Where does home care end and day care start?
Ambiguity raises billing questions
Last year, the Centers for Medicare & Medicaid Services (CMS) made a change in the homebound status for patients who spend their days in licensed adult day-care facilities.
However, some home care professionals are still questioning whether they can provide services, such as a dressing change, to patients while they are at the day-care facility and still be able to bill under Medicare Part A.
With patients spending as many as 12 hours a day in a supervised day-care center, the lines can blur a bit between what is and what isn’t reimbursable. Even so, it long has been the understanding that any services that are provided by a home care agency would take place in the home.
"Home health services must be provided in the patient’s residence," explains Beth Schoonmaker, director for Weirton (WV) Medical Center Home Health.
"A patient’s residence is wherever he makes his home, such as his own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. As a patient does not live at a day-care center, you can not provide services at that facility," she adds.
In an effort to further clarify the issue of whether home health services can be provided and covered when administered in a day-care setting, CMS has produced the following Q & A on its web site at www.hcfa.gov/medicare/hbqanda.rtf.
Can a home health agency (HHA) provide covered Medicare home health services to a beneficiary within the day-care center if the beneficiary is attending a licensed/certified day-care center?
The law does not permit a HHA to furnish a Medicare-covered billable visit to a patient under a home health plan of care outside his or her home, except in those limited circumstances where the patient needs to use medical equipment too cumbersome to bring to the home. The only statutory change to the home health eligibility requirement is to sections 1814(a) and 1835(a) of the Social Security Act (the Act), which was amended by the Beneficiary Improvement and Protection Act (BIPA).
BIPA did not amend section 1861(m) of the Act, which stipulates that home health services provided to a patient be provided to the patient on a visiting basis in a place of residence used as the individual’s home. A licensed/certified day-care center does not meet the definition of a place of residence.
May a HHA allow its staff to go to the day-care center to see a patient who is under a home health plan of care if it is not considered a billable visit?
Although, as indicated above, a HHA generally may not furnish a Medicare-covered billable visit in the adult day-care center, this does not preclude home health agency staff from providing a noncovered service to a beneficiary. Such a visit would not affect payment.
HHAs must remain cognizant of relevant state and local laws governing health care practice to assure that they are furnishing services consistent with their legally authorized activities.
If a HHA is providing skilled therapy services (physical therapy, speech language pathology, occupational therapy) to a beneficiary who is under a home health plan of care, can the patient also receive therapy in a day-care center?
As mentioned above, an HHA generally may not furnish a Medicare covered billable visit in the adult day-care center.
BIPA did not amend section 1861(m) of the Act, which stipulates that home health services be provided to the patient on a visiting basis in the individual’s home or in an outpatient setting (such as a skilled nursing facility, a rehabilitation center, or a hospital) when the patient needs to use medical equipment too cumbersome to bring to the home.
A licensed/certified day-care center does not meet the definition of a place of residence or the listed outpatient settings.
In responding to this question, it must be assumed that the HHA is aware of the requirement that it furnish directly or under arrangement all the medically necessary skilled therapy services required under the plan of care, including physical therapy, speech language pathology, and occupational therapy.
Consolidated billing rules require the HHA to bill for the episode and reimburse the entity providing therapy.
The entity providing therapy cannot bill Medicare for their services while the beneficiary is under a home health plan of care.
If therapy services are provided at the adult day-care center, then those services may not be services required under the plan of care or billed to Medicare. Consolidated billing rules would apply in that situation.
[For more information, contact:
• Beth Schoonmaker, Director, Weirton Medical Center Home Health, 601 Colliers Way, Weirton, WV 26062. Telephone: (304) 797-6495.]
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