Fillable Form CMS-485

What is Form CMS-485?

The Home Health Care Certification and Plan of Care, or Form CMS-485, is a document used by the Home Health Care Agency (HHA) and it serves as a plan of care and certification in the event that a patient’s physician oversees to provide patient care.

A ‘Plan of Care’ document compiles the orders given by a variety of medical disciplines into just one file and in it is a full and detailed description of the patient’s needs. In each Plan of Care document, it provides a comprehensive list of nurse care actions, home charts, and includes the demographics of both the patient and the provider. The patient’s medication orders, patient history, the nurse’s orders, diagnosis and procedure codes, list of supplies, patient’s nutritional requirements, any information of any allergy or allergies the patient may have, any physical or mental limitations the patient may have, ancillary care orders patient goals and any plans of discharge, and statements regarding the penalty/penalties that can be faced in the event that any information reported in the Plan of Care is falsified, misrepresented, or if any crucial information is purposely omitted or hidden on the form.

Form CMS-485 provides all the necessary and crucial information regarding a patient’s health and their needed medical procedures, orders, and medications that need to be taken note of and followed. All of the patient’s medical treatment and healthcare is stated and listed in the document, if needed to be administered to the patient outside of a specialized institution.

Following the guidelines the Centers for Medicare & Medicaid Services (CMS) placed, the patient on Form CMS-485 must be re-evaluated every sixty (60) days to change, adjust, add, or omit any orders in line with their health status. The CMS also has a rule wherein nurses will be supervised every sixty (60) days.

It is especially crucial to the patient’s overall health and wellbeing that the information, especially the treatments and procedures listed and stated on Form CMS-485, be updated with accuracy by their care providers.

What is the purpose of Form CMS-485?

The purpose of Form CMS-485 is to serve as a plan of care and certification in the event that a patient’s physician fails to provide patient care. As mentioned, Form CMS-485 provides all the necessary and crucial information regarding a patient’s health and their needed medical procedures, orders, and medications that need to be taken note of and followed. If, in the event that a patient will need to be administered any medical treatment or procedure outside of a specialized institution, all of the patient’s medical treatment and healthcare is stated and listed in the document.

Who should file and submit Form CMS-485?

Form CMS-485 should be completed and submitted by the patient’s physician. For an individual to be reognized as a legible physician who is able to provide home care, they must be the following:

• be a Medicare registrant,
• have an eligible specialty,
• and have an individual National Provider Identifier (NPI number).

Form CMS-485 is reviewed and revised, if need be, by the physician’s Nursing Supervisor, and then the form is endorsed by the Doctor every 60 days, but, as mentioned, the Plan of Care may be changed to adjust to the current health status of the patient.

Where should you file and submit Form CMS-485?

Once the physician completes Form CMS-485 and has been reviewed by the nurse and endorsed by the doctor, they will then have to submit the document to the HHA, for they are the agency responsible in providing care to the patient. It it strongly recommended that one copy of Form CMS-485 be kept to be filed with the patient’s medical records and another copy be given to the patient for their own record.

When should you file and submit Form CMS-485?

Although Form CMS-485 does not have any specific deadline, it is important to know that the homebound patient can only be administered treatment or medical procedures only once the necessary documents like the Plan of Care is submitted to the HHA. With that being said, it is strongly advised that the physician file and submit Form CMS-485 as early as they possibly can to have their patient begin receiving treatments and medical procedures.

It should be kept in mind that the physician is required to produce a document that confirms a face-to-face encounter with them and the patient. It should also be noted that the face-to-face encounter must have happened not earlier than ninety (90) days before the claim or within thirty (30) days after the patient’s home health care starts.

Form CMS-485 does not have any specific deadline, but the effective date of it cannot exceed sixty (60) days.

How should you fill out and complete Form CMS-485?

Filling out Form CMS-485 is straightforward. On the lines and spaces provided, provide legibly and accurately the information being asked. Remember that you may face penalties and even imprisonment if you falsify, misrepresent, or purposely omit or hide any crucial information from the form.

To fill out Form CMS-485, indicate the following in order:

1. Patient’s HI Claim No.

2. Start of Care Date

3. Certification Period (From and To)

4. Medical Record No.

5. Provider No.

6. Patient’s Name and Address

7. Provider’s Name, Address and Telephone Number

8. Date of Birth

9. Sex (Select between the ‘M’ or ‘F’ boxes. ‘M’ for Male and ‘F’ for Female.)

10. Medications: Dose/Frequency/Route

11. International Classification of Diseases (ICD)

• Principal Diagnosis
• Date

12. ICD

• Surgical Procedure
• Date

13. ICD

• Other Pertinent Diagnoses
• Date

14. Durable Medical Equipment (DME) and Supplies

15. Safety Measures

16. Nutritional Requirements

17. Allergies

18. A. Functional Limitations (check all that apply)

B. Activities Permitted (check all that apply)

19. Mental Status (check all that apply)

20. Prognosis (check what apply)

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

22. Goals/Rehabilitation Potential/Discharge Plans

23. Nurse’s Signature and Date of Verbal System of Care (SOC)

24. Physician’s Name and Address

25. Date of HHA Received Signed POT

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.