Connect your patients with hospital-grade home healthcareMedStar Health Home Care aims to help physicians and other healthcare providers connect their patients with the home healthcare service they need to heal and live safely at home. This web page offers several tools and information resources to help you successfully refer a patient into MedStar Health Home Care’s care.
Download an overview of home healthcare services
How to refer a patient
If your patient meets the eligibility requirements for home healthcare services, use the tools below to complete a referral.
Download Patient Referral Form: This downloadable form includes MedStar Health Home Care’s Face-to-Face Progress Note, Home Health Orders, and a fax cover sheet. After completing this form and the Required Referral Information (outlined below), fax to: 888-862-6082.
NOTE: Please call 800-862-2166 to verify all faxed documents were received.
Home care eligibility
There are several requirements for receiving home healthcare:
- Homebound: Leaving the home presents a hardship for the patient. Patient leaves home primarily to receive medical care. Walking or moving requires assistance or an assistive device (wheelchair, walker, etc.).
- Skilled service needed: Skilled medical care is necessary and can only be provided by an RN, LPN, physical therapist, occupational therapist, or speech therapist.
- Reasonable and Necessary: The patient needs treatment that requires skilled interventions.
- Intermittent and Part-Time: The patient has an ongoing need for professional skilled services on an intermittent or part-time basis.
- Face-to-Face Encounter: The Centers for Medicare and Medicaid Services (CMS) requires a face-to-face physician encounter to certify patients for homecare services.
- Authorization and Care of a Physician: The homecare orders must be written and signed by a licensed physician. A physician must also be willing to follow the patient's care at home during the course of treatment.
IV therapy (home infusion) eligibility
Individuals who require IV drug or nutritional therapy are likely to qualify for in-home IV therapy services. Insurance coverage of home infusion services varies by insurance provider. While many insurance companies cover in-home IV therapy as long as certain conditions are met, Medicare coverage of these services may be limited. Privately insured patients should contact their insurance carriers to determine if home infusion services are covered by their plan.
Required referral information
The information and documentation listed below must be included with all home healthcare referrals submitted to MedStar Health Home Care.
- Type of referral (i.e., is it a start-of-care for a new patient or a resumption of care?)
- Demographic sheet to include:
- Patient’s first and last name
- Address – This should be the location where the patient will receive home care services. It may differ from the patient's mailing address or home address
- Phone number
- Email address
- Insurance information
- Emergency contact information
- Patient's primary language
- Patient-selected representative or power of attorney
- Face-to-Face requirement documentation: The Centers for Medicare and Medicaid Services (CMS) require that a physician have a face-to-face encounter with a patient to certify him/her for home care
- Physician's home care order (if face-to-face encounter documentation not required)
- Referring physician's name and phone number
- Physician's name and phone number who will be following the patient for home care services
- Medication profile
- Hospital transfer/discharge summary and date (if applicable)
- Patient's history and physical
Download the Homecare Order Tip Sheet
Home infusion referral requirements
In addition to the items listed above, the following information is also needed for infusion referrals:
- Current labs
- Signed physician's order with medication, dose, frequency, and duration (NOTE: A nurse's verbal orders are not acceptable)
- PICC line X-ray including indicated tip placement and length of PICC line
- Lab/blood work orders (if applicable) and the physician who should receive the results
The Centers for Medicare and Medicaid Services (CMS) have a face-to-face requirement that calls for a physician encounter to certify patients for home care. Effective April 1, 2011, all Medicare patients receiving home care services must be seen by a physician 90 days prior to or 30 days after their admission to home healthcare services. Physicians must document face-to-face encounters with patients and certify that the patient has a defined need for home care services.
A Face-to-Face Encounter and Homecare Certification Form must be provided to the homecare agency prior to admission. In some cases, the homecare agency may refuse to accept patient referrals without receiving the documentation in advance. If documentation is not received within 30 days of the start of care, the homecare agency will be forced to discharge the patient.
To review a presentation that offers more detail and instructions for meeting this regulatory requirement, review the Guide to Home Health Certification. For more information about the face-to-face encounter requirement and answers to frequently asked questions, visit the CMS website.
Face-to-face document requirements
MedStar Home Health Care’s goal is to make the documentation process easier. Please, see the examples below to ensure your documentation is accurate and complete.
All documentation must include:
- The patient's name
- Date of encounter
- Explanation of clinical findings during encounter
- How clinical findings support homebound
- How clinical findings show need for skilled care
- Signed and dated by the certifying physician
Examples of documentation denied by Medicare:
- Diagnoses/clinical findings on Face-to-Face not related to home care ordered
- Altered documentation without acceptable notations for changes
- Face-to-Face signed by non-physician practitioner
- No date of Face-to-face encounter
- Not clearly titled as Face-to-Face encounter
- Face-to-Face completed by employee or representative of the home care agency
Download our Face-to-Face Encounter and Homecare Certification Form
Care plan oversight
Medicare reimburses physicians for qualified time spent overseeing the care of patients receiving home healthcare services. Care Plan Oversight (CPO) exists because the Center for Medicare and Medicaid Services (CMS) recognizes the importance of on-going physician engagement in patient care.
