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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS

 

DIVISION 127

HOME HEALTH CARE SERVICES

410-127-0020

Definitions

(1) Acquisition Cost — The net invoice price of the item, supply, or equipment plus shipping and/or postage for the item.

(2) Assessment — Procedures by which a client’s health strengths, weaknesses, problems, and needs are identified.

(3) Custodial Care — Provision of services and supplies that can safely be provided by non-medical or unlicensed personnel.

(4) Evaluation — A systematic objective assessment of the client for the purpose of forming a plan of treatment; and, a judgment of the effectiveness of care and measurement of treatment progress. The evaluation of direct care and effectiveness of care plans and interventions is an ongoing activity.

(5) Home — A place of temporary or permanent residence used as a person's home. This does not include a hospital, nursing facility, or intermediate care facility, but does include assisted living facilities, residential care facilities and adult foster care homes.

(6) Home Health Agency A public or private agency or organization which has been certified by Medicare as a Medicare home health agency and which is licensed by the Authority as a home health agency in Oregon, and meets the capitalization requirements as outlined in the Balanced Budget Act (BBA) of 1997. Home health agency does not include:

(a) Any visiting nurse service or home health service conducted by and for those who rely upon spiritual means through prayer alone for healing in accordance with tenets and practices of a recognized church or religious denomination;

(b) Health services offered by county health departments that are not formally designated and funded as home health agencies within the individual departments;

(c) Personal care services that do not pertain to the curative, rehabilitative or preventive aspect of nursing.

(7) Home Health Aide — A person who meets the criteria for Home Health Aide defined in the Medicare Conditions of Participation 42 CFR 484.36 and certified by the Board of Nursing.

(8) Home Health Aide Services — Services of a Home Health Aide must be provided under the direction and supervision of a registered nurse or licensed therapist. The focus of care shall be to provide personal care and/or other services under the plan of care which supports curative, rehabilitative or preventive aspects of nursing. These services are provided only in support of skilled nursing, physical therapy, occupational therapy, or speech therapy services. These services do not include custodial care.

(9) Home Health Services — Only the services described in the Division of Medical Assistance Programs (Division) Home Health Services provider guide.

(10) Medicaid Home Health Provider — A Home Health Agency licensed by Health Services, Health Care Licensure and Certification certified for Medicare and enrolled with the Division as a Medicaid provider.

(11) Medical Supplies — Supplies prescribed by a physician as a necessary part of the plan of care being provided by the Home Health Agency.

(12) OASIS (Outcome and Assessment Information Set) — a client specific comprehensive assessment that identifies the client's need for home care and that meets the client's medical, nursing, rehabilitative, social and discharge planning needs.

(13) Occupational Therapy Services — Services provided by a registered occupational therapist or certified occupational therapy assistant supervised by a registered occupational therapist, due to the complexity of the service and client's condition. The focus of these services shall be curative, rehabilitative or preventive and must be considered specific and effective treatments for a client's condition under accepted standards of medical practice. Teaching the client, family and/or caregiver task oriented therapeutic activities designed to restore function and/or independence in the activities of daily living is included in this skilled service. Occupational Therapy Licensing Board ORS 675.210-675.340 and the Uniform Terminology for Occupational Therapy established by the American Occupational Therapy Association, Inc. govern the practice of occupational therapy.

(14) Physical Therapy Services — Services provided by a licensed physical therapist or licensed physical therapy assistant under the supervision of a licensed physical therapist, due to the inherent complexity of the service and the client's condition. The focus of these services shall be curative, rehabilitative or preventive and must be considered specific and effective treatments for a patient's condition under accepted standards of medical practice. Teaching the client, family and/or caregiver the necessary techniques, exercises or precautions for treatment and/or prevention of illness or injury is included in this skilled service. Physical Therapy Licensing Board ORS 688.010 to 688.235 and Standards for Physical Therapy as well as the Standards of Ethical Conduct for the Physical Therapy Assistant established by the American Physical Therapy Association govern the practice of physical therapy. Physical Therapy shall not include radiology or electrosurgery.

