Tips for Getting Through the Second Round of Probe and Educate
May 27, 2016 11:07 AM
Well known to home health providers is that the first round of Probe and Educate has produced high denial rates related to the face to face (F2F) encounter requirement. The National Association for Home Care & Hospice (NAHC) has discovered that one area that has been particularly tripping up agencies is the F2F “encounter documentation form.” Many agencies developed such a form in order to comply with the F2F encounter regulations applicable prior to 1/1/2015 when a narrative describing the reason for homebound and skilled services was required. Although these forms are no longer necessary, many agencies continue to use them. If agencies continue to use an “encounter documentation form,” it is important to understand how the form should be used in the context of the new F2F encounter requirements.
One issue connected to use of the “encounter documentation form” is that some agencies mistakenly believe this form is the F2F encounter note. For Medical Review, the agency must be able to produce an actual F2F encounter note or discharge summary that includes the date of the encounter, is related to the primary reason for home health services, and has been completed by an allowed practitioner (non- physician practitioner (NPP) or physician). There is no requirement for the note itself to include the reason for homebound or the need for skilled services. If the visit note does not include documentation to support homebound and skilled services, the physician’s medical record will be reviewed for information that supports eligibility for home health services.
Another issue that arises concerning the use of this “form” is when the patient is admitted to home health from an inpatient stay and the facility physician completes an “encounter documentation form.” When a patient is admitted to home health from an inpatient stay, the facility physician is permitted to be the certifying physician IF the facility physician certifies to all five elements for certification (F2F encounter and date, homebound, in need of skilled services, under the care of a physician, and plan of care has been established), and also identifies the physician who will be following the patient in the community; if the facility physician will not continue to follow the patient after discharge.
When an “encounter documentation form” is used, the physician typically is not certifying to all the elements required for certification. Many of these “forms” leave the facility physician certifying only to the F2F encounter requirements. The agency then has the community physician sign the plan of care (POC) with a certification statement that certifies to the other four elements for certification, but not the F2F encounter requirements.
Home health agencies should note that the certification MAY NOT BE SPLIT between the facility physician and the community physician. This seems to be occurring when the facility physician conducts the encounter and completes an “encounter documentation form” while the community physician signs the plan of care (POC) and certification.
If the facility physician does not attests to all five elements of the certification and identify the physician who will be following the patient in the community, the agency will need to look to the community physician to be the certifying physician. The community (certifying) physician must attest to all five elements of the certification.
Therefore, if the agency determines that the community physician will serve as the certifying physician, the agency must ensure the physician includes, as part of the certification, an attestation that the F2F encounter occurred and the date of the encounter that the encounter was related to the primary reason for home health, and was conducted by an allowed practitioner. Ideally, the F2F encounter attestation should be included as part of the existing certification statement or included on the same document as the certification statement. The community physician does not need to conduct another encounter. The actual encounter note or discharge summary from the facility physician may be used to support the community physician’s attestation.
In addition to the technical requirements for a complete certification, a review of the physician’s medical record documentation to support eligibility for home health services will undoubtedly cause problems for agencies. NAHC continues to recommend that agencies, as part of their admission process, submit a summary of the agency’s findings that supports the reason for homebound and need for skilled services, along with pertinent sections of the assessment to the certifying physician to sign and incorporate into his/her medical record. Agencies should also send to medical review any information from the inpatient record that supports home health eligibility as well (such as therapy evaluations and progress notes).
Medicare Program Integrity Manual, Chapter 6, 6.2.1 - Physician Certification of Patient Eligibility for the Medicare Home Health Benefit
“Home health agencies (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 for certification and recertification has been met and must be able to provide it to CMS and its review entities upon request”
A guide has been developed to assist agencies in determining if the certification requirements have been met when either the facility or community physician is the certifying physician.
NAHC continues to seek information related to F2F encounter denials agencies are receiving during this first stage of the Probe and Educate program. We are looking for examples of denial reasons along with the medical records sent to the contractors in response to the ADRs. We are also very interested in the specifics regarding the education agencies are receiving from the Medicare contractors during the Probe and Educate.
We are seeking:
The reason for the denial as issued to agency by the contractor.
Medical records sent to the contractor for review.
Information on the contractor’s education received by the agency, such as notes or presentations provided by the contractor, or notes taken by the agency on the education provided by the contractor.
Evidence that disputes the findings by the contractor.
Any denials overturned on appeal.
Please send information to email@example.com.
We understand that we are requesting a lot of information but it will be a great help in making the case to CMS that the F2F requirement is actually worse with the revisions. It will also help us understand what exactly the contractors are telling providers in terms of compliance with the F2F requirement.