CMS Holds F2F Open Door Forum that Leaves More Questions than Answers
March 17, 2015 04:36 PM
On March 11, the Centers for Medicare & Medicaid Services (CMS) held the second in a series of Open Door Forums (ODF) for the voluntary electronic and paper clinical template for the home health Face to Face (F2F) encounter requirement. On the call were CMS officials from the Provider Compliance Group and the Medical Director for Strategic Health Solutions, a CMS Supplemental Medicare Review Contractor.
The formal portion of the presentation was brief with an overview of the documentation that could be requested for medical review. In addition, CMS presented two schematics as examples of workflows for the F2F encounter documentation. One workflow addressed the example of a community physician seeing a patient; the other addressed the example of a hospitalist conducting the encounter in the hospital.
Lastly, CMS presented its revised electronic and paper templates. The electronic template is an improvement in that it includes more checkboxes, less narrative and has been condensed from five to three pages. However, the paper template went from a combination of checkboxes and narratives to a form that requires all narrative responses. This appears to contradict what participants on the last ODF call clearly expressed—a desire for a paper clinical template that contained more predetermined language with checkboxes.
The presenter highlighted that, when determining compliance with the F2F encounter, the medical reviewers would look for the physician or practitioner’s documentation of the in-person visit, the need for skilled services, and homebound status in the physician’s record. The presenters did not specifically elaborate on what documentation within the physician’s medical record, such as information from the home health agency’s assessment findings, would be acceptable to support a patient’s eligibility for home health services.
During the question and answer session, several of the participants questioned the presenters about CMS’ policy that allows a physician to sign information from an agency’s assessment and incorporate it into his/her medical record to support eligibility. The CMS representative responded by comparing agency documentation to consultation notes that might be found in a physician’s record, concluding that CMS does not actually consider these documents to be part of the physician’s record, since they are not generated by that physician. CMS indicated it would only look for documentation the physician generated to support home health eligibility.
This interpretation is in conflict with what CMS clearly spelled out in the final rule for home health prospective payment system (HHPPS) rate update.
“…….. it would be 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. However, 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/re-certification 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, including the diagnoses and the patient’s condition reported on the comprehensive assessment.”
In addition to the stated policy in the final rule, CMS hosted a National Provider Call on the F2F encounter requirement, in which presenters from the Medicare Chronic Care Policy Group provided a documentation example of when it would be acceptable for an agency to provide information from its assessment for the physician to use in conjunction with the physician’s documentation to support home health eligibility.
The following is an excerpt from the transcript of the National Provider Call - Certifying Patients for the Medicare Home Health Benefit on December 16, 2014:
“This section from the home health agency, which has been incorporated into the physician’s record, has been signed and dated by the patient’s physician”…….. “it’s been signed and dated by certifying physician indicating review and incorporation into the patient’s medical record.”
The two together, the section from a comprehensive assessment done by the home health agency and the physician’s discharge summary, corroborate each other. The two fit together.
The discharge summary states that PT is needed to restore the ability to walk without support. And the section from the home health agency’s comprehensive assessment describes the supportive device, a wheeled walker. They both corroborate the patient’s clinical needs and why the patient is homebound.”
In addition to providing conflicting information, the presenters seemed to be unaware that CMS had previously issued other polices related to the F2F encounter. There was also confusion over whether a discharge planner or a physician support staff could compile a discharge summary for the physician to sign and use as the documentation of the F2F encounter, or whether the community physician could only cosign a F2F encounter note from the physician who conducted the encounter in a facility.
One bright spot on the call was when CMS stated it would allow a physician to document the F2F encounter using an electronic or paper template that included predetermined language with checkboxes.
The call raised concerns and confusion among the home health industry due to the conflicting information from different groups at CMS. It appears there is inadequate coordination between the policy division and the medical review division.
The National Association for Home Care & Hospice has contacted both the payment policy and the medical review divisions at CMS seeking clarification and guidance. We will keep our members updated as we learn more.