CMS Issues Home Health Coverage Manual Updates
May 7, 2015 02:08 PM
The Centers for Medicare & Medicaid Services issued Change Request (CR) 9119, which updates the Medicare Benefit Policy Manual, chapter 7, relating the requirements for physician certification and recertification. This CR also updates the timeframe required for therapy functional reassessments. All of the new provisions in the manual were discussed in the 2015 HH PPS Final Rule published on November 6, 2014. However, the CR leaves questions for providers regarding CMS’ expectation for implementing some of the new provisions. The National Association for Home Care & Hospice (NAHC) is seeking answers from CMS.
CMS reiterates it has eliminated the narrative requirement from the face to face (F2F) encounter document. However, the certifying physician is still required to certify that a F2F patient encounter occurred. The encounter document must include the date of the encounter, be related to the primary reason the patient requires home health services, and performed by an allowed provider type.
In the manual revision, CMS affirms a new requirement for documentation that was stated in the 2015 HH PPS Final Rule. When the patient is admitted to home health directly after discharge from an acute/post-acute care setting and the physician that cared for the patient in that setting is the certifying physician, but will not be following the patient after discharge, the certifying physician must identify the community physician who will be following the patient. CMS claims the addition documentation is needed in order for the certifying physician to meet the requirement that the patient be under the care of a physician. NAHC is seeking clarification from CMS regarding whether there is specific a format or location within the medical record this information must be located.
CMS maintains its policy thatthe certification must be completed prior to the home health agency bills Medicare; however, they also reiterate that it is not acceptable for HHAs to wait until the end of a 60-day episode of care to obtain a completed certification/recertification. CMS does not address good faith efforts made by the agency to obtain the certification and what the implications are for agencies if they are not able to obtain the certification until the “end” the episode.
The certifying physician’s medical record and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) is to be used as the basis for certification of patient eligibility. CMS includes in the manual update a provision from the Final Rule that permits the agency to provide the certifying physician with information from their assessment of the patient, for which the physician would sign and incorporate into his/her medical record. This information may be used to support the patient’s eligibility for home health services. However, the information must be corroborated by other medical record entries in the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.
Included in the manual update, which was also stated in the Final Rule, is the requirement from the regulation at §424.22 (b)(2) for home health recertification. The regulation states the physician’s “recertification statement must indicate the continuing need for services and estimate how much longer the services will be required”. This requirement has been in the regulation for many years but has never been incorporated into the Medicare manual. CMS’ policy for this portion of the regulation is stated in the manual as follows:
The physician must include an estimate of how much longer the skilled services will be required and must certify (attest) that:
The home health services are or were needed because the patient is or was confined to the home as defined in §30.1;
The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §18.104.22.168), the physician must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification;
A plan of care has been established and is periodically reviewed by a physician; and
The services are or were furnished while the patient is or was under the care of a physician. Medicare does not limit the number of continuous episode recertifications for beneficiaries who continue
Therefore, it is unclear whether the estimated duration for services can be stated as a physician order or must it be included in the recertification statement. NAHC is seeking clarification on this issue as well.
Finally, CMS updates the manual to reflect the change in policy for the therapy function reassessments timeframes to at least every 30 day, eliminating the 13/19th therapy visit threshold reassessments.
NAHC has expressed to CMS that agencies are genuinely trying to ensure they have adequate processes in place to comply with the F2F requirement. However, confusion and concerns remain surrounding CMS’ expectations. NAHC continues to seek clarification from CMS on the home health certification and recertification requirements.
Click here to view CR 9119