NAHC Provides Recommendations for Complying with New Face-to-Face Rules
January 26, 2015 10:52 AM
In the final rule for the 2015 home health prospective payment rate update, the Centers for Medicare & Medicaid Services (CMS) revised the face-to-face (F2F) encounter requirements for physician certification for home health services. In the rule, CMS eliminated the narrative requirement, which required the certifying physician to provide a detailed explanation on why the patient was homebound and in need of skilled services. CMS will still require that the face-to-face encounter 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, be related to the primary reason the patient is receiving home health services, and be performed by a physician or allowed non-physician practitioner (NPP).
In addition to eliminating the narrative requirement, CMS has also altered its medical review process for determining patient eligibility for home health services. Not only will CMS request the agency’s medical record when additional documentation is requested, they will also be looking for evidence that supports eligibility for home health services from the physician’s medical record.
CMS will require that the home health agency submit pertinent sections of the certifying physician’s medical record when an agency’s claim is requested for review. If the documentation in the physician’s record is insufficient to support eligibility, the home health agency’s claim will be denied. According to CMS:
“In determining whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care, we will require documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of home health eligibility.
We will require the documentation to be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described at § 424.22(a)(1) and § 424.22(b). HHAs should obtain as much documentation from the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS and its review entities upon request.”
CMS will permit the agency to inform the certifying physician of the agency’s findings from their comprehensive assessment that supports the patient’s eligibility for home health care. The certifying physician will need to sign the additional information and incorporate it into his/her medical record. States CMS:
“It is permissible for the HHA to communicate with and provide information to the certifying physician about the patient’s homebound status and need for skilled care and for the certifying physician to incorporate this information into his or her medical record for the patient. The certifying physician must review and sign off on anything incorporated into his or her medical record for the patient that is used to support his/her certification/recertification of patient eligibility for the home health benefit.
In addition, any information from the HHA (including the comprehensive assessment) that is incorporated into the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient (if the patient was directly admitted to home health) and used to support the certification of patient eligibility for the home health benefit, must corroborate the certifying physician’s and/or the acute/post-acute care facility’s own documentation/ medical record entries...”
CMS explained that it is eliminating the narrative requirement “to simplify the face-to-face encounter regulations, reduce burdens for HHAs and physicians, and to mitigate instances where physicians and HHAs unintentionally fail to comply with certification requirements.”However, CMS’ revisions seem to have made the F2F requirements even more burdensome. In addition, the only guidance CMS has provided thus far has been through a National Provider call held in late December 2014.
During the call, CMS reiterated the regulatory requirements and provided some examples of appropriate physician F2F encounter notes and discharge summaries along with a note that did not adequately address reasons for homebound and/or skilled services. When the encounter documentation is insufficient, CMS maintains that agencies would be permitted to fill in the “gaps” by supplying the physician with information from the agency’s assessment that supports eligibility. They also stated that the agency could add the information to the plan of care (POC) that is sent to physician for review and signature.
CMS failed, however, to address how agencies are expected to operationalize many other aspects of the new requirement, particularly as they relate to patients who have a F2F encounter conducted by a physician from an acute/post acute care facility. Further, there has been no indication of what the Medicare medical review contractors will be looking for in the physician’s record that substantiates eligibility.
In December, the National Association for Home Care & Hospice (NAHC) sent a letter to the Administrator of CMS requesting a phased–in approach to implementation of the new F2F requirements. Since then, NAHC has made multiple attempts to get answers from CMS. Only recently did a CMS official contact NAHC. They indicated that they were in serious discussions within CMS to develop an appropriate approach for implementation; however, nothing is concrete at this time.
So what are agencies to do in the meantime? Based on information NAHC has gathered thus far, the organization offers the following recommendations:
Agencies should submit to the certifying physician a summary of the clinical finding from their assessment that supports the need for skilled services and reason for homebound. Include the pertinent sections of the comprehensive assessment and the OASIS to substantiate the findings.
Include a statement at the end of the summary that will serve as an attestation that the physician agrees with the summary and is incorporating the information into his/her medical record.
Request that the physician sign and date the document and return it to the agency
Both the summary and attestation statement can be included on the POC that is sent to the physician. However, keep in mind that the elements required on a home health POC alone do not provide adequate information to support eligibility for home health services.
CMS will look at the physician’s medical record in determining that the certification requirements have been met, therefore, the physician should also keep a copy of any document that contains the certification statement.
CMS will review the physician’s encounter note/discharge summary for the date of the encounter, confirm that the encounter is related to the primary reason for home health service, and that the encounter was conducted by the physician or an allowed NPP.
If the documentation on the encounter note is insufficient to support eligibility, CMS will look to other documents or evidence in the physician’s record to support home health eligibility. Therefore, it is very important that the agency supply the physician with any information that supports eligibility so that it may be incorporated into the physician’s record as soon as possible.
CMS will not require that the agency obtain the physician’s medical record prior to billing. However, agencies will still need to be assured that F2F encounter occurred as part of the certification prior to billing. Agencies can accomplish this in several ways:
Agencies may continue to use the F2F encounter document form, or a modified form, that has been in place since the beginning of the F2F encounter requirement. Continuing to use the form will provide the agency with tangible evidence that a F2F encounter had been conducted. However, CMS will look for the actual visit note /discharge summary that the information is based on.
The agency could include a statement on the POC or documentation that is sent to the physician that serve as an attestation that a F2F encounter was conducted within the required time frame, the encounter was related to the primary reason for home health services, and the encounter was conducted by the physician or am allowed NPP.
Request the actual note from the physician
Agencies should still obtain as much information from the physician as soon as possible,
There are still many unanswered questions regarding how agencies are to adequately comply with the new F2F rules. NAHC, along with others, have many outstanding questions that have been submitted to CMS. We will continue to work with CMS to arrive at a reasonable resolution. Look for future NAHC report articles as we learn more.