In addition to homebound status, skilled need, and under the care of a physician, Medicare Home Health Benefit Eligibility must also include a face-to-face encounter within 90 days before to 30 days after the start of care.
The documentation requirements for the face-to-face (F2F) encounter changed for episodes beginning on or after January 1, 2015, eliminating the physician narrative except for when the qualifying service is skilled nursing for the management and evaluation of a care plan. All episodes beginning December 31, 2014 and before still need a physician narrative. F2F is only required for certification, not recertification . . . unless you have a significant change in the principal diagnosis. A new F2F will be needed stating the reason for home health services.
CMS is attempting to reduce fraud and abuse cases, where patients were kept in home health for extended periods of time without seeing their physicians. However, this has caused both physicians and home health agencies to assume a heavy administrative burden. Although the physician narrative is no longer required, the physician’s medical record must include information that justifies the referral for Medicare home health services.
The documentation must include:
- Need for the skilled services.
- Homebound status (this is the item missing most often).
- The actual clinical note for the F2F encounter visit that demonstrates that the encounter occurred within the required time frame.
- The encounter was related to the primary reason the patient requires home health services.
- The encounter was performed by an allowed provider type (MD/DO/NP/PA).
It is recommended that a trained home health clinician review all F2F documentation to assure that all necessary information has been provided.
Palmetto has denied $26.1 million of the $39.5 million in claims involving one HIPPS code – 80% of them due to F2F. Between July 1, 2014 and December 31, 2014, CGS denied 1,176 of 1,377 claims it reviewed as part of its edits involving F2F documentation. Conversely, the OIG stated that 32% of home health claims did not have the requisite or complete F2F documentation, resulting in $2 billion in payments that should not have been made.
CMS has provided only a little and very basic education to physicians regarding F2F. If a home health claim has been denied for inadequate F2F documentation, the physician’s claim for Care Plan Oversight will be denied as well. The link to “Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services” is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9119.pdf
On a related topic, effective May 11, 2015 for recertification, the physician must include an estimate of how much longer the skilled services will be required. This requirement has been in the regulation for many years but has never been incorporated into the Medicare manual until now. It is unclear whether the estimated duration for services can be stated as a physician order or must be included in the recertification statement. NAHC is seeking clarification on this issue.
As of this writing, NAHC’s lawsuit against CMS related to F2F is continuing. The allegations:
- Excess documentation required – ACA requirements only state that the physician must certify that a F2F encounter occurred and does not include all the additional requirements CMS has imposed.
- Failure to provide adequate and clear guidance on acceptable documentation.
- Failure to review the entire medical records for denials.
NAHC has many supporters in this lawsuit – members of Congress, disability rights groups, and state Medicaid programs. For more information, go to http://www.nahc.org.