Doctor Alliance Training of

US Department of Health and

Human Services, Centers for
Medicare & Medicaid
Services Form:
CMS-485
Certification (485 Cert)
Home Health Certification and Plan of Care

(Refer: Next pages of Doctor Alliance Training Materials

for explanation & details on each part of the form).

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 CMS-485 FORM

❏ Link to the CMS-485 PDF FILE Click here on Doctor Alliance Server.

If the above file doesn't open, use link (below) to access PDF file for the Doctor Alliance’s training:
❏ Link to CMS-485 PDF FILE Click here on Centers for Disease Control and Prevention (CDC) Server.

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Certification (CMS 485 / Cert) of Patient at HHA-H
A certification document is prepared for the Pt whose referral was received at HHA-H based on

❏ The F2F visit notes received.

❏ Referral received.
❏ Patient evaluation by HHA-H.
❏ Data from Pt evaluation added on the CMS (US govt) approved form.

❏ The form Used: The CMS Form 485 has been designed by the US Department of Health and
Human Services, Centers for Medicare & Medicaid Services as numbered as CMS-485 (C-3)
(12-14) which was earlier numbered as Health Care Finance Administration (HCFA)-485 form.
❏ The Office of Management and Budget (US government department) approved number for
the form is OMB No. 0938-0357.
❏ The CPT code G0180 is used for initial 485 certification & CPT code G0179 is used for
continued/re-certification at HHA-H, for the billing/reimbursements purpose of the F2F Provider
MD/DO/DPM/other NPPs as per state laws.
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❏ For an easy understanding of the CMS-485 form (for Doctor Alliance
Training Purposes), the form has been divided into 3 images including
different sections of the form.
❏ CMS-485 is a US Department of Health and Human Services, Centers for
Medicare & Medicaid Services approved form and has to be used in the
specific format as per the CMS.
❏ Any future updates or changes to the CMS-485 will be effective and
applicable as per the guidelines from the US government from
time-to-time for the same.
❏ There are a total of 28 sections in the CMS-485 form which will be
discussed in the next section/slides by dividing 28 sections to 3 parts of
CMS-485 and describing each section in detail, as per the requirements of
the Doctor Alliance Employee Training.
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Part A of CMS-485 Form for the
Doctor Alliance (DA) Training

5
PART A

6
Part A Doctor Alliance’s Training of CMS-485
There are a total of 13 sub-topics/sections on the CMS-485 included in the
Part-A of Doctor Alliance Training Manual.

The various parts in Part A are as follows:

1. Patient’s HI Claim No: This is the Pt’s health insurance number or

member number with the insurance. This is usually an alphanumeric code
which is unique to each patient and assigned by Medicare/the insurance
provider. The HI claim number must be verified on the EHR for each
patient by the Doctor Alliance’s personnel working on processing the
CMS-485 documentation.

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2. Start of Care (soc) Date

❏ This is the Pt’s SOC date, which is the date when the patient was initially evaluated by

HHA-H personnel, and MUST match with the ‘From Date’ /Certification Start date

(for initial certification only).

❏ Important: The SOC date should not & will not match with the recertification start

(from) date on the CMS-485 form. Be cautious when verifying the same. HHA-H

personnel may add this wrong & it is required that Doctor Alliance personnel verifies &

informs the HHA-H to correct the same if any errors found on CMS-485 for SOC date.

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Important Points about Start of Care (SOC) Date at HHA-H
Start of care (SOC) is the date when the HHA-H first accepts & initiates the
evaluations & care of the patient based on the referrals received by
MD/DO/DPM/NPPs. Exception: F2F within next 30 days of SOC (discussed earlier).

❏ HHA-H receive a referral from the certifying physician (MD/DO/DPM/NPPs)

and may decide to accept or decline the referral based upon these factors:
❏ Availability of personnel at HHA-H who can provide patient care at the current time.
❏ Acceptance/in-network patient’s insurance coverage by the HHA-H.
❏ Area/location/address of the patient and coverage areas by HHA-H (which is subject to change
based upon various factors including number of cases vs available personnel in the area).
❏ Services required by patient availability with HHA-H (this is also different from one to another
HHA-H) as must be checked properly before referring a patient to HHA-H.
❏ Total TAT (Turnaround Time) acceptance by the patient. Many patients reject the HHA-Hs if there
is a longer waiting period between referral received by HHA-H & start of care date.

