Get Cms 485 Form

The CMS 485 form, also known as the Home Health Certification and Plan of Care, is a crucial document used to certify that a patient requires home health services. This form captures essential patient information, including medical history, treatment plans, and safety measures, ensuring that healthcare providers can deliver appropriate care. To get started on filling out the CMS 485 form, click the button below.

Structure

The CMS 485 form is a critical document in the realm of home health care, serving as both a certification and a detailed plan of care for patients requiring skilled services. This form captures essential patient information, including the patient’s name, address, and medical history, as well as the provider’s details. Key components include the start of care date, certification period, and a comprehensive list of diagnoses coded using ICD standards. The form also outlines specific treatments and disciplines, such as nursing, physical therapy, and occupational therapy, that the patient requires. Additionally, it addresses functional limitations, safety measures, and nutritional requirements, ensuring a holistic approach to patient care. The attending physician must certify the necessity of home health services, signifying their ongoing involvement in the patient’s treatment plan. Furthermore, the CMS 485 form emphasizes the importance of accurate information, warning against misrepresentation that could lead to severe penalties. This document not only facilitates the provision of care but also plays a vital role in the reimbursement process for Medicare services.

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Department of Health and Human Services	Form Approved
Centers for Medicare & Medicaid Services	OMB No. 0938-0357

HOME HEALTH CERTIFICATION AND PLAN OF CARE

1.	Patient’s HI Claim No.	2. Start Of Care Date	3. Certification Period		4. Medical Record No.	5. Provider No.
			From:	To:
6.	Patient’s Name and Address			7. Provider’s Name, Address and Telephone Number

8. Date of Birth		9. Sex	M	F	10. Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD	Principal Diagnosis		Date

12. ICD	Surgical Procedure		Date

13. ICD	Other Pertinent Diagnoses		Date

14.	DME and Supplies	15.	Safety Measures

16.	Nutritional Req.	17.	Allergies
18.A. Functional Limitations		18.B. Activities Permitted

Amputation	5	Paralysis	9
			9
Bowel/Bladder (Incontinance)	6	Endurance	A
Bowel/Bladder (Incontinance)	6	Endurance

Contracture	7	Ambulation	B
Contracture	7	Ambulation

Hearing	8	Speech
Hearing	8	Speech

Legally Blind

Dyspnea With

Minimal Exertion

Other (Specify)

Complete Bedrest	6
Bedrest BRP	7
Up As Tolerated	8
Transfer Bed/Chair	9
Exercises Prescribed

Partial Weight Bearing	A
Independent At Home	B
Crutches	C
Cane	D

Wheelchair

Walker

No Restrictions

Other (Specify)

19. Mental Status	1	Oriented	3	Forgetful	5	Disoriented	7	Agitated
	2	Comatose	4	Depressed	6	Lethargic	8	Other

20. Prognosis	1	Poor	2	Guarded	3	Fair	4	Good	5	Excellent

21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)

22. Goals/Rehabilitation Potential/Discharge Plans

23. Nurse’s Signature and Date of Verbal SOC Where Applicable:

25. Date of HHA Received Signed POT

24.	Physician’s Name and Address	26.	I certify/recertify that this patient is confined to his/her home and needs
			intermittent skilled nursing care, physical therapy and/or speech therapy or
			continues to need occupational therapy. The patient is under my care, and I have
			authorized services on this plan of care and will periodically review the plan.

27.	Attending Physician’s Signature and Date Signed	28.	Anyone who misrepresents, falsifies, or conceals essential information
			required for payment of Federal funds may be subject to fine, imprisonment,
			or civil penalty under applicable Federal laws.

Form CMS-485 (C-3) (12-14) (Formerly HCFA-485) (Print Aligned)

Privacy Act Statement

Sections 1812, 1814, 1815, 1816, 1861 and 1862 of the Social Security Act authorize collection of this information. The primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals. Disclosure of this information may be made to: Peer Review Organizations and Quality Review Organizations in connection with their review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Social Security Act; State Licensing Boards for review of unethical practices or nonprofessional conduct; A congressional office from the record of an individual in response to an inquiry from the congressional office at the request of that individual.

Where the individual’s identification number is his/her Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.

Paper Work Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0357. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

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Document Data

Fact Name	Details
Purpose	The CMS 485 form is used for certifying and planning home health care services for Medicare beneficiaries.
Governing Agency	This form is approved by the Centers for Medicare & Medicaid Services (CMS).
OMB Number	The form is associated with OMB No. 0938-0357.
Information Required	It collects essential patient information, including medical history, diagnosis, and care plans.
Certification Period	The form specifies a start and end date for the certification of home health services.
Legal Implications	Misrepresentation on this form can lead to legal consequences, including fines and imprisonment.
Time to Complete	It typically takes about 15 minutes to complete the CMS 485 form.
Patient Confidentiality	The form is subject to the Privacy Act, ensuring patient information is handled confidentially.
State-Specific Forms	Some states may have additional requirements or specific forms governed by local health laws.

