How to Refer a Patient to Home Health: The Complete Guide for Physician Offices

Home health is one of the most valuable services a physician can order — skilled nursing, physical therapy, occupational therapy, speech therapy, and aide support delivered in the patient’s home, covered by Medicare with no patient cost-sharing. But the referral only works if the patient qualifies, the documentation is complete, and the right agency receives it. This guide covers the whole path.

Step 1: Confirm Medicare eligibility

Medicare covers home health when all of the following are true:

• The patient is confined to the home (“homebound”) — leaving home requires considerable and taxing effort, and absences are infrequent or for medical care
• The patient needs intermittent skilled nursing care, physical therapy, or speech-language pathology (or has a continuing need for occupational therapy)
• The patient is under the care of a physician or allowed practitioner, and the care is furnished under a plan of care
• A face-to-face encounter related to the primary reason for home health occurred within 90 days before or 30 days after the start of care
• The home health agency is Medicare-certified

Step 2: Is home health the right level of care?

Physicians and discharge planners often weigh home health against neighboring options, and the distinctions matter for both eligibility and patient expectations:

• Home health: intermittent skilled care in the patient’s home for homebound patients — nursing visits, therapy, wound care, medication management. Covered by Medicare Part A/B when criteria are met.
• Skilled nursing facility (SNF): 24/7 inpatient skilled care after a qualifying 3-day hospital stay — for patients who need daily skilled care that cannot be delivered at home.
• Assisted living: a residential setting with help for daily activities — not a Medicare-covered medical benefit. Importantly, a patient living in assisted living can still receive home health services there if they meet homebound and skilled-need criteria.
• Hospice: comfort-focused care for patients with a prognosis of six months or less who elect to forgo curative treatment — a separate benefit with its own certification process.

Step 3: Build a complete referral packet

Incomplete packets are the number-one cause of delayed starts of care. Agencies cannot begin until they have what they need, and every missing document becomes a callback to your front desk. A complete home health referral includes:

• Patient demographics and insurance information
• The ordering practitioner’s name and NPI
• Primary diagnosis and relevant clinical history — the reason home health is needed
• The services being ordered (nursing, PT, OT, SLP, aide) with any specifics
• Current medication list
• Face-to-face encounter documentation (or the plan for when it will occur)
• Recent clinical notes, hospital discharge summary if applicable

Step 4: Route with patient choice in mind

Medicare protects the patient’s right to choose their home health agency. Best practice is to capture the patient’s preference up front — along with ranked backups — so that if the first-choice agency declines (capacity, geography, service lines), the referral moves immediately to the next agency without re-collecting anything.

This is where fax-based referrals lose the most time: a declined fax is a dead end until someone notices. In a managed workflow, decline-and-reroute happens the same day.

Step 5: What happens after you send it

The agency reviews the packet, confirms eligibility and coverage, accepts the referral, and schedules the start-of-care visit — typically within 24–48 hours for a complete referral. The agency’s clinician performs the OASIS assessment, drafts the plan of care (usually a CMS-485), and sends it back to your office for the certifying signature.

That signature loop is the referral’s second act, and it comes with revenue attached: the initial certification is billable as G0180 and each 60-day recertification as G0179.

Doing all of this in one place

Klio gives physician offices a single dashboard for the entire loop: build a complete referral packet with a completeness check before it leaves, route it to the patient’s preferred agency with backups queued, watch acceptance in real time instead of calling, receive the plan of care digitally, sign it in one click from any device, and capture the G-code evidence automatically. It is free for physician offices, works alongside your existing EHR — Athena, eCW, Epic, or anything else — and takes about 10 minutes to set up.