MedStar Health Home Care wants to help physicians receive payment for their continuous involvement in their patients’ care. To simplify the process, we offer the resources below.
The Value of CPO
10 patients X $105 .81 (G0181 National Average) = $1,058.10
$1,058.10 X 12 months = $12,697/year
Annualized income for 16 Patients = $20,315
Annualized income for 24 Patients = $30,473
The Center for Medicare and Medicaid Services (CMS) recognizes the importance of on-going physician engagement in patient care. Therefore, they distinguished three different types of Care Plan Oversight (CPO).
Types of care plan oversight
- Certification (G0180)
This initial certification code is used when the patient has not received Medicare-covered home healthcare services for at least 60 days
- Recertification (G0179)
Recertification for patients who have received Medicare-covered home health care services over the past 60 days
- Home Healthcare Plan Supervision (G0181)
Physician supervision of a home health agency patient who requires complex and multi-disciplinary care modalities involving:
- Regular physician development
- Revision of care plans
- Review of subsequent reports of patient status
- Review of related laboratory and other studies
- Communication (including telephone calls)
- Other healthcare professionals involved in patient’s care
- Integration of new information into the medical treatment plan
- Adjustment of medical therapy
Supervision must total at least 30 minutes within a calendar month for eligibility.
Care plan oversight billing guidelines
Care Plan Oversight (CPO) reimbursement is an added incentive for physicians created by the Center for Medicare and Medicaid Services (CMS). While many doctors are continuously involved in their patient’s care, many do not take advantage of the reimbursement.
In order to start benefiting from this great incentive, MedStar Health Home Care is here to help you step-by-step.
Before billing for CPO be sure:
- Patient has received Medicare-covered home health services
- Physician has devoted 30 minutes or more to supervision of the patient’s care in a given month
- Physician has furnished a service requiring face-to-face contact with the patient at least once during the six-month period before the month for which CPO payment is first billed
- Physician does not have a significant financial or contractual relationship with the home health agency
- Physician is the one and only attending physician to bill for CPO for the patient during a calendar month
- If physician is billing for CPO services during a postoperative period, physician must document in the patient’s medical record that the CPO services are unrelated to surgery
- Physician has the provider number of patient’s home healthcare agency
- Physician who bills CPO is the same physician who signed the home health plan of care and personally furnished the services
- Physician is not billing for Medicare end-stage renal disease (ESRD) capitation payment and CPO for the same beneficiary during the same month
To help physicians take full advantage of the Center for Medicare and Medicaid Services’ (CMS) Care Plan Oversight (CPO) incentive, MedStar Health Home Care created a list of acceptable, billable CPO services.
Billable CPO Services:
- Activities to coordinate services (if the coordination of activities required the skill of a physician)
- Documenting the services provided, which includes writing a note in the patient chart describing services provided, decision-making performed, and amount of time spent performing the countable services
- Medical decision-making
- Review of charts, reports, treatment plans, labs or other test results, except for the initial interpretation or review of lab of test results that were ordered during or associated with a face-to-face encounter
- Telephone calls with other healthcare professionals (not employed in the same practice) involved in the care of the patient
- Team conferences (must document time spent per individual patient)
- Telephone or face-to-face discussions with a pharmacist about pharmaceutical therapies
To help physicians take advantage of the Center for Medicare and Medicaid Services’ (CMS) Care Plan Oversight (CPO) incentive, MedStar Health Home Care has created a list of non-billable CPO services.
Note: The services listed below are covered by Medicare, but they are either bundled into other services or included in the practice expense. Therefore, these services cannot be billed twice.
Non-Billable CPO Services:
- Getting and/or filing the chart
- Dialing the phone or time on hold
- Informal consultations with health professionals not involved in the patient’s care
- Initial interpretation or review of lab or study results that were ordered during or associated with a Face-to-Face encounter
- Low-intensity services included as part of evaluation and management services
- Preparation or processing of claims
- Staff time
- Telephone call to patient or family, even to adjust medication or treatment
- Telephoning prescriptions in to pharmacists
- Travel time
Care plan oversight rates
Depending on the type of Care Plan Oversight (CPO) and your location, the Center for Medicare and Medicaid Services (CMS) has predetermined rates for reimbursement. Use the chart below for rates in MD, DC, and VA.
|Medicare Part B Carrier|
|DC + MD/VA Suburbs||01||$117.76||$60.10||$47.38|
|Baltimore/Surrounding Counties, MD||01||$112.33||$56.78||$44.57|
|Other Areas of Maryland||99||$107.94||$54.32||$42.54|
The Centers for Medicare and Medicaid Services (CMS) require physicians—who order, refer, or receive payment for Medicare-covered home health service and supplies – to enroll in the Provider Enrollment, Chain and Ownership System (PECOS). The Patient Protection and Affordable Care Act allows CMS to deny Medicare home health services or supply claims from physicians who are not registered in PECOS.
