncture for the purpose of obtaining a blood sample) on a intermittent basis or physical or speech therapy.”. This is why OT has to have either PT or ST ordered on the referral and that the OT has to document the need for PT on their initial and/or SOC visit.

For additional information, click here.

No there is no new guidance regarding this. The OASIS Guidance Manual specifies “inpatient facilities” for this item. Observation status and outpatient surgery are not considered inpatient facility discharges so it’s not reportable for this item. Triggers from your EMR might be helpful to initiate conversations regarding treatment plan, but per OASIS guidance ER visits that do not result in an inpatient admission and subsequent inpatient discharge are not reported for M1000.

For PDGM payment, facility claims data is used to determine if the appropriate grouping is “institutional” or “community”. However, we know that not every facility bills timely enough that this claim is present in the Medicare system when we drop our claim. Therefore, CMS allows us to put an occurrence code on our claim to indicate the patient had a qualifying inpatient stay that impacts our Admission Source and Timing grouper. My assumption is that the EMR is using this information to assign the occurrence code on the home health claim when it applies. Note that if the occurrence codes below are on the claim, you will receive institutional credit whether there is a claim to support or not. You must ensure that these codes are only populating the claim when there has been an actual admission and discharge where the discharge date is within 14 days of the beginning of the next 30-day billing period.

Occurrence code 61 “Hospital Discharge Date” may be reported, but is not required, on final claims. Report the DC date of an inpatient hospital admission that ended within the 14 days of the “from” date of the HH period of care.

Occurrence code 62 “Other Institutional Discharge Date” may be reported, but is not required, on final claims. Report the DC date of a SNF, IRF, LTCH, or IPF stay that ended within the 14 days of the from date of the HH period of care.

For more information on the use of occurrence codes in billing home health claims, see The Medicare Claims Processing Manual – Chapter 10.

The only change to the face-to-face encounter rule is that any allowed practitioner can perform the encounter rather than only the certifying provider or directly referring facility. The certifying provider will need to certify the date of the compliant encounter in the certification statement.

When an operative note is used as the face-to-face encounter, it must be accompanied by a pre-op note, or post-op note to ensure that the condition being treated in home health is addressed and also because the patient is unable to participate in a two-way “face-to-face” encounter when under anesthesia. An operative note alone will not be compliant since it does not meet the requirements.

The certifying provider must include the date of the compliant F2F encounter as part of their certification statement.

The F2F encounter may be performed by any qualifying practitioner and is not limited to the certifying practitioner or a practitioner from a facility admission. Be very clear that regardless of who provides the F2F, it must still meet all the requirements – Within 90 days prior to the Start of Care or within 30 days after. Must be an actual visit note from the practitioner that is signed and dated. Must contain support for skilled need for home health and homebound status. Must document treatment to the primary reason for the home health admission.

The CMS regulations allow the patient to choose a NP or PA as their attending physician. However, if the attending/supervising physician for the NP/PA is not specifically chosen and is not named on the Hospice Election Statement, then that physician can’t perform as their attending and sign the POC and CTI.

If the patient chooses a NP or PA as their attending, then the hospice physician alone would complete and sign the written certification. NP/PAs cannot certify a patient for hospice care but can be involved in the patient’s plan of care.

Regulations: §418.102 Condition of participation: Medical director

NPs may function as the “Attending Physician” and may write orders within the scope of their state practice act.

PA’s functioning as the “Attending Physician,” PAs may write orders that are unrelated to the terminal illness, within the scope of their state practice act.

Neither NPs or PAs can function as the physician on the interdisciplinary team or certify terminal illness.

L515 (Rev. 210; Issued:02-03-23; Effective:02-03-23; Implementation:02-03-23)

§418.52(c)(4) Choose his or her attending physician;

Interpretive Guidelines §418.52(c)(4)

Patients have the right to choose their attending physician (generally a provider for whom the beneficiary has a relationship with and is not part of the current hospice staff) and to have this person involved in their medical care in collaboration with the hospice medical staff. An attending physician (if any) can also manage those aspects of his/her health care unrelated to the hospice services being provided.

