CMS Issues Instructions for Medical Review on Home Health Certifications
July 22, 2015 12:50 PM
The Centers for Medicare & Medicaid Services (CMS ) released Transmittal 602; Change Request (CR) 9189, which provides medical review instructions on the certification and recertification requirements for home health services.
The CR instructs reviewers that the physician’s entire medical record should be reviewed to determine if the eligibility criteria for home health services have been met. The physician’s record must include information that supports all the required elements for certification including the need for skilled service, reason for homebound, and a valid face to face (F2F) encounter. The CR affirms that documentation from the home health agency (HHA) can be incorporated into the physician’s record and is to be considered when determining eligibility for home health services:
“….. the patient’s medical record must support the certification of eligibility. Documentation in the patient’s medical record shall be used as a basis for certification of home health eligibility. Therefore, reviewers will consider HHA documentation if it is incorporated into the patient’s medical record held by the certifying physician and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) and signed off by the certifying physician. The documentation does not need to be on a special form.”
Any documentation from the HHA that is incorporated into the physician’s record must corroborate the physician’s medical record for the patient and be “signed off” by the physician in a timely manner.
“The reviewer shall consider all documentation from the HHA that has been signed off in a timely manner and incorporated into the physician/hospital record when making its coverage determination. HHA documentation that is used to support the home health certification is considered to be incorporated timely when it is signed off prior to or at the time of claim submission.”
The CR contains an inconsistent definition for “incorporated timely.” Business Section- 9189.4 of the CR states that timely incorporation is when the documentation is “signed off” prior to or at the time of certification. However, in the body of the CR under section 6.2.3, it reads that “incorporated timely” is when the documentation is “signed off” prior to or at the time of claim submission. CMS has clarified for the National Association for Home Care & Hospice (NAHC) that timely incorporation is prior to or at the time of claim submission. CMS will revise the Business Requirement section to reflect section 6.2.3.
CMS will require that the initial certification requirements be met in order for subsequent episodes to be covered, regardless of whether the requirements for recertification are met. Therefore, agencies will be required to submit documentation from physician’s record for the initial certification for home health services for any claim that is reviewed.
According to the CR, if the review contractor finds that the documentation in the certifying physician’s medical record, including the HHAs incorporated documentation, is insufficient to demonstrate the patient is or was eligible to receive services under the Medicare home health benefit, payment on the home health claim will be denied.
CMS, in the CR, also states the requirements for recertification and reiterates that a recertification for home health services must include a statement by the certifying physician which indicates a continuing need for services and estimate how much longer the services will be required. NAHC was hopeful that CMS would allow the duration for services as ordered by the physician to meet this requirement. However, it is apparent from the CR that CMS intends to require a statement from the physician in addition to orders for visit frequency and duration.
Several of the Medicare contractors have instructed agencies that the physician should estimate how much longer services will be needed for the entire spell of illness for the patient. Therefore, the estimated time frame could be stated longer than the 60 day recertification period. Since this is a physician’s estimate, the agency must obtain the information from the physician, but it can be an oral communication. CMS does not provide instructions to reviewers on how or where this statement needs to be located. The CR only states that “The contractor shall review for the certifying physician statement which must indicate the continuing need for services and estimate how much longer the services will be required.” NAHC recommends that agencies either incorporate a statement within the certification statement for recertification or include a separate statement in the medical documentation where it is obvious to the reviewer, such as on the plan of care.
However the agency chooses to address this, it should be clear that it is part of the certification for continued services. If using a statement separate from the certification statement, NAHC recommends that agencies phrase the physician’s estimation for services as a certification statement. For example: “I certify that in my estimation continued services will be required for _______.” A statement for the estimation of services is required for each recertification regardless of how long the physician expects home health services will be needed.
NAHC also recommends that agencies provide as much information as possible to the certifying physician to be incorporated into his/her medical record. At a minimum, agencies should provide the certifying physician with the POC and pertinent sections from the comprehensive assessment, along with an admission summary of the why the patient is in need of skilled services and is homebound. Agencies should also confirm that a face-to-face encounter has occurred within the required time frame. (See previous NAHC Report article on this topic here).
NAHC is concerned that CMS will be making initial coverage determinations based solely on the certification requirements contained in the physician’s record, similar to when the narrative was required for the F2F encounter requirement. CMS will not likely make determinations for reasonable and necessary care based on the agency’s medical record unless the certification requirements have been met.
Click hereto view the CR.