MedStar Home Health Care maintains this page on our website to help physicians access the resources they need to enroll in PECOS and meet CMS requirements. We want to ensure that every eligible Medicare beneficiary has access to the services and supplies ordered by their physician.
PECOS enrollment directions
All physicians who order, refer, or receive payment for Medicare-covered home health services and supplies are required to enroll in the Provider Enrollment, Chain and Ownership System (PECOS). Enrollment is fast and easy. To ensure your patients receive the care they need, when they need it, use the directions below.
- Make sure you have all of the documentation and information listed in the Pre-Enrollment Checklist (link to pre-enrollment checklist).
- Click the link on the right that says, “Register for a user account.”
- You will be asked whether you wish to register and create a PECOS account, click “yes.”
- Next, you will see the terms and conditions. If you agree, click “accept.”
- You will be prompted to register as a user. Type in your email address. Enter the image text. Then, click “submit.” Note: There are several video tutorials and a user guide on this page if you require additional assistance with your PECOS registration.
- When your registration is complete, you should print, sign, and date the two-page Certification Statement – available at the end of the online application.
- Mail the signed Certification Statement, along with supporting documentation, to your designated Medicare contractor within seven days of the electronic submission.
PECOS pre-enrollment checklist
Before you begin registration in the Provider Enrollment, Chain and Ownership System (PECOS), make sure you have all of the information Centers for Medicare and Medicaid Services (CMS) requires. The checklist below details all of the information and documents you will need to complete enrollment successfully.
- National Provider Identifier (NPI)
- National Plan and Provider Enumeration System (NPPES) ID & Password
- Personal Identifying Information:
- Legal name
- Date of birth
- Social Security number
- Schooling Information:
- School name
- Graduation year
- Professional License Information:
- Medical license number
- Original effective date
- Renewal date
- State issued
- Certification Information:
- Certification number
- Original effective date
- Renewal date
- State issued
- Specialty/Secondary Specialty Information
- Drug Enforcement Agency (DEA) Number
- Information About Final Adverse Actions (if applicable)
- Practice Location Information
- Medical practice location
- Special payment information
- Medical record storage information
- Billing agency information (if applicable)
- Any federal, state, and/or local professional licenses, certification and/or registrations required for practice
- Electronic Funds Transfer Documentation
What is PECOS?
PECOS stands for Provider, Enrollment, Chain and Ownership System. It is a database where physicians register with the Centers for Medicare and Medicare Services (CMS).
CMS developed PECOS as a result of the Patient Protection and Affordable Care Act. The regulation requires all physicians who order or refer home healthcare services or supplies to be enrolled in Medicare – or have officially opted out – and registered in PECOS.
Effective January 6, 2014, CMS started to deny claims for Medicare home health services or supplies from all physicians not registered in PECOS. Physicians who care for Medicare patients should enroll in PECOS to ensure their patients can receive the care and supplies they need.
What does it cost?
I’m already enrolled in Medicare, do I need to enroll with PECOS also?
YES! You must enroll with PECOS. If you have enrolled with the program since 2003 you may already be in the system. However, it is very important to your patients that you verify your PECOS status. Otherwise, they may not receive the items you prescribe.
What if I don’t want to be enrolled in Medicare?
In PECOS, you have the option to opt out of Medicare. This way, you will be able to continue ordering home healthcare services for your Medicare patients.
I have an NPI number, am I in PECOS?
Probably not. Your National Provider Identification (NPI) is not registered with the PECOS system until you complete the registration process.
What if I don’t have a National Plan & Provider Enumeration System (NPPES) login or need help changing my password?
Contact the NPI Enumerator at: 1-800-465-3203 or firstname.lastname@example.org
What if I don’t bill for Medicare? Do I still need to enroll in PECOS?
In some circumstances, a physician may order and refer home health services, but not bill for Medicare. These physicians are still required to be enrolled in PECOS.
When I submit an application, am I automatically approved?
The Medicare contractor will review your application to determine whether you meet all of the requirements for enrollment.
what other professionals must register with PECOS?
- Physician Assistants
- Certified Clinical Nurse Specialists
- Nurse Practitioners
- Clinical Psychologists
- Certified Nurse Midwives
- Clinical Social Workers
What happens if I do not register?
Any claims for items or services that you have prescribed will be denied if you are not in the PECOS system. This applies to Medicare claims only. Not being in the PECOS system will make it difficult for your patients to receive the items they need and will prevent/delay hospital discharges.
Also, you may have previously prescribed items that are being rented. These items can go back three years or more (oxygen for example). These claims will also be denied if you are not registered with PECOS.
The experienced nurses in MedStar Home Healthcare's Patient Intake Center can assist you and answer your questions about home healthcare services and submitting referrals.
- Fax: 888-862-6082