The HCI or Hospice Care Index is calculated solely from data found on the Hospice Claims. The following is a list of the 10 Indicators:

• 1. Continuous Home Care (CHC) or General Inpatient (GIP) - % of CHC and GIP level of care days reflected on the Medicare claims during the reporting period. (Need to be greater than 0%)
• 2. Gaps in Nursing Visits - Number of Medicare Elections that had Gaps in Nursing Visits greater than 7 days within a 30-day period. (Need to be < 90%)
• 3. Early Live Discharges - % of Early Live Discharges within 7 days of admission compared to other hospice providers (Need to be < 90%)
• 4. Late Live Discharges - % of Late Live Discharges on or after 180 days from the hospice admission compared to other hospice providers (Need to be < 90%)
• 5. Burdensome Transitions (Type 1) - % of Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission (Need to be < 90%)
• 6. Burdensome Transitions (Type 2) - % of Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital (Need to be < 90%)
• 7. Per-beneficiary Medicare Spending compared to other hospice providers - Calculate by the total # of payments, Medicare paid to hospice providers divided by the total # of hospice beneficiaries served. (Need to be < 90%)
• 8. Nurse Care Minutes per Routine Home Care (RHC) Day - Average SN Care Minutes per RHC Day compared to other hospice providers (Need to be Greater than 10%)
• 9. Skilled Nursing Minutes on Weekends –SN Minutes on the Weekends (Saturday & Sunday) out of all SNV during RHC services days (Need to be Greater than 10%)
• 10. Visits Near Death - The number of Visits Near Death reflected on the Medicare claims compared to other hospice providers. The % of beneficiaries receiving at least one visit by a SN or social worker during the last three days of the patient’s life (Need to be Greater than 10%) - A visit on the date of death, the date prior to the date of death, or two days prior to the date of death).

For additional information: Hospice Care Index Technical Report

The patient has the right to name an Attending in the community that is a Nurse Practitioner or a Physician Assistant. Neither of these practitioners can CERTIFY the terminal illness of the patient. This means that your Medical Director or physician member of the Hospice IDG will be the only one to provide the verbal and written certification of the patient’s terminal illness.

Medicare Benefit Policy Manual – Chapter 9 – Section 20.1

The patient has the choice whether to select an attending physician or not at time of election. If the patient does not choose an attending physician; the hospice medical director or other hospice physician assumes responsibility for the patient and only that physician is required to certify the patient at time of initial certification (first 90 days episode).

All subsequent benefit periods - 2nd and subsequent only require certification by the hospice physician even if the patient has chosen an attending physician.

Please see the Medicare Benefit Policy Manual Chapter 9 Sections 10 & 20

Face to Face Encounters continue to be a nightmare for some hospices when patients are admitted under the incorrect benefit period. First, in the above scenario you will have no other option, but to discharge and readmit the patient in conjunction with a Face to Face being conducted. You will have to absorb the cost from treating the patient during the time they have been on service with you with no reimbursement,

Tips to avoid in the future:

1. 1) If there is any evidence that a hospice has been with the patient prior and there is NOT a discharge claim or Notice of Termination/Revocation in place, then you should contact the prior hospice to determine the exact situation and you should proceed with conducting a Face to Face in case it is determined that the patient will be in their 3rd benefit period with you.
2. 2) IF IN DOUBT DO A FACE TO FACE! – Reminder – currently the Telehealth Face to Face Encounter Allowance is set to expire March 31, 2025.

CMS Hospice Center

The hospice physician that provides verbal CTI is not required to be the same hospice physician who complete the written CTI narrative.

