Home Health LUPA and Therapy Visit Audits: Documenting Skilled Need on Every Visit

Before Medicare pays for home health services, a physician or allowed practitioner must certify that the patient is eligible. For patients who need care beyond the first 60 days, the practitioner must recertify eligibility. These certifications, along with the plan of care and orders that support them, are among the first documents reviewers examine in any home health audit.

Certification problems are often technical: a missing statement, a missing date, an unsigned plan of care, or a verbal order that was never authenticated. But technical errors can still cause entire periods of care to be denied. Medicare Administrative Contractors (MACs), the Review Choice Demonstration (RCD), the Comprehensive Error Rate Testing (CERT) program, Recovery Audit Contractors, Unified Program Integrity Contractors (UPICs), and the HHS Office of Inspector General (OIG) all check certification requirements.

This article explains the certification and recertification requirements, the plan of care and order rules that support them, signature requirements, common audit failures, and a detailed checklist agencies can use for internal audits and pre-billing reviews. It is educational and does not replace legal or professional advice.

The Legal Basis

The certification requirement comes from Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act. CMS implements it at 42 CFR 424.22. Plan of care requirements appear at 42 CFR 409.43 and in the home health Conditions of Participation at 42 CFR 484.60. Chapter 7 of the Medicare Benefit Policy Manual provides detailed guidance, and the Medicare Program Integrity Manual describes signature requirements for medical review.

Who May Certify

The certification must be made by a physician or allowed practitioner. Since the CARES Act of 2020, allowed practitioners include nurse practitioners, clinical nurse specialists, and physician assistants, subject to state law. Under 42 CFR 424.22(d), a physician or allowed practitioner who has a financial relationship with the HHA that is prohibited under the regulation may not certify or recertify the need for home health services or establish or review the plan of care, subject to the exceptions in the rule.

Initial Certification Requirements

Under 42 CFR 424.22(a), the certifying physician or allowed practitioner must certify that:

• The patient needs or needed intermittent skilled nursing care, physical therapy, speech-language pathology services, or has a continuing need for occupational therapy.

• Home health services are or were required because the patient is or was confined to the home.

• A plan of care has been established and is periodically reviewed by a physician or allowed practitioner.

• Services will be or were furnished while the patient is or was under the care of a physician or allowed practitioner.

• A face-to-face encounter occurred within the required timeframe, was related to the primary reason the patient requires home health services, and was performed by a permitted practitioner, with the date of the encounter documented by the certifying practitioner.

The Management and Evaluation Narrative

If the patient's underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and the registered nurse must be involved in management and evaluation of the plan of care, the certifying physician or allowed practitioner must include a brief narrative describing the clinical justification for this need. The narrative must be part of the certification or recertification form or an addendum, and it must be written or dictated by the certifying practitioner.

Timing of the Initial Certification

Under 42 CFR 424.22(a)(2), the certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible, and must be signed and dated by the physician or allowed practitioner before the claim is submitted for payment.

Supporting Documentation

Under 42 CFR 424.22(c), documentation in the certifying practitioner's medical records or the acute or post-acute care facility's records must support the certification of eligibility. HHA documentation may be incorporated if it is signed and dated by the certifying practitioner and is consistent with the practitioner's records.

Recertification Requirements

Under 42 CFR 424.22(b), recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day period. Recertification should occur at the time the plan of care is reviewed.

The recertification must:

• Be signed and dated by the physician or allowed practitioner who reviews the plan of care.

• Indicate the continuing need for skilled services. The need for occupational therapy may be the basis for continuing services that were initiated because the patient needed skilled nursing, physical therapy, or speech-language pathology.

• Include an estimate of how much longer the services will be required.

• Include the management and evaluation narrative when that is the basis for continued skilled nursing.

Under PDGM, each 60-day certification period contains two 30-day payment periods. Agencies must track both the payment periods and the certification periods.

Plan of Care Requirements

Required Elements

Under 42 CFR 484.60(a), the individualized plan of care must include all pertinent diagnoses and, among other things:

• The patient's mental, psychosocial, and cognitive status.

• The types of services, supplies, and equipment required.

• The frequency and duration of visits to be made.

• Prognosis.

• Rehabilitation potential.

• Functional limitations.

• Activities permitted.

• Nutritional requirements.

• All medications and treatments.

• Safety measures to protect against injury.

• A description of the patient's risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.

• Patient and caregiver education and training to facilitate timely discharge.

• Measurable outcomes and goals identified by the HHA and the patient.

• Information related to any advance directives.

• Any additional items the HHA or physician or allowed practitioner may choose to include.

Coverage Requirements for the Plan of Care

Under 42 CFR 409.43, the plan of care must contain those services, including the amount, frequency, and duration, necessary to meet the patient-specific needs identified in the comprehensive assessment. It must be established and periodically reviewed by a physician or allowed practitioner, and it must be signed and dated before the claim is submitted.

Frequency and Duration Orders

Orders must specify the type of services, the frequency of visits, and the duration. Ranges of frequency may be acceptable if they are reasonable, but vague orders such as "as needed" without parameters may cause problems. Changes in frequency must be ordered.