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SOC Date Changes with Recertification? & other important facts
Note:

❏ The Start of Care (SOC) date is fixed (one date) and does not change with recertification
(continued care) of the patient with the same HHA-H.
❏ The SOC is to be documented on the initial certification for the patient at HHA-H, signed by the
referring MD/DO/DPM or other NPPs, as per applicable state laws.
❏ SOC date is exactly the same as the episode start date for 1st Certification (485 Cert).
❏ SOC date is different from the date on subsequent Re-Certifications (ReCerts).
❏ SOC is an important date to know when the actual care was initiated by the HHA-H.

Concepts of HHA-H Pt Certification (485 Cert) and Re-certification (485 ReCert) will be discussed in the
chapter(s) cont’ d.

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3. Certification Period ‘From:’ and ‘To:’
This is the from = start of the certification and to = end of the certification date.

❏ For Home Health Agency (HHA) Patients = 60 days

❏ For Hospice Patients = 180 days

❏ Based on the disease condition & continued care requirements for some chronic
diseases like dementia, the MD/DO/NPPs as per state laws applicable may even certify
patient for a different (other than above) for example 360 days at a time, which can be
acceptable.

❏ Both certification & recertifications use the same format.

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4. Medical Record No.

It is the patient’s registered number at the HHA-H (usually from the

HHA-H’s patient management software). This can also be a specific
identification number allocated to the patient for assignment of services
& billing purposes. This is usually filled but can remain empty or N/A
added by HHA-H.

5. Provider No.

It is the serial ID issued by Medicare to the HHA-H. It contains 6-digit

number which has 2 digits, a hyphen, and 4 digits. This can be
represented as 12-3456. This allows easy identification the HHA-H where
the Pt is currently under care.

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6. Patient's Name and Address

This is added by the HHA-H exactly as per the the patient's last name, first
name, and middle initial as shown on the health insurance card with the
correct current street address, city, State, and ZIP code (it is important
that the data must match with the insurance registered data of the
patient).

7. Provider’s Name, Address and Telephone Number

The HHA-H enters its legal/registered business name and/or branch office
(if appropriate), street address (or other legal address details), city, State
and ZIP code, telephone number, fax number and email address/website
details.

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8. Patient's Date of Birth (DOB)

This is added by the HHA-H exactly as per the the patient's DOB as shown
on the health insurance card (it is important that the data must match
with the insurance registered data for DOB of the patient). It uses
standard (month, day, year) in numbers, i.e., MMDDYYYY in US date
format.

Note: It should NOT be confused as DDMMYYYY (common mistake to avoid.)

9. Patient’s Sex/Gender

The HHA-H enters the correct gender of the patient.

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10. Medications: Dose/Frequency/Route (N)ew (C)hanged
❏ This is filled-in exactly as per the physician's orders for all medications
including:
❏ dosage,
❏ frequency and
❏ route of administration for each drug.

❏ Drugs, which cannot be listed on the plan of care due to lack of space, can be listed
on an addendum.
❏ The letter "N" is used after the medication(s) that are "new" orders.
❏ The letter "C" is used after the medication(s) that are "change" orders either in dose,
frequency or route of administration.
❏ "New" medications are those that the patient has not taken recently, i.e., within the
last 30 days.
❏ "Change" are medications which include dosage, frequency or route of
administration changes within the last 60 days.

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11. ICD, Principal Diagnosis and Date:

ICD-10: The International Statistical Classification of Diseases and Related Health Problems
(ICD)-10 is currently used all over the world including in all 50 US states. The ICD has been the basis
for comparable statistics on causes of mortality and morbidity between places and over time.

However, ICD-11 is already released and can be implemented very soon even all over the US. As per
World Health Organization (WHO), ICD-11, was adopted by the 72nd World Health Assembly in 2019
and came into effect on 1st January 2022.
"A key principle in this revision was to simplify the coding and provide users with all necessary electronic tooling – this will allow
health-care professionals to more easily and completely record conditions," says Dr Robert Jakob, Team Lead, Classifications
Terminologies and Standards, WHO.

The concept of principal diagnosis: is the diagnosis most related to the current POC. The diagnosis
may or may not be related to the patient's most recent hospital stay, but must relate to the services
rendered by the HHA. If more than one diagnosis is treated concurrently, the diagnosis that
represents the most acute condition and requires the most intensive services should be entered.