The regulation that supports this is in the State Operations Manual appendix A page 275. It is a general Medicare reference: SOM Appendix A (cms.gov) Interpretive Guidelines §482.24(c)(2)

In some instances, the ordering practitioner may not be able to authenticate his or her order, including a verbal order (e.g., the ordering practitioner gives a verbal order which is written and transcribed, and then is “off duty” for the weekend or an extended period of time). In such cases it is acceptable for another practitioner who is responsible for the patient’s care to authenticate the order, including a verbal order, of the ordering practitioner as long as it is permitted under State law, hospital policies and medical staff bylaws, rules, and regulations. Hospitals may choose in their policies to restrict which practitioners it would authorize to authenticate another practitioner’s orders. For example, a hospital could choose to restrict authentication of orders for pediatric patients to practitioners who are privileged to provide pediatric care. (77 FR 29053, May 16, 2012).

Click here to view State Operations Manual - Appendix M

The submission of HQRP CY data will impact the corresponding FY APU. The submission of Q4 2025 data will count for the FY 2027 APU calculations. HQRP compliance is based on a full CY of data submissions (HIS/HOPE + CAHPS). The graphic in the HOPE Guidance Manual is just an example to show that submission for the first full year of HOPE data (CY2026) will count toward the FY 2028 APU.

There is concern that there may be issues with the transition from QIES to iQIES for HOPE transmission as both go into effect on 10/01/2025. Having said that there are requests to possibly not utilize the 1st quarter of HOPE data as it is implemented. As of today, May 9, 2025, there will be a direct impact on 2027 APU for HOPE data starting 10/01/2025.

Yes, there were changes to the HOPE document and some clarifications in the Guidance Manual. In addition, they have now issued an update for the vendors that create the software to extract and transmit the HOPE data.

HOPE Document & Manual

Vendor Updates

Yes, this is required based on the following Conditions of Participation:

§ 418.108 Condition of participation: Short-term inpatient care.

Inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility.

(a) Standard: Inpatient care for symptom management and pain control. Inpatient care for pain control and symptom management must be provided in one of the following:

(1) A Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in § 418.110.

(2) A Medicare-certified hospital or a skilled nursing facility that also meets the standards specified in § 418.110(b) and (f) regarding 24-hour nursing services and patient areas.

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§ 418.110 Condition of participation: Hospices that provide inpatient care directly.

A hospice that provides inpatient care directly in its own facility must demonstrate compliance with all of the following standards:

(a) Standard: Staffing. The hospice is responsible for ensuring that staffing for all services reflects its volume of patients, their acuity, and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided.

(1) The hospice facility must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient's plan of care. Each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.

(2) If at least one patient in the hospice facility is receiving general inpatient care, then each shift must include a registered nurse who provides direct patient care.

Schedule or PRN Opioids should be noted as initiated or continued on the first date the hospice receives the order for the medication AND hospice staff have instructed the patient/caregiver to start using the medication.

If the patient in your example was instructed to continue either the PRN or Scheduled medication at time of admission and an order was received for the medication by the hospice physician, the initiation date would be 12/1/25, the date of admission. If the hospice physician ordered the medication at time of admission, but instruction to take the medication was not given by hospice staff until 12/10/25, the date of the HUV visit, the HUV visit date would be date of initiation.

In the circumstance when comfort medications are ordered but no instruction to administer the medication has been provided, the medication would not be considered initiated or continued.

This also applies for N0520 Bowel Regimen.

The Medicare regulations do not state that signatures are required on IDG meeting notes; however, please consider that the documentation of each meeting should support that all core members of the IDG participate in the meetings. If a scribe is used, the scribe should note the attendance and include credentials to support participation by all required members. Please ensure your agency policy regarding IDG does not require signatures. If this is the case, signatures by all participants would be required. Another thing to consider is that if the IDG meeting notes are used as updates to the POC with new order, the IDG meeting notes must be signed following signature requirements by a hospice physician.

Does both the oral and written CTI need to be signed by the attending MD? Only the initial certification. Verbal certifications/Oral certifications are not required to be signed by the physicians. It is a certification statement obtained by your RN stating that the physician has said that this patient has a six month or less prognosis. If your agency EMR is setup to require it, then it's perfectly fine if they are signed, but it's not required. The initial certification is required to be signed by the hospice physician and the attending physician, if one is chosen, and documented on their Hospice Election Statement.

