Form CMS-10564 Progress Note and Guidance

OMB Control Number: 0938-XXXX
Form CMS-10564
Expires: XX/XX/XXXX

Paper/Electronic Progress Note Guidance
Purpose:
The purpose of this Progress Note is to assist the Physician, and/or Medicare allowed Non-Physician
Practitioner (NPP)*, in documenting patient eligibility for the Medicare home health benefit. This document can
be placed in the “progress notes” section of the patient’s medical record. The use of this Progress Note is
entirely voluntary/optional and is intended ONLY to assist the physician or allowable Medicare NPP in
documenting patient eligibility (i.e. the encounter and homebound status of the patient.)
The completion of this Progress Note alone will not substantiate eligibility for the Medicare Home Health
benefit.
Medicare Home Health Services Patient Eligibility Certification Requirements:
The face-to-face encounter is one of several requirements for the initial certification of eligibility for Medicare
home health services. For the initial certification of eligibility for Medicare home health services, a physician
must certify (attest) that the patient meets all of the following criteria:
1.
2.
3.
4.

The patient is, or was, confined to the home at the time home health services were furnished;
The patient needs, or needed, skilled services;
The patient is under the care of a physician;
The patient is receiving or received home health services while under a plan of care established and
reviewed by a physician; and
5. The patient has had a face-to-face encounter that:
 occurred no more than 90 days prior to the home health start of care date or within 30 days of
the start of the home health care;
 was related to the primary reason the patient requires home health services; and
was performed by a physician or allowed non-physician practitioner.
The certifying physician must also document the date of the encounter.
Who Can Complete this Progress Note:
The following practitioners are eligible to satisfy the face-to-face encounter requirement described in #5 above
and may complete this Progress Note:
1. The physician who certifies the patient’s eligibility for home health benefit/services;
2. A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which
the patient was directly admitted to home health; or
3. A Medicare allowed NPP*, defined as a nurse practitioner, clinical nurse specialist, certified nurse
midwife or a physician assistant (as those terms are defined in section 1861(aa) (5) of the Social
Security Act).
The Home Health agency cannot complete this form and send to the physician for his signature.
The Patient’s Medical Record is the Basis for Certification:
The certifying physician shall use the patient’s medical record as a basis for certification of home health
eligibility. Therefore, in cases where an eligible entity other than the certifying physician completes theface-toface encounter, the certifying physician may review, sign-off (evidencing his/her review) and incorporate the

completed Progress Note into the patient’s medical record held by the certifying physician.

Paper/Electronic Progress Note
The use of this document is entirely voluntary/optional.

Patient:

First Name:

Last Name:

Date of Birth:

/ /

Name of physician/Medicare allowed non-physician practitioner (NPP)* who performed theencounter:
Date of encounter: / /
Is this encounter with the patient related to the primary reason the patient requires Home Health Services?
Yes  No  (Please check one :)

Subjective:
Patient’s ChiefComplaint:



Check if not completing a history and physical during the encounter.
[In the e-clinical template, the “History of Present Illness” and “Review of Systems” will not appear if
checked.]

History of Present Illness:
Pain Assessment:
Location:
Quality:  aching  burning  radiating  other:
Severity: 1
2
3
4
5 6
7
8
Duration:  1day  2days  3days  other:
Timing:  constant  intermittent  time of day?
Context: better/worse  at work  rest  sleep
 other:
Moderating Factors: better/worse with  heat
 ice
 other:
Associated Signs/Symptoms:

9

 10

Medical History:
Surgical Procedure(s) History:
Allergies:
Current Medications:

Review of Systems:
Eyes:  visual changes  other
ENT:  sore throat  rhinitis  other
CV:  chest pain  other
Resp:  SOB  cough  hemoptysis  other
Gastro:  nausea  vomiting  diarrhea  abd pain  other
GenitoUr:  dysuria  frequency  urgency  other
Musc/Skel:  back pain  joint pain  other
Skin/Breast:  rash  itching  other
Neurologic:  numbness  dizziness  other
Psych:  anxiety  depression  other
Endocrine:  hypoglycemia  thirsty  other

_
_
_
_

Hem/Lymph:  anemia  bleeding  other
Allergy/Immune:  deficiency  other

Other:

Objective:
Vital Signs: T=

P=

R=

BP=

/

Height=

Weight=

General Appearance
Objective Findings:

Assessment:

Plan/Orders:

Plan for Home Health Services:
This patient requires Skilled Nursing Services: (s

.)

This patient needs to be evaluated and treated for one or more of the following services

(Check all that apply.)

To receive home health services, the patient must be homebound and meet Medicare’s criteria for “Confined
to the Home.”
 Check here and continue if choosing to document homebound status as part of this Progress Note.
[In the e-clinical template, the “Homebound Status” section will not appear if not checked.]
 Home health services are not required at this time

Homebound Status:
Medicare considers the patient homebound if the ONE of criteria A and BOTH of criteria B are met:

Criteria A: Select and describe at least one.

 Because of illness or injury, the patient needs the aid of supportive devices such as crutches, canes, wheelchairs, and

walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.
Specify:

_

_
 The patient has a condition such that leaving his or her home is medically contraindicated.

Specify:

_
_

Criteria B: (To meet Medicare’s confined to home requirement, patient must meet at least one Criteria A AND both Criteria B.)
 There must exist a normal inability to leave the home.

Specify:

_
_

 Leaving home requires a considerable and taxing effort.

Specify:

_
_

Note: If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are
infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment (examples: outpatient dialysis,
or chemotherapy/radiation therapy, attendance at adult day centers to receive medical care)

_
PHYSICIAN OR MEDICARE ALLOWED NPP* SIGNATURE

/
PRINTED NAME

/
DATE

PHYSCIAN’s/NPP ADDRESS:
PHONE:
* Medicare allowed NPP: Physician assistant, nurse practitioner,
clinical nurse specialist or certified nursemidwife
who is working in accordance with State law
and in collaboration with the certifying physician
or in collaboration with an acute or post-acute care
physician with privileges who cared for the patient in the
acute or post-acute care facility from which the patient was
directly admitted to home health.

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