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ICD-11 highlights (improvements)
❏ Legally mandated health data standard.*
❏ Comparable statistics with semantic interoperability.
❏ Conceptual framework for all languages and cultures.
❏ Integration of terminology and classification.
❏ Up-to-date clinical and scientific knowledge.
❏ End-to-end digital solution.
❏ Freely available through open license.

*International Nomenclature Regulations.

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The concept of principal diagnosis:
❏ The patient’s diagnosis most related to the current POC is considered as
the principal diagnosis.

❏ The principal diagnosis may or may not be related to the patient's most
recent hospital stay, but must relate to the services rendered by the HHA.

❏ If more than one diagnosis is treated concurrently, the diagnosis that

represents the most acute condition (clinical understanding of the same is
necessary) and requires the most intensive services should be entered in
the CMS-485, in the S. No. 11 for Primary Diagnosis with its ICD-10 & the
date of diagnosis to be added.

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12. ICD, Surgical Procedure and Date:

❏ The surgical procedures for the patient (if any) done (at any point of time) must be
listed in this section 12 of the CMS-485 form by the HHA-H.

❏ The F2F documentation sent by the Physician Group along with the patient referral or
any other clinical notes can be used for the same.

❏ At a minimum, the details such as month and year must be present for date of
surgery if the exact date for the surgery is not documented and the patient or
Physician Group does not have a record of it.

❏ The Doctor Alliance personnel processing the CMS-485 must verify all the ICDs,
Surgical Procedures and Date for it V/S the available Physician Group’s EHR data.

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13. ICD, Other Pertinent Diagnoses and Date:

❏ All the other procedures for the patient (if any), other than the Primary diagnosis &
Surgical procedures are to be listed in the section 13 of the CMS-485 form by the
HHA-H.

❏ The F2F documentation sent by the Physician Group along with the patient referral or
any other clinical notes can also be used for the same.

❏ The Doctor Alliance personnel processing the CMS-485 must verify all the ICDs, Other
Pertinent Diagnoses and Date for it V/S the available Physician Group’s EHR data.

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Doctor Alliance Personnel Verification of Part-A of CMS-485 & Next Steps
❏ The Doctor Alliance (DA) personnel processing the CMS-485 must carefully examine all
the data entered by the HHA-H for Part-A (section 1 to 13) to verify the Pt’s details
available on the Physician Group’s EHR.

❏ Any errors or discrepancies must be communicated back to the HHA-H using a

suitable communication method for corrections to be done on the CMS-485.

❏ Part-A of CMS-485 has most important sections (1 to 13), which have to be perfectly
correct. The verifying DA personnel must make sure that there are no errors in it.

❏ Next: CMS-485 part B & C of Doctor Alliance Employee Training Manual.

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Part B of CMS-485 Form for the
Doctor Alliance (DA) Training

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PART B

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14. DME and Supplies (to be listed on the CMS-485):

❏ Any DMEs & supplies for the patient must be listed (a few exceptions, also
discussed in the chapter).
❏ The HHA-H must list DME ordered by the physician that will be billed to
Medicare.
❏ The HHA can also just enter N/A if there are no supplies or DME which are
were/are to be billed.
❏ DMEs are to be ordered by the Physician Group and NOT by HHA-H but
the HHA-H lists down all the DMEs on the CMS-485, as per the CMS
mandated guidelines & as HHA-H personnels are the ones examining &
providing the care to the patient.

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What MUST be listed on CMS-485 section 14:

❏ DME order(s) for wound care may require use of nonroutine supplies, which would vary by
patient. Therefore, the non-routine supplies would be required to be listed on CMS-485.
❏ If the HHA-H lists a commonly used commercially packaged kit, it is not required to list the
individual components. However, if there is a question of cost or content, the Regional Home
Health & Hospice Intermediary (RHHI) can request a breakdown of kit components.
❏ RHHIs should reference the regulation 11, §206.4 for a definition of non-routine supplies.

❏ Exception:
❏ For example, an order for foley catheter insertion requires specific supplies, i.e., foley,
catheter tray. Therefore, these supplies are not required to be listed on the CMS-485 form.
❏ If there are few bundled items in a package of wound care DME, those need not be listed
on the CMS-485 form and can be just added as the package name without listing all items
contained in a package (it is only applicable for standard package bundle supplies).