How to Use Cms 485

Completing the CMS 485 form is an important step in ensuring that the necessary home health services are authorized and provided. After you fill out the form, it will be submitted to the appropriate parties for review and processing. Follow the steps below to accurately complete the form.

Begin by entering the Patient’s HI Claim Number in the designated field.
Fill in the Start of Care Date and the Certification Period (From and To dates).
Provide the Medical Record Number and the Provider Number.
Enter the Patient’s Name and Address.
Fill in the Provider’s Name, Address, and Telephone Number.
Input the Date of Birth and Sex (M or F).
List the Medications with their Dose/Frequency/Route and indicate if they are (N)ew or (C)hanged.
Provide the ICD Principal Diagnosis and the corresponding Date.
Enter the ICD Surgical Procedure and its Date.
List any ICD Other Pertinent Diagnoses along with their Date.
Specify any DME and Supplies needed.
Outline the Safety Measures that should be taken.
Indicate the Nutritional Requirements for the patient.
List any Allergies the patient has.
In section 18.A, describe the Functional Limitations using the provided codes.
In section 18.B, outline the Activities Permitted using the provided codes.
Assess the Mental Status of the patient using the appropriate code.
Indicate the Prognosis using the provided scale.
Detail the Orders for Discipline and Treatments, specifying the Amount/Frequency/Duration.
Describe the Goals/Rehabilitation Potential/Discharge Plans.
Sign and date the form in the Nurse’s Signature section, indicating the date of verbal Start of Care (SOC) where applicable.
Fill in the Date of HHA Received Signed POT.
Provide the Physician’s Name and Address.
In the certification section, confirm the patient’s need for home health services and sign and date it.
Finally, ensure that the Attending Physician’s Signature and Date Signed are included.

Key Facts about Cms 485

What is the CMS 485 form used for?

The CMS 485 form, also known as the Home Health Certification and Plan of Care, is a critical document used by healthcare providers to certify that a patient requires home health services. It outlines the patient's medical needs, including the type of care required, such as skilled nursing or therapy services. This form serves as a plan for care and ensures that Medicare can process claims for the services provided.

Who is responsible for completing the CMS 485 form?

The attending physician is primarily responsible for completing and signing the CMS 485 form. This includes certifying that the patient is homebound and requires intermittent skilled care. Additionally, home health agencies must also fill out relevant sections to outline the specific services they will provide based on the physician's orders.

What information is required on the CMS 485 form?

The form requires several key pieces of information, including the patient's name, address, and medical record number, as well as the start of care date and certification period. It also includes details about the patient's diagnoses, medications, functional limitations, and any safety measures or nutritional requirements. This comprehensive information helps ensure that the care plan is tailored to the patient's specific needs.

How does the CMS 485 form impact Medicare reimbursement?

Accurate completion of the CMS 485 form is essential for Medicare reimbursement. The information provided must clearly demonstrate the medical necessity for the services rendered. If the form is incomplete or contains inaccuracies, it may lead to delays in payment or denial of claims. Therefore, it is crucial for healthcare providers to ensure that all required information is filled out correctly.

What should I do if I need to make changes to the CMS 485 form?

If changes are necessary after the CMS 485 form has been submitted, the healthcare provider must update the form accordingly. This may involve documenting any new diagnoses, changes in medications, or adjustments to the care plan. It is important to communicate these changes to both the physician and the home health agency to ensure that the patient's care remains consistent and compliant with Medicare requirements.

Common mistakes

Filling out the CMS 485 form can be tricky. Many people make mistakes that can lead to delays or issues with care. One common error is not including the patient’s claim number. This number is crucial for processing the claim. Without it, the form may be incomplete, causing unnecessary hold-ups.

Another frequent mistake is failing to accurately record the start of care date. This date is essential for establishing the timeline of care. If it is incorrect, it can lead to confusion about when services began, which might affect reimbursement.

Many people also overlook the importance of detailing the medications the patient is taking. It's not just about listing them; you need to include the dose, frequency, and route. Missing this information can lead to potential safety issues and may delay the provision of necessary services.

Additionally, some individuals forget to specify the functional limitations and activities permitted for the patient. This section is vital for understanding the patient's needs and capabilities. Incomplete or vague entries can result in inadequate care plans.

Another common oversight is neglecting the attending physician’s signature. This signature confirms that the physician has reviewed and approved the care plan. Without it, the form may not be valid, leading to complications in obtaining services.

Finally, people often fail to provide a clear prognosis. This section should reflect the patient’s expected recovery trajectory. A vague prognosis can hinder the planning of effective treatment and care strategies.

Documents used along the form

The CMS 485 form is essential for documenting a patient's home health certification and plan of care. It is often accompanied by other forms and documents that provide additional information and support the patient's care plan. Below are four commonly used documents that complement the CMS 485 form.