(15) Plan of Care — Written instructions describing how care is to be provided. The plan is initiated by the admitting registered nurse, physical therapist, occupation therapist or speech therapist and certified by the prescribing physician. The plan of care must include the client’s condition, rationale for the care plan, including justification for the skill level of care and the summary of care for additional certification periods. This includes, but is not limited to:

(a) All pertinent diagnoses;

(b) Mental status;

(c) Types of services;

(d) Specific therapy services;

(e) Frequency, and duration of service delivery;

(f) Supplies and equipment needed;

(g) Prognosis;

(h) Rehabilitation potential;

(i) Functional limitations;

(j) Activities permitted;

(k) Nutritional requirements;

(l) Medications and treatments;

(m) Safety measures;

(n) Discharge plans;

(o) Teaching requirements;

(p) Individualized, measurably objective short-term and /or long-term functional goals;

(q) Other items as indicated.

(16) Practitioner — A person licensed pursuant to Federal and State law to engage in the provision of health care services within the scope of the practitioner’s license and certification.

(17) Responsible Unit — The agency responsible for approving or denying payment authorization.

(18) Skilled Nursing Services — The client care services pertaining to the curative, restorative or preventive aspects of nursing performed by a registered nurse or under the supervision of a registered nurse, pursuant to the plan of care established by the prescribing practitioner in consultation with the Home Health Agency staff. Skilled nursing emphasizes a high level of nursing direction, observation and skill. The focus of these services shall be the use of the nursing process to diagnose and treat human responses to actual or potential health care problems, health teaching, and health counseling. Skilled nursing services include the provision of direct client care and the teaching, delegation and supervision of others who provide tasks of nursing care to clients, as well as phlebotomy services. Such services will comply with the Nurse Practice Act and administrative rules of the Oregon State Board of Nursing and Health Division, division 27, Home Health Agencies, which rules are by this reference made a part hereof.

(19) Speech and Language Pathology Services — Services provided by a licensed speech-language pathologist due to the inherent complexity of the service and the patient's condition. The focus of these services shall be curative, rehabilitative or preventive and must be considered specific and effective treatment for a patient's condition under accepted standards of medical practice. Teaching the client, family and/or caregiver task oriented therapeutic activities designed to restore function, and/or compensatory techniques to improve the level of functional communication ability is included in this skilled service. Speech-Language Pathology and Audiologist Licensing Board ORS 681.205 to 681.991 and the Standards of Ethics established by the American Speech and Hearing Association, govern the practice of speech and language pathology.

(20) Title XVIII (Medicare) — Title XVIII of the Social Security Act.

(21) Title XIX (Medicaid) — Title XIX of the Social Security Act.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: SSD 4-1983, f. 5-4-83, ef. 5-5-83; SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0001; HR 12-1991, f. & cert. ef. 3-1-91; HR 14-1992, f. & cert. ef. 6-1-92; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 4-1998(Temp), f. & cert. ef. 2-5-98 thru 7-15-98; OMAP 24-1998, f. & cert. ef. 7-15-98; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 36-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 1-2003, f. 1-31-03, cert. f. 2-1-03; DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 29-2013, f. & cert. ef. 6-27-13

410-127-0040

Coverage

(1) Home health services are made available on a visiting basis to eligible clients in their homes as part of a written “plan of care.”

(2) Home health services must be prescribed by a physician and the signed order must be on file at the home health agency. The prescription must include the ICD-9-CM or ICD-10-CM diagnosis code indicating the reason the home health services are requested. The orders on the plan of care must specify the type of services to be provided to the client, with respect to the professional who will provide them, the nature of the individual services, specific frequency and specific duration. The orders must clearly indicate how many times per day, each week and/or each month the services are to be provided. The plan of care must include the client’s condition, the rationale for the care plan including justification for the required skill level of care, and the summary of care for additional certification periods.