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❏ Regulation 11, §206.4
Durable Medical Equipment (Rev. 1, 10-01-03) A3-3119.4.B, HHA-206.4.B

Durable medical equipment which meets the requirements of the Medicare

Benefit Policy Manuals, Chapter 6, "Hospital Services Covered Under Part B,"

§80, and Chapter 15, “Covered Medical and Other Health Services” §110, is

covered under the home health benefit with the beneficiary responsible for

payment of a 20 percent coinsurance.

26
15. Safety Measures
❏ The physician's instructions, are usually listed on the the F2F documentation and
HHA-H referral received by HHA-H.
❏ Any further clarifications or instructions from MD/DO/DPM/NPPs (if required) by
HHA-H personnel, can be obtained via a telephone call or a direct communication via
Doctor Alliance (DA) portal.
❏ Communication from HHA-H (with questions & concerns about the safety measures to
be filled on the CMS-485) via a Telephone call or communication system on the DA
portal to the assigned DA team working on behalf of the MD/DO/DPM/NPPs helps
HHA-H to get the correct details for the patient.
❏ The assigned DA team uses the Patient’s EHR (from Physician Group) & even directly
contacts the MD/DO/DPM/NPPs, as needed, for a proper communication to the
Physician Group (PG), regarding the safety measures which were listed on the
documentation received via the Doctor Alliance for HHA-H Referral System.
❏ The HHA-H is communicated with the correct answers for the case by the assigned DA
Team for the Physician group.
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16. Nutritional Requirements
❏ This section on CMS-485 form is also equally important as it lists any specific
nutritional needs & regimen to be followed for the patient and helps the HHA-H
personnel & the patient along with the family members to exactly know the
dietary needs of the patient to follow.
❏ The HHA-H personnel enters the physician's orders for the diet in the section 16
of CMS-485.
❏ The details includes specific therapeutic diets and/or any specific dietary
requirements to be followed by the patient.
❏ The fluid needs or daily restrictions are also to be clearly listed in this section for
the HHA-H personnel to know the daily I/O of fluids to be recorded.
❏ For Total Parenteral Nutrition (TPN) cases: It can also can be listed under this
item (section 16) or under medications too if more space is needed, (both are
correct; but it is more suitable to be listed under section 16 of CMS-485 form).

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17. Allergies
❏ The section 17 of CMS-485 Form is the space on form designated for any
kind of patient known allergies to be listed.
❏ The personnel at HHA-H should refer the received referral from Doctor
Alliance for HHA-H & the F2F documentation included in referral
bundle/digital paperwork on the DA Referral received by HHA-H for the
details documented by the MD/DO/DPM/NPPs.
❏ This section also requires all medications to which the patient is allergic to
be listed.
❏ All other allergies that is already known or the patient
experiences/reports (such as the allergy to any specific foods, adhesive
tapes, iodine, environmental conditions, and any others) are to clearly
listed in this section 17 for allergies of the CMS-485 form.
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 NOTE: Section 18 to 20 of the CMS-485 Form
❏ It is important to note that the various numbers provided on the CMS-485
form such as 1, 2, 3, 4, and so on or A, B, C, D, and so on are just for
adding a serial number for the proper listing on CMS-485 form.
❏ The numbers do NOT mean any specific scale such as Pain 1 to 10 or
rating system. The HHA-H personnel entering the data & the assigned
Doctor Alliance (DA) team members for verification & preparing the
document must not confuse it to be a scale system for numbering.
❏ The numbers and/or letters adjacent to the various blocks in items 18
through 20 are added to correspond to the codes for Medicare Electronic
Media Claims (EMC) transmission only (which means for simple
numbering purposes) for claims later to the insurances.
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18 A. Functional Limitations
The various functional limitations listed on CMS-485, section 18 A are:
1. Amputation
2. Bowel/Bladder (Incontinence)
3. Contracture
4. Hearing
5. Paralysis
6. Endurance
7. Ambulation
8. Speech
9. Legally Blind
and
A. Dyspnea With Minimal Exertion
B. Other (Specify) = For this, description is required to be added in the CMS-485
describing any other functional limitation of the patient.

