FAQs Section 13: Home health services questions

13.1 Are orders from an Advanced Registered Nurse Practitioner for care acceptable or do the orders have to be from a physician?

There are differences in the federal requirements for the certified home health agencies and the state law for state-licensed-only home health agencies.

If your home health agency is Medicare and/or Medicaid certified, home health agency federal regulations require that orders for care come from a physician only. The federal regulations at do not accept orders from an Advanced Registered Nurse Practitioner.  If you are getting orders from an Advanced Registered Nurse Practitioner on behalf of the physician she/he works for, the physician needs to also sign them before billing for services. Here is the home health agency federal regulation, 42 Code of Federal Regulation 484.18(c) that requires physician orders:

"(c) Standard: Conformance with physician orders. Drugs and treatments are administered by agency staff only as ordered by the physician with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per agency policy developed in consultation with a physician, and after an assessment for contraindications. Verbal orders are put in writing and signed and dated with the date of receipt by the registered nurse or qualified therapist (as defined in Sec. 484.4 of this chapter) responsible for furnishing or supervising the ordered services. Verbal orders are only accepted by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the home health agency’s internal policies."

If your home health agency is not Medicare or Medicaid certified and these are private paying or insurance patients (and not Medicare or Medicaid patients that your agency is under contract with a certified agency to provide services for), the state law permits the home health agency to accept orders from an Advanced Registered Nurse Practitioner or physician’s assistant. Here is the home health agency state law, section 400.487(2), Florida Statutes that permits licensed-only, non-certified agencies to accept Advanced Registered Nurse Practitioner orders:

"(2) When required by the provisions of chapter 464; part I, part III, or part V of chapter 468; or chapter 486, the attending physician, physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice, shall establish treatment orders for a patient who is to receive skilled care. The treatment orders must be signed by the physician, physician assistant, or advanced registered nurse practitioner before a claim for payment for the skilled services is submitted by the home health agency. If the claim is submitted to a managed care organization, the treatment orders must be signed within the time allowed under the provider agreement. The treatment orders shall be reviewed, as frequently as the patient's illness requires, by the physician, physician assistant, or advanced registered nurse practitioner in consultation with the home health agency."

13.2 Can the plan of care specify a range of services or does the exact number of visits per week have to be specified?

For Medicare home health agencies, the CMS Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, states:

“30.2.2 - Specificity of Orders

The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.

EXAMPLE 1:

SN x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for 1 week; 3 times per week for 4 weeks; and 2 times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes and to perform sterile dressing changes. The sterile change consists of (detail of procedure).

Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided during the 60-day episode to home health patients. When a range of visits is ordered, the upper limit of the range is considered the specific frequency.

EXAMPLE 2:

SN x 2-4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical site.

Orders for services to be furnished "as needed" or "PRN" must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained.”

For Medicaid home health agencies, the Florida Medicaid Home Health Services Coverage and Limitations Handbook, chapter 2 requires the frequency and duration of the services.

The home health agency law and rules do not address this for licensed-only home health agencies.

13.3  If I want to set up a business to provide therapists to be subcontractors for home health agencies what license do I need? 

Answer: The kind of license you need depends on what you intend to do. 

  1. If you intend to subcontract with home health agencies for your business to provide therapy to patients on an on-going, as-needed basis – the therapists are assigned to patients by your business, make home visits to patients under the name of your business, you supervise the work of the therapists, and bill the home health agency for the visits made – you would need a home health agency license unless:   

    (a) your business is a certified rehabilitation agency or a comprehensive outpatient rehabilitation facility (CORF).  The state law exempts from home health agency licensing certified rehabilitation agencies and CORFs (400.464(5)(m), Florida Statutes) . 
    (b) you provide just one type of therapy, such as such as only physical therapy.  An entity that provides a single health care professional discipline is not an organization for the purposes of home health agency licensing per 400.462 (22), Florida Statutes. 

  2. If you intend to subcontract with home health agencies to provide therapists who will actually work as therapy staff for the home health agency on a temporary basis – the home health agency supervises and assigns each therapist to specific patients; the therapists go to the home identified as staff from the home health agency; and you bill the home health agency for use of the temporary staff -- you would need a health care services pool license under 400.980 Florida Statutes.  However, you must comply with the following:

 

13.4  Can our home health agency contract with a homemaker companion services for home health aides and certified nursing assistants to provide personal care to our patients?

No.  A homemaker companion service cannot provide home health aides and certified nursing assistants to your home health agency since the personal care services they provide are beyond the scope of the services permitted under a homemaker companion registration according to state law. 

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