Verbal Orders

Under 42 CFR 484.60(b), drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. Verbal orders must be accepted only by authorized personnel, documented in the patient's record, and authenticated and dated by the physician or allowed practitioner in accordance with applicable law and HHA policy. Under 42 CFR 409.43, services furnished under verbal orders must be documented in a way that supports coverage, and the plan of care, including orders received verbally, must be signed before the claim is submitted.

Common verbal order problems include:

• Orders documented but never signed.

• Orders signed without a date.

• Orders taken by staff not authorized under agency policy.

• Services furnished before an order was received.

• Orders that conflict with the plan of care.

Signature Requirements

The Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, describes signature requirements for medical review.

• Services provided or ordered must be authenticated by the author.

• Signatures must be handwritten, electronic, or digital. Stamped signatures are generally not acceptable, except in limited circumstances described in the manual.

• Illegible signatures may be supported by a signature log or attestation statement.

• Missing signatures on orders generally cannot be fixed with an attestation; the manual describes when attestations are acceptable.

• Electronic signatures must meet system requirements that ensure authentication.

Common Certification and Recertification Failures

• Certification not signed or not dated.

• Certification signed after the claim was submitted.

• Missing certification statements, such as homebound status or the plan of care statement.

• Face-to-face encounter date not documented by the certifying practitioner.

• Management and evaluation narrative missing when it is the basis for skilled nursing.

• Narrative written by HHA staff rather than the certifying practitioner.

• Recertification missing the estimate of how much longer services are needed.

• Recertification late or missing.

• Plan of care unsigned or undated before billing.

• Plan of care missing required elements or frequency and duration.

• Verbal orders not authenticated.

• Services provided beyond ordered frequency without an order.

• Certification by a practitioner with a prohibited financial relationship with the HHA.

• Signatures illegible without a log or attestation.

• Certifying practitioner's records that do not support eligibility.

The Audit Checklist

Initial Certification

• Is there a certification signed and dated by a physician or allowed practitioner?

• Was it signed and dated before the claim was submitted?

• Does it state that the patient needs intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy?

• Does it state that the patient is confined to the home?

• Does it state that a plan of care has been established and will be periodically reviewed?

• Does it state that the patient is under the care of a physician or allowed practitioner?

• Does it address the face-to-face encounter, with the encounter date documented by the certifying practitioner?

• If management and evaluation is the skilled service, is there a narrative written or dictated by the certifying practitioner?

• Is the certifying practitioner free of a prohibited financial relationship with the HHA?

Supporting Documentation

• Do the certifying practitioner's or facility's records support homebound status?

• Do they support the need for skilled services?

• If HHA documentation was incorporated, is it signed and dated by the certifying practitioner?

• Is the face-to-face encounter note present and compliant?

Plan of Care

• Does it include all required elements under 42 CFR 484.60(a)?

• Does it specify the type, frequency, and duration of services?

• Was it signed and dated by the physician or allowed practitioner before billing?

• Does it match the services provided?

Orders

• Is every service supported by an order?

• Are verbal orders documented, signed, and dated?

• Are frequency changes ordered?

• Were services provided only after orders were received?

Recertification

• Is there a recertification for each 60-day period beyond the first?

• Is it signed and dated by the practitioner who reviews the plan of care?

• Does it state the continuing need for skilled services?

• Does it include an estimate of how much longer services will be required?

• Does it include the management and evaluation narrative if applicable?

• Is the updated plan of care signed and dated before billing?

Signatures

• Are all signatures legible or supported by a signature log or attestation?

• Are electronic signatures valid under system requirements?

• Are signatures dated?

Certification and Recertification Timeline Example

Consider a patient with a start of care on March 1.

• Before or at start of care: obtain the referral, face-to-face documentation, and practitioner records.

• Start of care, March 1: complete the comprehensive assessment and develop the plan of care. Obtain verbal orders as needed.

• As soon as possible after March 1: send the certification and plan of care to the practitioner.

• Before billing the first 30-day period: confirm the certification and plan of care are signed and dated.

• Before billing the second 30-day period: confirm any interim orders are signed and dated.

• During the last five days of the 60-day certification period: complete the recertification assessment.

• By the start of the next certification period: obtain the recertification with the continuing need and estimate, and the updated plan of care, signed and dated before billing.

Agencies should build this timeline into their tracking system for every patient.

Electronic Signatures and Portals

Many practitioners sign home health documents through electronic portals. Agencies should:

• Confirm the portal meets requirements for authentication, including user identification and protection against alteration.

• Make sure the signature date is captured and visible on the document.

• Keep audit logs that show when documents were sent, viewed, and signed.

• Be able to print or export signed documents in a readable format for ADRs and pre-claim review.

Discharge and Transfer Considerations

• When a patient is discharged and later readmitted, a new certification is required, and a new face-to-face encounter may be required.

• When a patient transfers to another HHA, the receiving agency needs its own certification and plan of care.