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18 A. Functional Limitations (cont’ d)
❏ The section 18 A of CMS-485 Form designated for different items that indicates
the patient's current functional limitations.
❏ The information to add on this section 18 A by HHA-H personnel, can be found
in the clinical note received from Doctor Alliance (DA) team along with the
HHA-H Referral.
❏ The MD/DO/DPM/NPPs assess the functional limitations of the patient and the
agency (HHA-H) lists it on the CHS-485 section 18 A.
❏ If HHA-H personnel finds any missing limitations listed or patient reports any
new functional limitation, the same must be communicated to the DA team
assigned to the Physician Group (via the DA portal communication or telephone
call to the assigned DA team members), to get it clarified/notified, as needed for
the case with the MD/DO/DPM/NPPs for the patient before adding it to
CMS-485.

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18 B. Activities Permitted
The various activities permitted are listed on CMS-485, section 18 A are:
1. Complete Bedrest
2. Bedrest BRP (BRP = Bathroom Privilege, meaning patient can go to bathroom, as
needed)
3. Up As Tolerated
4. Transfer Bed/Chair
5. Exercises Prescribed
6. Partial Weight Bearing
7. Independent At Home
8. Crutches
9. Cane
and
A. Wheelchair
B. Walker
C. No Restrictions
D. Other (Specify)
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18 B. Activities Permitted (cont ‘d)
❏ All the activities permitted for the patient are listed properly in the section 18 B,
of the CMS-485 Form.
❏ The information required for the same by HHA-H can be obtained from the
Patient Referral documentation received by HHA-H from the DA team
(which includes a written Physician Group Referral/order for HHA-H and
supporting Clinical/F2F visit Note documentation verified by the DA team
assigned to the Physician Group.
❏ The HHA-H also performs the evaluation of the patient for acceptance
/admitting patient under their services and can list additional/new found
improvements or decline in activities permitted for the patient. The same MUST
be communicated to the overseeing F2F physician for approval.
❏ The assigned DA Team members working on behalf of the Physician Group,
is the point of contact for HHA-H to get information or send information to
the PG.
❏ All communications MUST be documented on the DA portal for
MD/DO/DPM/NPPs approval.
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19. Mental Status

The following mental status (available listed on CMS-485 form), for the patient should be
correctly listed by HHA-H personnel:
1. Oriented
2. Comatose
3. Forgetful
4. Depressed
5. Disoriented
6. Lethargic
7. Agitated
8. Other
❏ The block(s) which are the most appropriate for patient's mental status is to be
checked on the form. If ‘Other’ option is checked, the patient's condition has to be
specified, in detail (other option can not be checked without a description of the
condition of the patient’s other mental status).
❏ The assigned DA Team members to the PG, verify the details as per the Patient’s
EHR (PG)’s records available.
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20. Prognosis

The following prognosis are available listed on CMS-485 form, for the patient which should be correctly selected
by the HHA-H personnel:

1. Poor
2. Guarded
3. Fair
4. Good
5. Excellent
❏ These (above listed), are the standard prognosis types divided in five (above) categories listed on
the CMS-485 form.
❏ Only one of the above should be selected by the HHA-H personnel based on the patient’s clinical
condition.
❏ Note: The overall prognosis for various ICDs which patient has including the Primary Diagnosis)
should be the deciding factor in adding prognosis on CMS-485.
❏ The assigned DA Team members to the PG, verify the details as per the Patient’s EHR (PG)’s records
available.
❏ As prognosis changes after start of care, the DA team members assigned will use specific forms
available for patient care to record prognosis changes of the patient & document it on the DA portal
for Physician’s signature. HHA-H will be contacted by the DA team for the same. Prognosis tracking
is one of the important steps in the patient care anywhere, including at HHA-H.
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21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)

❏ The section 21 of CMS-485 form, lists all the orders for the patient’s care by the
HHA-H which were received from the Doctor Alliance (DA) on behalf of the the
MD/DO/DPM/NPPs of the Physician Group (PG) who conducted the initial F2F &
certified patient eligible to be referred to the HHA-H.
❏ The HHA-H must enlist the frequency with the expected duration of the visits (for
each discipline), along with the duties in the treatments to be performed by each
discipline must be stated.
❏ A discipline may be one or more of the following: Skilled Nursing (SN), Physical
Therapy (PT), Speech Language Pathology or commonly known as Speech Therapy
(ST), Occupational Therapy (OT), Social Services also sometimes referred as
Medical Social Services (MSS) (also known as Social Service), or AIDE = Home
health Aide (person who is trained under a licensed practitioner such as nurse in
providing basic care to the needs of the HHA-H patients). The orders listed on
CMS-485 in this section must include all disciplines and treatments, even if they
are not billable to Medicare.
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❏ The orders listed under this section must have the amount, frequency, duration, or any other
specifications written in a standard format.

