Form CMS-485 Home Health Certification and Plan of Care

What Is a CMS-485 Form?

Form CMS-485, Home Health Certification and Plan of Care, also known as the CMS Home Health Certification form is a form issued by the Department of Health and Human Services (HUD) - Centers for Medicare and Medicaid Services.

The Home Health Certification and Plan of Care form was released in February 1994 and is available for digital filing. Download an up-to-date CMS-485 fillable form down below or look it up on the HUB website.

A patient in need of health services has to file this form, which is used as a fiduciary document authorizing professional health services. The form is filled out by the patient's attending physician. Use the form if you are a Medicare registrant, have an eligible specialty, and have an individual National Provider Identifier (NPI number).

ADVERTISEMENT

What Is a CMS-485 Form Used for?

Although Home Health is known for a great number of documents, the CMS Home Health Certification form stands out, as it combines the orders of various medical disciplines into one form. The importance of this document explains its name "Mother Document". By filing this form, the doctor prescribes relevant health care services that are covered by Medicare home health benefits. This document governs the home charts and care provided by the nurses.

CMS-485 contains the patient and provider demographics and statistics, medication information, nursing orders, diagnosis and procedure codes, lists of supplies, nutritional requirements, allergy information, patient activities and limitations, ancillary care orders (e.g. OT, PT), goals and discharge plans, and, finally, a Penalty statement for falsification, misrepresentation or concealment of essential information in the document.

CMS Home Health Certification requirements state that the patient must be evaluated. The nurses have to be supervised and orders rewritten at least every 60 days. All treatment and medications listed on the form become Doctors Orders once signed. All other documents in the home chart (i.e., Medication Administration Record) follow the orders documented on CMS-485 Form (with the exception of interim orders written and signed after the date of the form). The form is used in cases when the doctor or nurse is unsure, or when verification of Rx/Tx's is required.

Health care providers must keep this form updated and accurate. Although it is edited by the nursing supervisor and endorsed by the physician every 60 days, the plan is usually adjusted during this period to match the current condition of the patient. Medications can be changed, diet, therapies, and activity can be started or stopped. When these interim alterations take place, the caregiver is responsible to verify the information and pass it on to the nursing supervisor. The changes must be justified and the form adjusted in a timely manner to be accurate in the next certification period. Verification can be done either through the phone, fax or Verbal/Telephone (VO/TO) orders forms.

Timely and accurate communication is the professional caregivers' responsibility. CMS-485 and interim orders are checked on a consistent manner and timely communication is the cornerstone of excellent health care.

Form CMS-485 Instructions

The form should not take more than 15 minutes to fill out. Enter the patient's personal information in Sections 1 to 9. Enter their treatment information including medication, allergies, safety and nutritional requirements in the following sections. Specify the amount, frequency and duration of treatment in Section 21. Follow by Goals and Discharge plans in Section 22. The document requires the signature of the nurse and the patient's physician. All interim order copies must be kept with the 485 for reconciliation by all health caregivers.

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.
6. Patient's Name and Address
7. Provider's Name, Address and Telephone Number
8. Date of Birth
9. Sex
10 .Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD-9-CM
Principal Diagnosis
Date
12. ICD-9-CM - Surgical Procedures - Date
13. ICD-9-CM - Other Diagnoses - Date
15. Safety Measures
14. DME and Supplies
16. Nutritional Req.
17. Allergies:
18.B. Activities Permitted
18.A. Functional Limitations
1
Complete Bed Rest
6
Partial Weight Bearing A
Wheelchair
1
Amputation
5
Paralysis
8
Speech
2
Bedrest BRP
7
Independent At Home
B
Walker
2
Bowel/Bladder
6
Endurance 9
Legally Blind
(Incontinence)
3
Up as Tolerated
8
Crutches
C
No Restrictions
3
Contracture
7
Ambulation A
Dyspnea
4
Transfer Bed-Chair
9
Cane
D
Other (Specify)
w/minimal
exertion
5
Exercises Prescribed
Other (Specify)
4
Hearing
B
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 HHA Received Signed POT
1 of 2
485ID: 2948
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.
6. Patient's Name and Address
7. Provider's Name, Address and Telephone Number
8. Date of Birth
9. Sex
10 .Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD-9-CM
Principal Diagnosis
Date
12. ICD-9-CM - Surgical Procedures - Date
13. ICD-9-CM - Other Diagnoses - Date
15. Safety Measures
14. DME and Supplies
16. Nutritional Req.
17. Allergies:
18.B. Activities Permitted
18.A. Functional Limitations
1
Complete Bed Rest
6
Partial Weight Bearing A
Wheelchair
1
Amputation
5
Paralysis
8
Speech
2
Bedrest BRP
7
Independent At Home
B
Walker
2
Bowel/Bladder
6
Endurance 9
Legally Blind
(Incontinence)
3
Up as Tolerated
8
Crutches
C
No Restrictions
3
Contracture
7
Ambulation A
Dyspnea
4
Transfer Bed-Chair
9
Cane
D
Other (Specify)
w/minimal
exertion
5
Exercises Prescribed
Other (Specify)
4
Hearing
B
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 HHA Received Signed POT
1 of 2
485ID: 2948
Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0357
Home Health Certification and Plan of Care
Patient Name:
Cert Period:
24. Physicians's Name and Address
26. I 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 the 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)(02-94)(Formerly HCFA-485)
2 of 2
485ID: 2948

Download Form CMS-485 Home Health Certification and Plan of Care

873 times
Rate
4.4(4.4 / 5) 42 votes
ADVERTISEMENT
Page of 2