Home Care Glossary
Accreditation: A voluntary process where an agency, facility or education program has met the standards established by the accrediting body. Home care accreditation programs are conducted by the NLN (CHAP), Home Caring Council and Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Adult Day Care: A facility for the care and/or supervision of patients during the day. Where the adult day care facility is a medical model (i.e. provides medical services based on an individualized plan of care), the patient continues to meet the homebound criteria for home health coverage. If the facility is a social model day care facility, the patient will not be considered homebound and will not quality for home health agency coverage under Medicare.
Advance Directives: A living will or durable power of attorney executed by a person based on state-specific statutes and regulations specifying the patient’s wishes related to care to be provided if the patient is unable to direct his/her care. Home health agencies are required to inquire of each adult patient at the time of admission, if he/she has executed an advance directive and to provide information regarding the agency’s policies on advance directives and state-specific information regarding advance directives.
Case mix: Factor used to calculate claim-specific payment rates based on the overall patient assessment and plan of care. Medicare determines the annual base episode payment rate that home health agencies and other home care providers receive. The purpose of case mix creep adjustment is to modify payment rates to the extent that Medicare expenditures have increased due to factors unrelated to changes in patient characteristics.
Centers for Medicare and Medicaid (CMS): Federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
Coding: The process of assigning data to categories for a diagnosis. It determines medical necessity for requested services and interventions on the patient's plan of care.
Durable Medical Equipment (DME): Equipment primarily and customarily used to serve a medical purpose, generally not useful to a person in the absence of illness or injury; appropriate for use in the home, and for the conditions exhibited by the patient.
Durable Medical Equipment Supplies: Those supplies and drugs necessary for the effective operation of the medical equipment that may include IV drugs used in conjunction with a pump, when the pump and drug meet coverage requirements and a pump is necessary for the administration of the drug.
DMEPOS: Durable medical equipment, prosthetics, orthotic supplier number. This number is acquired by entities that do not participate in the home health program – including Company specialized DME offices. These suppliers must meet certain standards to obtain a billing number and are required to provide notices of the standards to Medicare patients.
Evaluation Visit: A home visit made to determine if the patient qualifies for services and if home care services are appropriate. The visit may or may not be billable, depending on whether skilled services are also ordered, provided, and meet intermittent requirements, and to what payer the visit will be billed.
Face-to-Face Requirement: As mandated by the Affordable Care Act, a physician must order Medicare home health services and must certify a patient's eligibility for the benefit. Prior to certifying a patient's eligbility for the home health benefit, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient.
Homebound: Medicare home health coverage requirement that the patient must be confined to his home, due to illness or injury; leaves home infrequently, for short periods of time or to receive medical care; and where leaving home requires considerable and taxing effort, or requires the use of assistive devices, another person, and/or special transportation.
Home Health Agency: A public agency/private organization/subdivision of an agency, primarily engaged in providing skilled nursing and other therapeutic services in the patient’s place of residence.
Home Health Care Access Protection Act (HHCAPA): A bill introduced to amend title XVIII of the Social Security Act to protect Medicare beneficiaries' access to home health services under the Medicare program.
Home Health Aide: An employee whose primary function is the provision of personal care services under the supervision of a registered nurse or licensed therapist.
Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS): Consumers and patients are asked to complete surveys to evaluate the interpersonal aspects of home health care they receive.
Home Health Prospective Payment System (HHPPS): Pays home health agencies a predetermined rate for each 60-day episode of home health care.
Home Health Resource Groups (HHRGs): Home Health Medcaire patients receiving five or more visits are assigned to an HHRs, based on clinical and functional status and service use as measured by an OASIS assessment.
Non-personal care worker responsible for housekeeping duties.
Hospice: An agency/institution/subdivision of a facility that is primarily engaged in the provision of services to patients with terminal illnesses focusing on the alleviation of pain, palliative care, and counseling.
Intermediate Care Facility (ICF): Nursing facility that usually provides nursing and other therapeutic services to its residents, and therefore does not qualify as a resident for the purpose of home health agency services.
Intermittent Care (Medicare): Medicare home health agency coverage requirement for skilled nursing, whereby the patient must receive visits on a medically predictable frequency (usually at least once every 90 days) and less than daily, or daily for a finite and predictable period of time.
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): An organization that offers a program of voluntary accreditation for hospitals, home health agencies, infusion providers, DME dealers, hospices, etc.
Licensure: Permission granted by a government entity to an individual or organization to engage in a practice, occupation, or activity that would otherwise be unlawful.
Low Utilization Payment Adjustment (LUPA): When four or fewer home health visits are provided in a 60-day period, Medicare reimburses the home health agency for this limited number of visits at an established per-visit rate, instead of the full episode rate.
Maintenance Care: Repetitive services not involving complex or sophisticated procedures, designed to maintain functional levels. Covered under Medicare only for establishing a program of care to be carried out by the family or other caregivers.
Managed Care: Programs whereby the services for a patient are authorized by a third party (“case manager”) prior to care; frequently found in insurance cases.
Market Basket: A fixed-weight index because it answers the question of how much more or less it would cost, at a later time, to purchase the same mix of goods and services that was purchased in a base period. A market basket is constructed in three steps. First, a base period is selected and total base period expenditures are estimated for mutually exclusive and exhaustive spending categories based upon type of expenditure. Then the proportion for total costs that each spending category represents is determined. These proportions are called cost or expenditure weights. The second step is to match each expenditure category to an appropriate price/wage variable, called a price proxy. In the third and final step, the price level for each spending category price proxy is multiplied by the expenditure weight for that category. The sum of these products (that is, weights multiplied by proxied index levels) for all cost categories yields the composite index level in the market basket in a given year. The CMS market baskets are used to update payments and cost limits in the various CMS payment systems. The CMS market baskets reflect input price inflation facing providers in the provision of medical services.