Example:

❏ Registered Nursing (RN)/Skilled Nursing (SN) Evaluation for Homecare Services (it's usually
called SN but can also be written as RN):
❏ RN/SN Visit 3 to 6 months for AIDE supervision, patient assessment and 1-3 PRN visits
for changes in the patient’s clinical condition, environment, resumption of care and
recertification;
❏ RN/SN visits may be done using the telehealth methods or, via a telephone call with
the patient’s permission due to the COVID-19 precautions.
❏ Home Care Services (by Home Health Aide/AIDE) Personal Care Assistant (PCA)
❏ PCA for all 7 days 12/12 hours/day x 180 days assist with personal care, light
housekeeping, meal preparation, medication reminders, errands, accompany to MD
appointments.

Note: Similarly, all the other services by HHA-H for the patient, as referred by the MD/DO/DPM/NPPs
must be listed properly in this section 21 of the CMS-485 form which will be signed by the referring (the
provider at PG who initially conducted the F2F & for whom the DA team assigned sent HHA-H with
referral).
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22. Goals/Rehabilitation Potential/Discharge Plans
❏ This section of the CMS-485 form lists all the goals, the rehabilitation potential
and the discharge plans with the conditions of the discharge.
❏ When a patient is referred to the HHA-H on behalf of the Physician Group, by
the Doctor Alliance (DA) team assigned to a specific Physician Group (PG) of a
specific region, the goals for the HHA-H care are to be very clearly listed.
❏ MD/DO/NPPs who conduct the F2F visit & established patient in-need of/eligible
for HHA-H care MUST clearly state the goals from the referral of patient to
HHA-H, patient’s rehabilitation potential to be independent or to be having a
better prognosis, to minimize pain, to be able to perform Instrumental Activities
of Daily Living (IADLs) or Activities of Daily Living (ADLs) independently, or as
applicable for the referred patient’s case when referring the patient to a HHA-H.
❏ Discharge Plans: There should be clear instruction from Physician Group to
HHA-H about the re-certification or for improvement in patient’s health status
when a Patient can be discharged from HHA-H, which MUST be clearly
documented on the section 22 of the CMS-485 form by the HHA-H.

39
22. Goals/Rehabilitation Potential/Discharge Plans (Cont ‘d)

❏ The goals/rehabilitation potential must be realistic as per the clinical

condition:

Examples of realistic goals:

❏ For a patient on complete bed rest due to multiple ICD/diagnosis (but
improvement potential as seen in prognosis) = the goal can be ‘Independence in
transfers and ambulation with walker/wheelchair or any other assistive DME device,
as found appropriate upon evaluation by the Physician for DME mobility
assessment’.
❏ For a patient with multiple ICD/diagnosis of Cardiovascular system including
HTN, CHF, and others = the goal should be to achieve optimal level of
cardiovascular status, with restrictive diet compliance & other precautions, and with
cardiovascular medication adherence, as prescribed by the MD.

40
22. Goals/Rehabilitation Potential/Discharge Plans (Cont ‘d)
❏ Tasks & verifications of the assigned DA Team to Physician Group:

❏ You MUST verify the section 22, of the CMS-485 data filled-in for all goals listed by HHA-H
(it must be realistic goals as per the Physician Group’s instructions).
❏ The verification is to ensure compliance: that all the PG’s instructions are listed on
CMS-485 and not missed by HHA-H.
❏ Any unrealistic goals added by HHA-H must be notified (to HHA-H based on EHR & PG’s
instructions) for correction by HHA-H personnel.
❏ If any other errors are found, those must be communicated back to the HHA-H personnel
for correction(s), as per the Physician Group’s instructions for the patient care.
❏ DA clinical Team, the callers, and all other teams assigned to the Physician Group
(PG) & the DA region: All teams MUST work together for an overall Physician Group
(PG) Customer/Client Happiness/Retention/Success model, as assigned to you from
Doctor Alliance. Verifying details on CMS-485 are very important for this. 41
Doctor Alliance Personnel Verification of Part-B of the CMS-485 & Next
Steps
❏ The Doctor Alliance (DA) personnel processing the CMS-485 must carefully examine all the
data entered by the HHA-H for Part-B (section 14 to 22), to verify that all the Pt’s details
available on the form are as per the data available on the Physician Group’s EHR records of
the patient.
❏ Any errors or discrepancies in part-B of CMS 485 FOrm, must be communicated back to the
HHA-H using a suitable communication method for corrections to be done on the CMS-485.
❏ Part-B of the CMS-485 has most important sections for evaluations & orders, among other
important things (14 to 22), which are required to be perfectly correct.
❏ The verifying DA personnel (team assigned on behalf of the Physician group) must make sure
that there are no errors in the respective section of CMS-485 form.

