Earlier this month, CMS held a Special Open Door Forum for the voluntary electronic and paper clinical template for the home health Face-to-Face (F2F) encounter document. During this call, a presenter provided inaccurate information regarding what would be acceptable documentation within the physician’s medical record to support home health eligibility.
Several participants questioned the presenters about the CMS policy that allows a physician to sign information from an agency’s assessment and incorporate it into his or her medical record to support eligibility. CMS answered by comparing agency documentation to consultation notes that may be found in a physician’s record, saying that CMS does not actually consider these documents to be a 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. However, this interpretation goes against what CMS has spelled out in the final rule for home health prospective payment system (HHPPS) rate update.
NAHC contacted CMS requesting clarification of this matter. On March 24, CMS released the following statement:
“In reviewing the transcript, CMS realizes that inaccurate information was provided related to HHA documentation to support certification for home health services. Per 42CFR 424.22 (a) and (c), the patient’s medical record must support the certification of eligibility and 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 and signed off by the certifying physician. More guidance will follow regarding the review of home health claims shortly. CMS apologizes for the confusion.”
When CMS refers to the certifying physician, they are referring to the physician who is certifying that the patient is eligible for home health services. There are five things the physician certifies to:
The home health services are or were needed because the patient is homebound.
The patient needs or needed skilled services on an intermittent basis.
A plan of care has been established and is periodically reviewed by a physician.
The services are or were furnished while the patient is or was under the care of a physician.
The patient had a face-to-face encounter within the prescribe time frame, was related to the primary reason for home health services, and was conducted by a physician or allowed non-physician practitioner (NPP).
A physician who is not signing the POC is permitted to certify the patient only when the patient has been cared for by a physician in an acute or post-acute facility. Therefore, it is possible for the physician in the facility to conduct and complete the F2F encounter documentation and certify the patient without signing the POC. The facility physician may also choose to complete the encounter documentation and not certify the patient (does not complete all five elements of the certification). The facility physician would send the encounter findings to the physician in the community to complete the certification and sign the POC.
In the final rule for the 2015 home health prospective payment rate update, CMS revised the face-to-face (F2F) encounter requirements for physician certification for home health services. CMS has eliminated the narrative requirement but will still require that the F2F encounter occurred no more than 90 days prior to the start of home health care or within 30 days of the start of the home health care, and be performed by a physician or allowed non-physician practitioner (NPP).
CMS has also altered its medical review process for determining patient eligibility for home health services. CMS will now request the agency’s medical record when additional documentation is requested, and will also look for evidence that supports eligibility for home health services from the physician’s medical record.
CMS says it has eliminated the narrative requirement to simplify the F2F encounter regulations and reduce burdens for agencies and physicians. However, NAHC believes CMS’ revisions have only made the F2F requirements even more burdensome. NAHC is still in communication with CMS regarding F2F and how agencies are expected to operationalize the new aspects of the requirement. Based on information NAHC has gathered so far, NAHC offers a number of recommendations.
Yesterday, the federal district court issued a victory for the National Association for Home Care & Hospice (NAHC) and the home health agencies, Medicare participating physicians, caregivers, and beneficiaries it represents. The U.S. District Court for the District of Columbia declared that it has the power to hear a challenge to the validity of a Medicare rule that requires physicians to provide a narrative explaining why the patient meets Medicare coverage standards for home health services. The court issued the order to deny Medicare’s effort to have the lawsuit dismissed by the court.
The court also granted dismissal of two additional claims in the lawsuit. NAHC challenged the ambiguity of the interpretive guidance issued by CMS along with its failure to waive the recoupment of alleged overpayments under the Medicare “without fault” provision. The court found that the factual complexities warranted a review of individual claims determinations at the administrative levels prior any judicial intervention.
NAHC and Medicare are now moving forward with the lawsuit. If the lawsuit is successful, Medicare will be required to reopen and pay any claim previously denied for an insufficient narrative and stop any further claim reviews related to the narrative requirement. NAHC has urged home health agencies to consider appealing any narrative-related claim denials while the lawsuit is progressing. This will give agencies the opportunity to have the claims reviewed by the Administrative Law Judges and will also allow for easy identification of claims that may be subject to reopening if the lawsuit is successful.
On July 1, CMS issued a proposed rule that includes the annual payment rate update along with positive changes to the documentation requirements in the face-to-face physician encounter requirements (F2F). Click here to see our recent post about the Physician F2F Encounter rule modifications.
The proposed rule also includes:
2015 Home Health Prospective Payment System rates
Significant change to the requirement for professional therapy reassessments
A new standard for the submission of OASIS to avoid payment rate reductions
Modifications of the standards for qualification of speech-language pathologists under the CoPs
The introduction of possible new coverage standards on the administration of insulin injections
The unveiling of a likely model for Value Based Purchasing
Clarifications of the requirements for imposition of alternative Civil Money Penalty sanctions for CoP violations
Changes to recertification requirements
Click here for detailed info on the proposed rule from NAHC
In a policy change that is included in a proposed Medicare payment rule for home health agencies for 2015, CMS has decided to drop the narrative requirement for home health claims. The Patient Protection and Affordable Care Act requires that a Medicare beneficiary have a face-to-face encounter with a physician before the physician can certify that the patient is homebound and in need of skilled care. CMS also required that the physician provide a detailed narrative explaining the patient’s circumstances. Because home health providers saw an increase in retroactive denials of claims based on inadequate narratives supporting the services, CMS has noted in a draft rule issued yesterday that it will eliminate it to simplify the face-to-face encounter regulations. However, physicians would still be required to document the encounter to certify a patient’s eligibility.
*Note: In our experience, we have found that there is often not a lot of information to support a patient’s homebound status in the medical record. CMS will still be looking for the certifying doctor’s medical records (office notes or hospital/SNF records) to see if they support the patient’s HB status and R&N of the ordered service or the face-to-face certification could still be found to be inadequate.
Home health agencies must ensure the Face-To-Face is completed correctly. This may mean repeatedly requesting that the certifying physician add or correct information on the Face-To-Face
Home health agencies cannot bill for their services without a completed Face-To-Face Encounter document
*Hint: In an effort to avoid repeated corrections to certifications and Face-To-Face Encounter documents, share all educational materials with the physicians facilities that frequently utilize your home health agency.