Additionally, in most agencies the hospice certifying physician completes the written narrative, signs it, and then the attending physician co-signs it. It's perfectly acceptable to do that. You are not required to have two separate narratives. You can have just one with both physicians signing.

The issue will be the date the representative signed the election statement and what date the SOC was initiated. If the representative signed the election statement the day after the effective date with the SOC occurring on that same day or after, then there is no issue. However, if the SOC occurred prior the date the election statement was signed, then the election is not valid.

For example, effective date is 2/1/26 on the election statement and it was signed on 2/3/26. Then hospice initiates care on 2/1/26 and all documents including billing reflect 2/1/26, then the patient must be discharged and readmitted if not caught in time. Essentially care was initiated prior to the signature on the form which is not allowed.

Second example, effective date is 2/1/26 on the election statement and it was signed 2/3/26. The SOC is initiated on 2/3/26 and all documents including billing reflect 2/3/26, then there is no issue.

The regulation states:
42 CFR § 418.24 - Election of hospice care.

(4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement.

Thanks for reaching out to us. Regarding your question below, the regulations state that the CTI must be completed and signed within 15 days prior to or within 2 days after the beginning of the benefit period. If the written CTI is not completed within that timeframe, then a verbal certification is required. From your example below, the written CTI would be in compliance if it completed and signed within 15 days prior to the benefit period. don’t hesitate to reach out if you have any further questions. The regulation is as follows:

20.1 - Timing and Content of Certification

(Rev.13133; Issued: 03-20-25; Effective: 01-01-25; Implementation: 04-21-25)

For the first 90-day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual’s attending physician if the individual has an attending physician.

Initial certifications may be completed up to 15 days before hospice care is elected. Payment normally begins with the effective date of election, which is the same as the admission date. If the physician forgets to date the certification, a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained.

For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins. For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification statement from the medical director of the hospice or the physician member of the hospice’s IDG. If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days.

Yes - Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. Providers may formally delegate the delivery of the notices to a designated agent such as a courier service; however, all of the requirements of valid notice delivery apply to designated agents.

The new forms were issued with an expiration date of 11/30/2027. Make sure to use the new forms as of 1/1/2025.

For additional information: Click here

Face to Face telehealth flexibilities were extended through September 30, 2025 as part of the law that delayed the government shutdown for FY 2025. The law, Full-Year Continuing Appropriations and Extensions Act, 2025 is found here, and specifically Section 2207 is where you will find the Telehealth Flexibilities extension.

SEC. 2207. EXTENSION OF CERTAIN TELEHEALTH FLEXIBILITIES.
(a) Removing Geographic Requirements and Expanding Originating Sites for Telehealth Services.--Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended--

(1) in paragraph (2)(B)(iii), by striking ``ending March 31,
2025'' and inserting ``ending September 30, 2025''; and
(2) in paragraph (4)(C)(iii), by striking ``ending on March
31, 2025'' and inserting ``ending on September 30, 2025''.

Ideally, the supervising RN or PT and the LPN or PTA would be communicating weekly regarding their schedule and visits so that an accurate DC date is noted on the NOMNC. However, CMS states the following regarding Amending the Date of the NOMNC:

“If the initial NOMNC was delivered to a beneficiary and the effective date was changed, the provider may amend the notice to reflect the new date. The newer effective date may not be earlier than the effective date of the original notice except in those cases involving the abrupt end of services, as discussed in §260.3.4.

The beneficiary must be verbally notified as soon as possible after the provider is aware of the change. The amended NOMNC must be delivered or mailed to the beneficiary and a copy retained in the beneficiary’s file. If an expedited determination is already in progress, the provider must immediately notify the QIO of the change and provide an amended notice to the QIO.”

Additional information about NOMNC can be found in the Medicare Claims Processing Manual, Chapter 30 – Financial Liability Protections, Section 260.3.