Next: CMS-485 part C of Doctor Alliance Employee Training Manual.

42
Part C of CMS-485 Form for the
Doctor Alliance (DA) Training

43
PART C

44
23. Nurse’s Signature and Date of Verbal SOC, Where Applicable

❏ This section 23 of CMS-485 is for verification, that a registered nurse,

qualified therapist (PT, OT, ST, MSW), or any other health professional,
who was responsible for furnishing or supervising the patient's care,
spoke to the attending physician and received verbal authorization
to visit the patient.
❏ The date of the communication (telephone call) is required to be added in
this section.
❏ Note: This date is the exact date of the telephone call & may precede or
be the same as the Start of Care (SOC) at HHA-H date, in the section 2 and
also may precede or be same as the ‘From’ date in section 3 of CMS-485.

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24. Physician’s Name and Address
❏ This is a very important section of the CMS-485 because this MUST have
the name of the F2F MD/DO/DPM/NPPs.
❏ The name, address, Phone and fax numbers, must be exactly as per their
registered NPI for billing to be successful with 100% rates.
❏ Note: CMS rejects claims where name does not match to the letter. For example,
Odette L Campbell, MD, PA, it can NOT be billed as Odette Louise Campbell, MD, PA or
Odette Campbell, MD, PA. Only Accepted would be: Dr. Odette L Campbell, MD, PA =
which is as per the NPI database, this is a practical example).
❏ It MUST be the same MD/DO/DPM/NPP, who had initially established that the
patient requires a HHA-H referral, and whose referral was sent to HHA-H by the
Doctor Alliance (DA) team working on behalf of the Physician Group.
❏ The address also MUST match the NPI database and can NOT be different. If a
MD/DO/DPM/NPPs requests DA or HHA-H to change address, it must be 1st updated by
Physician Group (PG) in the NPI database/with the CMS and then requested to update on
CMS-485 form, which is very important for billing purposes.
❏ The Phone & Fax numbers should also MATCH the NPI registry and MUST be the one
where a MD/DO/DPM/NPPs can be contacted directly.
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25. Date of HHA Received Signed POT/POC
❏ POT = Plan of Treatment/Therapy also known commonly as POC = Plan of Care.

❏ The section 25 of the CMS-485 form MUST be left BLANK/EMPTY when the HHA-H is
sending/creating/uploading the CMS-485 on the Doctor Alliance (DA) Portal to be signed by the Physician
by selecting the correct Physician on the DA portal, who had conducted the initial F2F & signed the
referral for HHA-H.

❏ The date when the agency received the signed POC from the attending/referring physician is entered
AUTOMATICALLY by the Doctor Alliance (DA) Portal, as the document is signed.

❏ This section is OPTIONAL and is required only if the Physician/NPP does not date section 27 of CMS-485.

❏ The HHA-H personnel should enter N/A or the same date as per section 27 of CMS-485 when this is done
on a manual basis, which has chances of error & rejected claims as a result of a simple error.

❏ Using Doctor Alliance: This automatically gets added on the Doctor Alliance (DA)
CMS-485 designed to take care of these requirements & is also verified for every
prepared CMS-485 document by the assigned DA’s clinical team, so that our clients,
HHA-H & Physician Groups (PGs) do NOT have to worry, and can get the CMS-485
readymade for patient care & billing purposes on Doctor Alliance Portal.
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26. MD/DO/DPM/NPPs Certification Statement
❏ The CMS-485 has this section filled-in with standard CMS statement for
Physician Group (PG), i.e. for the MD/DO/DPM/NPPs stating,
❏ ‘I certify/re-certify 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’.

