Home health agencies, adds Perling, will usually let a physician know if he's ordering home care that doesn't conform to the rules. "If they evaluate the patient and he doesn't meet the criteria, they'll tell the doctor that, so they won't have to refund the money to Medicare."

Home health rules in a nutshell

Medicare will pay for home healthcare if it's medically necessary; if the patient is homebound; if the patient is under the care of a physician who has established a plan of care; and if the patient needs intermittent skilled nursing care, physical therapy, speech therapy, or a continuation of occupational therapy. There are no specific limits on the number of visits or the length of coverage. However, a patient must be recertified for home care every 60 days.

Many physicians believe that a patient must be bedridden to qualify for home health coverage, notes William Restum, CEO of Health Care Partners, an agency in Southfield, MI. But that's not what "homebound" means. According to CMS, "the condition of these patients should be such that there exists a normal inability to leave home, and, consequently, leaving home would require a considerable and taxing effort."

A patient who's considered homebound may go to a doctor's office, a dialysis center, or an outpatient cancer treatment facility. Occasional outings to attend church services, go to the barber, or attend a family reunion would also not disqualify a patient from receiving home care. So the definition doesn't preclude patients from leaving their home; it just must be difficult for them to go out.

CMS lists a number of things it expects to see in a plan of care for a home health patient. (For details, see "Medicare Benefit Policy Manual, Chapter 7—Home Health Services," at www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf.) Home care agencies will usually "flesh out" your instructions to include all of these elements in the care plan they send you. However, remember that you are responsible for reviewing the plan and making sure the medications included in it are correct.

Seeing the patient is not mandatory

Physicians usually want to see patients before they certify them for home care, says Cheryl Lamade, executive director of Cambridge Home Health Care, based in Medina, OH. But the Medicare home health regulations don't actually require it. "It is expected, but not required for coverage, that the physician who signs the plan of care will see the patient," says the CMS policy manual.

In many cases, Restum notes, patients are referred to home care agencies as part of hospital discharge planning. If the patient's personal physician attends her in the hospital, he can sign the certificate and follow up with the patient later. If a hospitalist is following the patient, Restum points out, that physician can certify the need for home care; but the discharge planner should tell the patient to follow up with her primary care physician in a week or two and should also let that doctor know that she's receiving home care.

While it's not easy for debilitated patients to come to your office for certification, most of them can get there with the aid of family members, notes med-peds specialist Salvatore S. Volpe of Staten Island, NY. He wants to see them before recertification, as well, with one exception: If they're recovering from a procedure such as a hip operation, he'll rely on reports from the home care nurses.

A minority of doctors, including Volpe and Kagan, make house calls to patients who can't leave home without an ambulance. If an office-based doctor can't or won't visit a patient, or the person doesn't have a regular physician, some agencies will use a specialized home care physician to check on the patient for home health certification. While there are only a few thousand such doctors in the country, their ranks are growing.

Coding and care plan oversight

Doing the work to certify patients for home care entitles you to file claims under a pair of "G codes": G0180, for initial certification, is worth an average of $74.28; G0179, for recertification, pays $56.85. In addition, there's G0181, paying $124.30, for "home healthcare supervision."

Also known as "care plan oversight," this provision is supposed to encourage physicians to work more closely with agencies to make sure they're providing adequate care. However, few physicians bill for this kind of oversight, and not many more are doing it. The main reason is that care plan oversight requires too much time. A doctor has to spend at least 30 minutes on it over the course of a month for each patient, and he has to document what he did.

Kagan used to do care plan oversight as defined by the government, "but it was a little more trouble than it was worth," he says. Volpe doesn't do it, either, because he believes that this kind of oversight would be labor-intensive and difficult to document. "If there's a significant change in the patient's condition, I'm not only talking to the nurse or physical therapist, I'm also talking to the family, and I usually don't keep track of time."

Communication can be a problem

The physicians interviewed for this story say they're in regular contact with the nurses who care for home care patients and who supervise home health aides. Volpe, for instance, often hears from nurses about changing medications. These clinicians, he says, are his "eyes and ears" in the patient's home.

Jeffrey K. Pearson, a family physician in San Marcos, CA, says that home health nurses will make him aware of any changes in a patient's status, such as the development of decubitus ulcers or a worsening trend in a diabetic patient's blood sugar level. "They're providing me with valuable information," he says. "So if they call me, I answer."

Unfortunately, this kind of communication seems to be the exception rather than the rule. Because of difficulties in getting through to doctors and the lack of a relationship with them, says Peter Boling, home health nurses alert doctors that patients need new orders only about a quarter to a third of the time. The complexity of primary care practice, says Constance Row, executive director of the American Academy of Homecare Physicians, is one reason for this lack of communication. "A lot of doctors don't interact with the home care nurses at all, or rarely," she says. "They delegate it to someone else, and have some involvement, but not a lot."

If you want to be more involved, and can find the time to make occasional house calls on patients who are truly stuck at home, Medicare will pay you for the visits. Reimbursement ranges from $45 to $164 for an established patient and from $58 to $203 for a new patient, depending on the level of care provided.

These visits can be very valuable to patients. For example, Pearson has a patient with COPD who was recently discharged from the hospital and is receiving home care. She has a difficult time getting around, doesn't drive anymore, and is on oxygen. So he doesn't insist on her coming in to see him. He visits her instead.

When patients can no longer get to Jeff Kagan's office, he arranges to see them twice a year. "I've had colleagues refer patients to me because they haven't seen the person in a year or two, and they don't want to go to the house. So sometimes I'll take them over as house-call patients." As a result, he adds, home care agencies often send him new patients, and most of those come to his office.

Bridges between home and office

To help overcome communication barriers between home health nurses and physicians, internist Peter Boling, professor of medicine at Virginia Commonwealth University School of Medicine and a former president of the American Academy of Home Care Physicians, has devised a series of condition-specific templates that nurses can use when faxing requests to physicians. The one-page templates offer "a subset of facts the doctor needs in order to answer the question about that particular condition," he says. "The nurse can check off some boxes, add a comment, and then fax it to the doctor. He can write his order on the bottom and fax it back."

The American Academy of Home Care Physicians (www.aahcp.org) offers the package of templates, which comes with a manual, for $95. While this approach is geared to home health agencies, doctors could encourage agencies they deal with to use the templates, says Boling.

One of the nation's largest home care agencies, the Visiting Nurse Service of New York, is using Internet technology to facilitate communication. For some time, VNS nurses have been taking notes on tablet computers and uploading them to a central server. Now, in a pilot test, a group of referring physicians has gained access to this constantly updated database. When they log onto a secure website, they can see the latest information on their patients.

"This will allow the doctor to give us new orders on a patient if he's changing the medications or the treatment regimen," says Thomas Check, VNS' chief information officer. In addition, he notes, the web-based communication will allow the physician to work with the nurse to fine-tune a plan of care.

In this phase of the project, VNS is sending e-mails to participating physicians to let them know when a care plan is awaiting their approval on the website. "In the future, we'll develop the ability for the nurse to alert the doctor to other things the nurse is seeing that don't require a change in the plan of care," says Check. "We'll give the nurse a way to initiate that communication from her tablet."