(3) The plan of care must be reviewed and signed by the physician every two months to continue services.

(4) The following services or items are covered, if diagnoses are on the portion of the prioritized list above the line funded by the Legislature:

(a) Skilled nursing services;

(b) Skilled nursing evaluation (includes Outcome and Assessment Information Set (OASIS) assessment);

(c) Home Health aide services;

(d) Occupational therapy services;

(e) Occupational therapy evaluation (may include OASIS Assessment);

(f) Physical therapy services;

(g) Physical therapy evaluation (may include OASIS Assessment);

(h) Speech and language pathology services (may include OASIS Assessment;

(i) Speech and language pathology evaluation (may include OASIS assessment);

(j) Medical/surgical supplies.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: PWC 682, f. 7-19-74, ef. 8-11-74; PWC 798, f. & ef. 6-1-76; AFS 8-1979, f. 3-30-79, ef. 4-1-79; Renumbered from 461-019-0400 by Chapter 784, Oregon Laws 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 4-1983, f. 5-4-83, ef. 5-5-83; SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0000; HR 14-1992, f. & cert. ef. 6-1-92; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00; DMAP 29-2013, f. & cert. ef. 6-27-13

410-127-0050

Client Copayments

Copayments may be required for certain services. See OAR 410-120-1230 for specific details.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 79-2002, f. 12-24-02, cert. ef. 1-1-03; ; Suspended by DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14

410-127-0060

Reimbursement and Limitations

(1) Reimbursement. The Division of Medical Assistance Programs (Division) reimburses home health services on a fee schedule by type of visit (see home health rates and copayment chart on the Oregon Health Authority (OHA) Web site at: http://www.dhs.state.or.us/policy/healthplan/guides/homehealth/main.html.

(2) The Division recalculates its home health services rates every other year. The Division will reimburse home health services at a level of 74% of Medicare costs reported on the audited, most recently accepted or submitted Medicare Cost Reports prior to the rebase date and pending approval from the Centers for Medicare and Medicaid Services (CMS), and if indicated, Legislative funding authority.

(3) The Division will request the Medicare Cost Reports from home health agencies with a due date, and will recalculate potential rates based on the Medicare Cost Reports received by the requested due date. It is the responsibility of the home health agency to submit requested cost reports by the date requested.

(4) The Division reimburses only for service which is medically appropriate.

(5) Limitations:

(a) Limits of covered services:

(A) Skilled nursing visits are limited to two visits per day with payment authorization;

(B) All therapy services are limited to one visit or evaluation per day for physical therapy, occupational therapy or speech and language pathology services. Therapy visits require payment authorization;

(C) The Division will authorize home health visits for clients with uterine monitoring only for medical problems, which could adversely affect the pregnancy and are not related to the uterine monitoring;

(D) Medical supplies must be billed at acquisition cost and the total of all medical supply revenue codes may not exceed $50 per day. Only supplies that are used during the visit or the specified additional supplies used for current client/caregiver teaching or training purposes as medically necessary are billable. Client visit notes must include documentation of supplies used during the visit or supplies provided according to the current plan of care;

(E) Durable medical equipment must be obtained by the client by prescription through a durable medical equipment provider.

(b) Not covered service:

(A) Service not medically appropriate;

(B) A service whose diagnosis does not appear on a line of the Prioritized List of Health Services which has been funded by the Oregon Legislature (OAR 410-141-0520);

(C) Medical Social Worker service;

(D) Registered dietician counseling or instruction;

(E) Drug and or biological;

(F) Fetal non-stress testing;

(G) Respiratory therapist service;

(H) Flu shot;

(I) Psychiatric nursing service.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: PWC 682, f. 7-19-74, ef. 8-11-74; PWC 798, f. & ef. 6-1-76; PWC 854(Temp), f. 9-30-77, ef. 10-1-77 thru 1-28-78; Renumbered from 461-019-0420 by Chapter 784, Oregon Laws 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 4-1983, f. 5-4-83, ef. 5-5-83; SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0010; HR 14-1992, f. & cert. ef. 6-1-92; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 77-2003, f. & cert. ef. 10.1.03; DMAP 16-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 22-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-25-12; DMAP 39-2011, f. 12-15-11, cert. ef. 1-1-12; DMAP 29-2013, f. & cert. ef. 6-27-13

410-127-0065

Signature Requirements

(1) The Division of Medical Assistance Programs (Division) requires practitioners to sign for services they order. This signature shall be handwritten or electronic, and it must be in the client's medical record.