Medicaid: (Title XIX of the Social Security Act). A program to pay for certain health care services to the poor funded by federal, state and local funds.
Medicaid and CHIP Payment Access Commission (MACPAC): MACPAC is tasked with reviewing state and federal Medicaid and CHIP access and payment policies and making recommendations to Congress, the Secretary of Health and Human Services (HHS), and the states on a wide range of issues affecting Medicaid and CHIP populations, including health care reform.
Medicaid Waiver: Special Medicaid programs for specific purposes or patient populations; vary from state to state; may include services not otherwise covered by Medicaid and may allow coverage of persons not otherwise eligible for Medicaid.
Medical Supplies: Items that are essential for the home health agency staff and/or the patient/caregiver to effectively carry out the care that the physician has ordered for treatment or diagnosis of the patient’s illness or injury. To be billed to Medicare, they must serve a medical purpose rather than a comfort or convenience purpose and must be ordered by the physician (examples: insulin syringes, dressings, irrigation solutions, etc.).
Medical Social Worker (MSW): A professional with a masters degree in social work and one year of experience in a health care setting; under the home health benefit, provides social work services focusing on patient problems that inhibit recovery and adherence to the medical regimen.
Medicare Advantage: Medicare HMO that replaces the usual Medicare coverage. Formerly called Medicare+ Choice.
Medicare Payment Advisory Commission (MedPAC): An independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. In addition to advising Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
National Association for Home Care (NAHC): Trade association of home health agencies.
Nebraska Association of Home & Community Health Agencies (NAHCHA): Trade association of Nebraska home health agencies.
OASIS: The “Outcome and Assessment Information Set” data elements that are included in a comprehensive assessment system to collect patient information that will enable the office to determine changes in the patient’s condition over time. The OASIS data set is incorporated into the comprehensive assessment and must be completed for each adult, non maternity patient in the certified office who receives skilled care. It is also required for maternity and pediatric patients whose services will be billed to Medicare.
Occupational Therapist (OT): A graduate of an accredited occupational therapy curriculum with eligibility for the National Registration Examination (AOTA). Provides services for improving or restoring functions that have been impaired by illness or injury, or with improving the patient’s ability to function independently when functions are permanently lost or limited.
Occupational Therapy Assistant: A person who meets the requirements established by the American Occupational Therapy Association. Provides occupational therapy services under the supervision of a registered occupational therapist.
Outlier Payments: To qualify for outlier payments, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for outliers).
Outpatient Therapy: Therapy services provided on an outpatient basis by a participating hospital, SNF, HHA, clinic, rehabilitation agency or public health agency under Medicare Part B. Includes services in the home for patients that are not homebound, services in facilities, etc.
Palliative Care: Specialized care focused on relieving the pain, symptoms and stress of serious illness.
Part A: Medicare Hospital Insurance program covering hospital services, extended care facilities, and home health care; basic program for which patients qualify by age, disability or ESRD.
Part B: Medicare Medical Insurance program covering physician services, outpatient services (including outpatient therapy), Durable Medical Equipment, DME supplies, home health services, and other services; patients must pay a monthly premium for Part B coverage.
Part-time Care (Medicare): In determining the extent of skilled nursing and home health aide coverage after a patient has qualified for coverage, up to 35 hours a week but less than 8 hours a day of combined nursing and home health aide services.
Physical Therapist: A graduate from an approved physical therapy curriculum licensed as a physical therapist. Provides services designed to restore or improve the patient’s functional level.
Physical Therapy Assistant: A graduate from an approved physical therapy assistant program licensed by the state, if applicable. Provides services under the supervision of a registered physical therapist.
Physician: For the purposes of Medicare certification, a doctor of Medicine, Osteopathy, or Podiatry, legally authorized to practice medicine and surgery by the state in which such function or action is performed.
Provider Enrollment, Chain and Ownership System (PECOS) is a way for physicians and other health care practitioners to modify their provider file online. Physicians must enroll with the system, in order to be reimbursed for Medicare claims.
Plan of Care (POC) / Plan of Treatment (POT): A written plan developed and authorized by the patient’s physician in cooperation with the agency staff; includes the HCF 485 (or equivalent form for non-Medicare patients) and any change orders modifying the POC.
Primary Payer: The payer that must be billed first for home health services.
Reasonable and Necessary: A Medicare coverage requirement that services are specific and effective treatments for the patient’s condition under accepted standards of medical practice, and are of a level of complexity requiring the judgment and skills of a professional and/or the patient’s condition requires the skills of a professional for services to be provided safely.
Registered Nurse (RN): A graduate of an approved school of nursing, licensed as a registered nurse by the state(s) in which he or she practices. Provides skilled nursing care and supervises the activities of licensed practical nurses and home health aides.
Secondary Payer: A payer that is billed after the primary payer has paid its share of the claim or has denied the claim.
Skilled Nursing Facility (SNF): Nursing home facility providing skilled care to its residents. Does not meet the definition of a residence for the purpose of Medicare home health agency coverage.
Social Work Assistant: A person who possesses a baccalaureate degree in social work or a related field and one of social work experience in a health care setting. Provides social work services under the supervision of a medical social worker.
Speech Pathologist / Therapist: A person who meets the educational and experience requirements for a Certificate of Clinical Competence granted by the American Speech and Hearing Association. Provides services for the diagnosis and treatment of speech and language disorders that result in communication disabilities.
Telehealth: The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.
Telemonitoring: The process of using audio, video, and other telecommunications and electronic information processing technologies to monitor the health status of a patient from a distance.
Veteran’s Administration: Federal government agency providing coverage for certain services to veterans.
Workers’ Compensation: Program for the payment of services related to conditions resulting from occupational injuries and illnesses.