Supplemental Medicare Eligibility Criteria

Addendum to Certification for Home Health Services

Supplemental Medicare Eligibility Criteria

This information is being provided to supplement your documentation of the patient’s eligibility for Medicare Home Health Services. The information is extracted from the Partners HealthCare at Home (PHH) patient Medical Record. Please sign indicating you are in agreement, return a signed copy to PHH and retain a copy in your medical record.

Patient NameJane Doe DOB10/20/1930F2F Encounter date 1/22/2015

Skilled Need:

The following is extracted from the initial assessment and visit documentation in this patient’s home care record as noted and is provided as corroborative support for meeting the Medicare eligibility criteria of skilled need:

01/23/2015 59 year old married man referred after CABGc3 psot NSTEMI.Patient denies significant pain and is able to take deepbreths w/ some discomfort and ambulates short distances with AD but gatigues quickly and becomes SOB after climbing 5 stairs at a slow pace. SN T/R energy conservation, daily weight and temperature monitoring, s/sx wound infectin and potiential side effects of new Plavix and Metoprolol but he will require reinforcement.

Homebound:

The following is extracted from the initial assessment and visit documentation in this patient’s home care record as noted and is provided as corroborative support for meeting the Medicare eligibility criteria of the patienthaving a normal inability to leave the home except with the assistance of another or an assistive device:

Criterion 1

[ ] This patient is homebound as evidenced by the need for assistance of another or an assistive device as follows:

Requires Assistance: Device and another person to climb stairs

Requires assistive device(s): cane

OR

[ ] This patient is homebound because it is medically contra-indicated to leave home because:

Criterion 2

[ ] (a)This patient has a normal inability to leave home as evidenced by

Homebound limitations:Severe SOB with climbing 5 stairs at a slow pace

[ ] (b)Specifically, to leave the home requires

Homebound is primarily due to: Profound generalized fatigue due to deconditioning and shortness of breath

Extracted from the clinical documentation found in the patient’s medical record as follows:

Clinician(electronic signature on file): Smith, Elaine M. RN Date of clinical finding:1/23/2015

My signature indicates review and incorporation into this patient’s medical record and a signed copy will be sent to: Partners HealthCare at Home

281 Winter Street, Suite 240

Waltham, MA 02451

Physician printed name: Dr. Joseph Mengele

Physician Signature & Credentials______Date______