• When a patient is hospitalized and resumes care, update the plan of care and orders as needed.

Roles and Responsibilities

• Intake staff obtain referral documents and face-to-face documentation.

• Clinical managers ensure plans of care are complete and accurate.

• Medical records staff track and follow up on unsigned documents.

• Billing staff confirm documentation is complete before submitting claims.

• The compliance officer oversees audits and corrective actions.

Building a Strong Certification Process

Track Every Document

Use a tracking system that shows the status of certifications, recertifications, plans of care, and verbal orders for every patient, with due dates.

Send Documents Promptly

Send plans of care and certifications to practitioners as soon as they are prepared. Delays at the agency increase the risk of late signatures.

Follow Up Systematically

Follow up on unsigned documents on a schedule, escalating when needed. Track turnaround times by practitioner.

Hold Claims Until Documents Are Complete

Build billing edits that hold claims until the certification and plan of care are signed and dated.

Educate Practitioners

Explain certification requirements, the face-to-face date documentation, the management and evaluation narrative, and recertification estimates. CMS's MLN materials on home health certification can help.

Review Before Billing

Use the checklist in a pre-billing review for every period, or at least for high-risk periods.

Certification Under the Review Choice Demonstration

In RCD states, certification documentation is part of every pre-claim review request and postpayment review response. Missing or deficient certifications cause non-affirmations and denials and lower the agency's affirmation or approval rate. Agencies in RCD states and California agencies preparing for the demonstration should prioritize certification tracking.

Responding to Certification Denials

• Review the denial reason carefully.

• Look for documentation that existed but was not submitted.

• Confirm signature dates relative to claim submission dates.

• Use signature attestations where the manual allows them for illegible or missing signatures on documents other than orders.

• Submit all evidence by the reconsideration level.

• Fix the root cause to prevent repeated denials.

A Hypothetical Example

An internal audit of 30 periods at an agency finds that nine had plans of care signed after the claim was submitted, five recertifications lacked an estimate of how much longer services would be needed, and three skilled nursing periods relied on management and evaluation without a practitioner narrative. The agency builds a billing hold for unsigned plans of care, updates its recertification form to include a required estimate field, and educates practitioners and staff on the narrative requirement. It also evaluates whether claims submitted without signed plans of care resulted in overpayments that must be reported and returned. A follow-up audit three months later finds no claims billed before signatures and much improved recertification documentation.

Key Takeaways

• Certifications must include every required statement and be signed and dated before billing.

• The face-to-face encounter date must be documented by the certifying practitioner.

• The management and evaluation narrative must come from the certifying practitioner.

• Recertifications must include the continuing need and an estimate of how much longer services are needed.

• Plans of care must include required elements and be signed before billing.

• Verbal orders must be documented and authenticated.

• A tracking system and billing holds prevent most certification denials.

• Practitioner records must support eligibility, not just the signed certification.

Frequently Asked Questions

When must the certification be signed?

At the time the plan of care is established or as soon as possible thereafter, and before the claim is submitted.

How often is recertification required?

At least every 60 days when continuous home health care is needed.

What must a recertification include?

The continuing need for skilled services, an estimate of how much longer services will be required, and the practitioner's signature and date.

When is a narrative required?

When management and evaluation of the care plan is the skilled nursing service, the certifying practitioner must include a brief narrative describing the clinical justification.

Can verbal orders be used?

Yes, but they must be documented, accepted by authorized staff, and authenticated and dated by the practitioner, and the plan of care must be signed before billing.

Conclusion

Certification and recertification documentation may seem technical, but it is a basic condition of payment and one of the most common sources of home health denials. By making sure every certification includes the required statements and face-to-face documentation, recertifications include the continuing need and estimate, management and evaluation narratives are present when required, plans of care and orders are complete and signed before billing, and signatures meet Medicare requirements, agencies can avoid preventable denials. A consistent checklist, a reliable tracking system, and billing holds for incomplete documents make compliance routine.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps home health agencies build certification and recertification tracking systems, conduct pre-billing and internal audits, educate staff and practitioners, and respond to certification-related denials. If certification documentation is causing problems for your agency, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR 424.22, Requirements for Home Health Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-B/section-424.22

• Electronic Code of Federal Regulations. 42 CFR 409.43, Plan of Care Requirements. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-409/subpart-E/section-409.43

• Electronic Code of Federal Regulations. 42 CFR 484.60, Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-484/subpart-B/section-484.60

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 7, Home Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions (Section 3.3.2.4, Signature Requirements). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Calendar Year (CY) 2026 Home Health Prospective Payment System Final Rule (CMS-1828-F) Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-home-health-prospective-payment-system-final-rule-cms-1828-f

• Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services Operational Guide. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/downloads/rcd-operational-guide.pdf

• U.S. Social Security Administration. Social Security Act, Section 1814. https://www.ssa.gov/OP_Home/ssact/title18/1814.htm

• U.S. Social Security Administration. Social Security Act, Section 1835. https://www.ssa.gov/OP_Home/ssact/title18/1835.htm