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Home Healthcare Nurse:
Regulation & Accreditation: legislative/regulatory update

CMS Updates HIM-11


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Author Information

Jeanie Stoker, MPA, RN, BC, is Director of Home Care Services, AnMed Home Care, Anderson, SC.

Address for correspondence: AnMed Home Care, P.O. Box 195, 1926 McConnell Springs Road, Anderson, SC 29622-0195.

The Centers for Medicare and Medicaid Services (CMS) updated the HIM-11 inclusive of the PPS regulations on December 17, 2001. Agencies now have a resource for PPS regulations as defined by CMS. Over 40 updates have been provided and are in effect January 22, 2002. The updates include: 1. Consolidated billing language and requirements, 2. PPS definitions, 3. Payment acronyms and rules, 4. BIPA updates, and 5. BBA mandates.

Items agencies will want to read closely include:

* Section 200-A-3, which explains that an agency must directly provide the qualifying service and secondary services may be provided under arrangement with another agency or organization. 1/07/02 CMS Update: An HHA must directly provide at least one of the six services allowed under the HH benefit (nursing, physical therapy, occupational therapy, speech therapy, medical social services, or home health aide services).

* Section 201.1, which defines the 60-day episode and the inclusion of all covered home health services as well as routine and nonroutine supplies and clarifies the exclusion of durable medical equipment.

* Section 201.4, which clarifies the “from” and “to” dates on the 485. There was confusion with these dates initially but this sections defines the “from” date as the start of care (SOC) date or the date of the first billable visit. The “to” date is any date up to 60 days. Remember that this is the SOC date plus 59 days.

* Section 201.6, which explains when payment can be collected. A verbal order from the physician is required in order to submit a request for anticipated payment (RAP).

* Section 201.13, which defines the use of telehealth services in home health. Although not counted as a visit, telehealth services may be included in the plan of care.

* Section 204.1, which provides a new definition and update of the “confined to home” regulation.

The new language includes:

“Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by the State, or accredited, to furnish adult day-care services in a State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify and individual if the absence is of an infrequent or of relatively short duration. For purpose of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.”

This section also provides guidelines for home care services for those patients in assisted living facilities as well as adult day care programs.

* Section 204.4, which has been updated to reflect the venipunctures rule that was mandated by the Balanced Budget Act of 1997 (BBA). Nursing care can be solely for venipuncture services provided there is a qualifying service ordered such as physical therapy, speech therapy, or ongoing occupational therapy. Section 205 further details the reasonable and necessary guidelines for venipuncture.

* Section 205.1-C, which defines intermittent care as provided for by the BBA. The definition includes

“... ‘intermittent’ means skilled nursing care that is either provided or needed on fewer than 7 days each week, or less than 8 hours each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable.”

This section also describes the circumstances for anticipated nursing visits with greater than every 60 days duration.

* Section 205.2, which provides validation of the use of physical therapist for wound care when it is defined within the State’s Practice Act.

* Section 206.2, which clarifies insulin administration by home health aides as allowed by federal and state law.

* Section 219.4-C, which provides clarification of outpatient therapy services as part of the consolidated billing rule.

Almost 100 pages have been changed or updated in the HIM-11. Transmittal 298 is available from CMS or online

© 2002 Lippincott Williams & Wilkins, Inc.