(2) The ordering practitioner is responsible for the authenticity of the signature.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 38-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11

410-127-0080

Prior Authorization

(1) Home health providers must obtain prior authorization (PA) for services as specified in rule.

(2) Providers must request PA as follows (see the Home Health Supplemental Information booklet for contact information) and include the documentation requirements from the Supplemental (e.g. plan of care, primary diagnosis, initial assessment, evaluation, etc.):

(a) For clients enrolled in a Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), from the CCO or the PHP;

(b) For all other clients, from the Division of Medical Assistance Programs (Division).

(3) For services requiring authorization, providers must contact the responsible unit for authorization within five working days following initiation or continuation of services. The FAX or postmark date on the request will be honored as the request date. It is the provider's responsibility to obtain payment authorization. Authorization will be given based on medical appropriateness and appropriate level of care, cost and/or effectiveness as supported by submitted documentation. The plan of care submitted must include the client’s condition, the rationale for the care plan, including justification for the required skill level of care and the summary of care for additional certification periods.

(4) Payment authorization does not guarantee reimbursement (e.g. eligibility changes, incorrect identification number, provider contract ends).

(5) For rules related to authorization of payment, including retroactive eligibility, see General Rules, 410-120-1320.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: PWC 682, f. 7-19-74, ef. 8-11-74; PWC 798, f. & ef. 6-1-76; AFS 8-1979, f. 3-30-79, ef. 4-1-79; Renumbered from 461-019-0410 by Chapter 784, OL 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 4-1983, f. 5-4-83, ef. 5-5-83; SSD 6-1986, f. & ef. 4-24-86; SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0005; HR 12-1991, f. & cert. ef. 3-1-91; HR 30-1992(Temp), f. & cert. ef. 9-25-92; HR 2-1993, f. 2-19-93, cert. ef. 2-20-93; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 15-1999, f. & cert. ef. 4-1-99; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 1-2003, f. 1-31-03, cert. f. 2-1-03; OMAP 91-2003, f. 12-30-03 cert. ef. 1-1-04; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 29-2013, f. & cert. ef. 6-27-13

410-127-0200

Home Health Revenue Center Codes

Payment authorization is required for those services indicated by the Code PA. Following are the procedure codes to be used for billing:

(1) Medical/surgical supplies and devices:

(a) 270 -- General classification;

(b) 271 -- Non sterile supply;

(c) 272 -- Sterile supply.

(2) Physical Therapy:

(a) 421 -- Visit charge -- PA;

(b) 424 -- Evaluation (includes OASIS assessment) or re-evaluation.

(3) Occupational Therapy:

(a) 431 -- Visit charge -- PA;

(b) 434 -- Evaluation or re-evaluation.

(4) Speech-language pathology:

(a) 441 -- Visit charge -- PA;

(b) 444 -- Evaluation (includes OASIS assessment) or re-evaluation.

(5) Skilled nursing:

(a) 551 -- Visit charge -- PA;

(b) 559 -- Other skilled nursing -- evaluation (includes OASIS assessment).

(6) Home health aid -- 571 -- Visit charge -- PA.

(7) Total charge -- 001 -- Total Charge.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 28-1990, f. 8-31-90, cert. ef. 9-1-90; HR 12-1991, f. & cert. ef. 3-1-91; HR 14-1992, f. & cert. ef. 6-1-92; HR 15-1995, f. & cert. ef. 8-1-95; OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00

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