CMS 486 Form: This form is used to establish the home health agency's plan of care. It includes details about the patient's diagnosis, the services to be provided, and the frequency of those services. It ensures that all aspects of care are documented and approved by the attending physician.
CMS 484 Form: Known as the Home Health Agency Plan of Care, this document outlines the specific services the patient will receive, including skilled nursing, therapy, and any additional support. It is crucial for coordinating care among various healthcare providers.
Patient Assessment Instrument (PAI): This instrument evaluates the patient's needs and conditions. It collects data on functional abilities, medical history, and social circumstances, which helps inform the care plan and ensures that it is tailored to the patient's unique situation.
Physician's Orders: This document includes specific instructions from the physician regarding the patient's treatment and care. It details the medications, therapies, and any other interventions required, ensuring that the home health agency follows the physician's directives accurately.

These forms and documents work together with the CMS 485 to create a comprehensive picture of the patient's needs and the care they will receive. Proper completion and coordination of these documents are vital for effective home health care management.

Similar forms

The CMS 485 form, also known as the Home Health Certification and Plan of Care, is essential for home health care providers. It serves as a comprehensive document that outlines a patient’s care plan and medical needs. Several other documents share similarities with the CMS 485 form, each serving specific purposes in health care documentation. Here are six such documents:

CMS 486 - Home Health Agency Plan of Care: This document outlines the specific plan for care and services to be provided to a patient. Like the CMS 485, it includes details on the patient's medical condition and the types of services required, ensuring continuity of care.
CMS 484 - Home Health Agency OASIS Assessment: The Outcome and Assessment Information Set (OASIS) is a standardized assessment tool for home health care. It gathers patient data similar to the CMS 485, focusing on clinical and functional status to guide care planning.
CMS 500 - Home Health Certification: This certification document verifies that a patient qualifies for home health services. It includes essential patient information, much like the CMS 485, and is necessary for Medicare reimbursement.
CMS 2728 - End-Stage Renal Disease Medical Evidence Report: This form collects medical evidence for patients with end-stage renal disease. It details the patient’s diagnosis and treatment plan, paralleling the comprehensive nature of the CMS 485.
CMS 855A - Medicare Enrollment Application: This application is for organizations seeking to enroll in Medicare. It requires detailed information about the organization and its services, similar to the CMS 485's requirement for provider details and care plans.
CMS 1500 - Health Insurance Claim Form: This form is used by healthcare providers to bill Medicare and other insurers. It captures patient and service details, akin to the data collected in the CMS 485, ensuring accurate billing and reimbursement.

Each of these documents plays a vital role in the healthcare system, ensuring that patients receive appropriate care while facilitating the administrative processes necessary for reimbursement and compliance. Understanding these similarities can help streamline patient care and documentation efforts.

Dos and Don'ts

When filling out the CMS 485 form, it is essential to adhere to certain guidelines to ensure accuracy and compliance. Below is a list of things to do and avoid during this process.

Do: Verify all patient information, including name, address, and date of birth, for accuracy.
Do: Include all relevant medical information, such as diagnoses and medications.
Do: Ensure that the certification period is clearly indicated.
Do: Sign and date the form where required, especially by the attending physician.
Do: Review the form for completeness before submission.

Don't: Leave any fields blank unless specifically instructed to do so.
Don't: Use abbreviations that may not be universally understood.
Don't: Provide inaccurate or misleading information, as this can lead to penalties.
Don't: Forget to keep a copy of the completed form for your records.
Don't: Submit the form without ensuring that it has been reviewed by all necessary parties.

Misconceptions

Misconception 1: The CMS 485 form is only for new patients.

This form is used for both new patients and those who are continuing care. It helps document ongoing needs and services.

Misconception 2: Only doctors can fill out the CMS 485 form.

While a physician must sign the form, other healthcare professionals can assist in gathering the necessary information.

Misconception 3: The CMS 485 form is not important for Medicare reimbursement.

This form is crucial for Medicare to process and pay for home health services. It outlines the patient's care plan and needs.

Misconception 4: Completing the CMS 485 form is a quick process.

Although it may take about 15 minutes to complete, gathering accurate information can take longer, especially for complex cases.

Misconception 5: The information on the CMS 485 form is not confidential.

The form contains sensitive patient information. It is protected under privacy laws, and care must be taken to safeguard it.

Misconception 6: Once the CMS 485 form is submitted, it cannot be changed.

Changes can be made if necessary. However, it is important to document any updates and ensure they are communicated properly.

Misconception 7: The CMS 485 form is the only document needed for home health services.

While it is essential, other documents may also be required, depending on the specific services and patient needs.

Key takeaways

Filling out the CMS 485 form correctly is essential for ensuring that patients receive the necessary home health services. Here are some key takeaways to keep in mind:

Provide accurate patient information, including the patient's name, address, and date of birth.
Clearly indicate the start of care date and the certification period to avoid delays in service.
List all medications the patient is taking, noting any changes or new prescriptions.
Document the patient's principal diagnosis using the appropriate ICD codes.
Include detailed information about the patient's functional limitations and permitted activities.
Ensure the attending physician signs and dates the form to validate the plan of care.
Be aware that misrepresenting information can lead to serious legal consequences.

Completing the CMS 485 form accurately helps facilitate the delivery of essential home health services. Pay attention to detail and ensure all necessary sections are filled out correctly.