❏ This standard statement on section 26 of the CMS-485 Form, is to verify

that the physician/NPP has reviewed the plan of care for this patient,
found it suitable as per the initial F2F & referral to that HHA-H via Doctor
Alliance and certifies to the need for the services listed on the CMS-485
form which is to be signed on the Doctor Alliance portal, after review.
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27. Attending Physician’s Signature and Date Signed
❏ CMS’s Compliance Note: The HHA-H MUST NOT predate this section for the physician,
nor write the date in this field. If the physician left it blank, the HHA-H should enter the date
it received the signed POC under section 25 manually. Our client HHA-H & Physician
Groups (PGs) NEED NOT WORRY about this when they are using Doctor Alliance. Our
smart software & dedicated clinical and quality check teams assigned to you (as per the
partnership agreement with Doctor Alliance), takes care of all the hassles for you to
make patient care & revenue resulting from good patient care simple for you. That is the
value Doctor Alliance (DA) adds to our clients HHA-H & Physician Groups (PGs).

❏ Data on CMS-485’s verified & prepared by Doctor Alliance Software & assigned
clinical & quality teams: When our client HHA-H using the Doctor Alliance (DA) portal
adds data on DA’s CMS-485/uploads CMS-485 to DA portal, each & every fields are
verified by DA’s software, the assigned DA clinical & data teams working on behalf of the
client Physician Group (PG), including multiple levels of quality checks done, and then the
MD/DO/DPM/NPPs gets notified of a prepared CMS-485 form ready for review by
Physician Group (PG) & signature. This robust process eliminates all the hassles & errors.
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27. Attending Physician’s Signature and Date Signed (cont ‘d)
❏ Physician Group (PG), MD/DO/DPM/NPPs signature

❏ Using Doctor Alliance, the attending Physician’s signature & date are
added electronically and perfectly each time on the CMS-485 Form
when the Physician verifies all fields on the form are correct, after
MD/DO/DPM/NPPs review the completed form & they use the one
click to sign feature to electronically sign on the CMS-485 form.

❏ The signature(s) for the MD/DO/DPM/NPPs are available on the

Doctor Alliance (DA) portal, as they set-up their DA account for the
first time (as a client), which allows them to sign electronically using
their own logins.
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27. Attending Physician’s Signature and Date Signed (cont ‘d)
❏ The signed CMS-485 is again quality checked by Doctor Alliance’s
software, clinical & quality teams, which is then sent back to the HHA-H,
and also added to the Physician Group’s patient records on the EHR.

❏ For client HHA-Hs, the signed CMS-485 Form (POC) is also added to
their own HHA-H software, as needed through Doctor Alliance’s
automations & Health Insurance Portability and Accountability Act
(HIPAA)-compliant software.

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28. Standard Penalty Statement on CMS-485 section 28 states, ‘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.’
❏ This is a standard statement on the section 28 of the CMS-485 form,
which warns that there are penalties imposed for misrepresentation,
falsification or concealment of essential information.

❏ All the data added on CMS-485 must be correct & updated, as per the
patient’s clinical condition.

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 Privacy Act Statement &
Paperwork Burden Statement
on the
CMS-485 Form

53
Privacy Act Statement on CMS-485 Form
The privacy statement on the CMS-485 form is as follows: ‘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 non-professional
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.’

❏ Value addition by using Doctor Alliance (DA): This is a standard statement for privacy act & by
using Doctor Alliance (DA), the client HHA-H & Physician Group (PG)’s MD/DO/DPM/NPPs are
automatically compliant to the HIPAA & Privacy Act as per the statement on the CMS-485 form.
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Paperwork Burden Statement on CMS-485 Form
The paperwork burden statement on the CMS-485 form is as follows:
‘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.’

Note: OMB Control Number is US ‘Office of Management and Budget’ (OMB) Control
Number.
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Added benefit when using Doctor Alliance: for
Client HHA-H & Physician Groups (PGs)
❏ When client HHA-H and Physician Group (MD/DO/DPM/NPPs) use the Doctor
Alliance (DA) portal & services, all the information on F2F documentation,
HHA-H Referral to the CMS-485 are verified MULTIPLE times using DA’s US
Healthcare system’s FIRST, ONLY END-TO-END SOLUTION including the smart
DA software, the assigned clinical & quality teams.
❏ The clinical & quality teams are assigned to the client Physician Group &
HHA-H, as per their individual documents volume & the total number of the
patients.
❏ Doctor Alliance is a smart, HIPAA-compliant and effective system to go green
with DIGITAL PAPERWORK & ASSIGNED CLINICIANS and QUALITY CHECK
TEAMS, as per your CUSTOMIZED REQUIREMENTS as our client HHA-H and
Physician Group (PG). 56