Cms 485 PDF Details

In navigating the labyrinth of healthcare documentation, the CMS 485 form stands as a critical instrument for ensuring that patients receiving home health services are accorded the necessary care tailored to their unique health conditions. Mandated by the Department of Health and Human Services and approved by the Centers for Medicare & Medicaid Services, this form, formally titled "Home Health Certification and Plan of Care," serves a pivotal role in the Medicare system. It captures comprehensive details ranging from the patient's personal information, medical diagnosis, to the prescribed medications and treatment plans, thereby laying the groundwork for personalized patient care. Central to this process is the certification or recertification of the patient’s eligibility for home health services under Medicare, stressing the requirement for home confinement and the need for skilled nursing care, physical, speech, or occupational therapy. Beyond its function as a tool for healthcare delivery, the form also acts as a safeguard, ensuring that the information provided is true and accurate under the penalty of law, thereby upholding the integrity of federal healthcare benefits. With privacy considerations taken into account, the CMS 485 encapsulates the essential elements of home health care planning, serving as both a directive for care and a document of legal and ethical significance.

QuestionAnswer
Form NameCms 485
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshome health certification and plan of care, 485 form home health, cms 485 plan, cms 485

Form Preview Example

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

1

2

3

4

Amputation

5

 

Paralysis

9

 

 

 

 

Bowel/Bladder (Incontinance)

6

 

Endurance

A

 

 

 

 

 

Contracture

7

 

Ambulation

B

 

 

 

 

 

Hearing

8

 

Speech

 

 

 

 

 

 

 

 

Legally Blind

Dyspnea With

Minimal Exertion

Other (Specify)

1

2

3

4

5

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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