face-to-face and cr 9119three changes to face-to-face requirements . 1. cms eliminated the narrative...

Face-to-Face and CR 9119 Ask-the-Contractor Teleconference June 24, 2015

Home Health Coverage Resources CMS “Medicare Benefit Policy Manual” (CMS Pub. 100-02)

Chapter 7; Home Health http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

Medicare Benefit Policy Manual

Chapter 7 - Home Health Services

Table of Contents

(Rev. 208, 05-11-15)

July 21, 2015 © 2015 Copyright, CGS Administrators, LLC. 2

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

Home Health Coverage Resources CGS “Home Health Coverage Guidelines” Web page http://www.cgsmedicare.com/hhh/coverage/Home_Health_Cove

rage_Guidelines.html


http://www.cgsmedicare.com/hhh/coverage/Home_Health_Coverage_Guidelines.html

http://www.cgsmedicare.com/hhh/coverage/Home_Health_Coverage_Guidelines.html

Change Request (CR) 9119


CR 9119 “Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services”

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9119.pdf





CR 9119 CMS Manual System; Pub 100-01 Medicare General Information, Eligibility, and Entitlement; Change Request 9119

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R92GI.pdf




CR 9119 CMS Manual System; Pub 100-02 Medicare Benefit Policy; Change Request 9119

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R207BP.pdf


CR 9119

Three Changes to Face-to-Face Requirements

1. CMS eliminated the narrative requirements

2. If HHA claim is denied, the certifying/recertifying physician claim is noncovered. • Because there would be no corresponding claim

3. Clarification that the face-to-face (FTF) encounter is required for certifications; rather the initial episodes

• New FTF for every completed start of care OASIS assessment


CR 9119: Supporting Documentation

Per 100-02 Ch. 7 section 30.5.1.2, for SOC effective January 1, 2015, documentation in certifying physician’s medical record and/or acute/post-acute care facility’s medical record:

Will be used as basis for patient’s home health eligibility

Must contain information to justify the referral for home health services including:

• Need for skilled services; and

• Homebound status



Per 100-02 Ch. 7 section 30.5.1.2, for SOC effective January 1, 2015, documentation in certifying physician’s medical record and/or acute/post-acute care facility’s medical record:

Must be provided to home health agency when requested


CR 9119: Supporting Documentation • Change Request 9112, “Clarification of Ordering and Certifying

Documentation Maintenance Requirements”,

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9112.pdf




Per 100-02 Ch. 7 section 30.5.1.2, certifying physician and/or acute/post-acute facility medical record (if the patient was directly admitted to home health) for the patient must contain the actual clinical note for the FTF encounter visit that demonstrates that the encounter: Occurred within required timeframe;

Was related to primary reason patient requires home health services; and

Was performed by an allowed provider type.



CR 9119: Supporting Documentation Information from home health associations (HHAs), such as initial and/or comprehensive assessment of the patient, can be incorporated into certifying physician’s medical record for the patient and used to support patient’s homebound status and need for skilled care

HHA’s documentation must be signed/dated by certifying physician

to indicate acceptance of documentation into their medical records

Physician’s dated signature must be on/before the date of the physician’s certification


Physician Certification


The physician certification must include:

1. Patient is confined to home

2. Patient needs skilled services 3. Plan of care has been established and is periodically reviewed by physician 4. Patient is under care of a physician



I certify/recertify that this patient is confined to his/her home and

needs intermittent skilled nursing care, physical therapy

and/or speech therapy or continues to need occupational

therapy. The patient is under my care, and I authorized services

on this plan of care and will periodically review the plan.



The physician certification must be completed prior to billing.

The physician should complete the certification when the plan of care

is established, or as soon as possible thereafter.

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c07.pdf

(Pub 100-02; Chapter 7; Section 30.5.1)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

CR 9119: Supporting Documentation Information from the HHA incorporated into the physician’s medical

record must not conflict with other medical record entries in certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient

• Information submitted & incorporated from HHAs must be received

timely to ensure certifying physician has all relevant information when making decision to certify/recertify the patient

• The certifying physician (or allowed non-physician provider) must have a face-to-face encounter with the beneficiary before they certify the beneficiary's eligibility


CR 9119: Physician Recertification

New requirement: The physician must include an estimate of how much longer skilled services will be required. This estimate may be longer than the benefit period The ordered frequency (on the 485) CANNOT be used as the

physician’s estimate Note: A recertification that does not include this information may

result in a claim denial


CR 9119

Scenario #1 Patient discharged from acute/post-acute facility directly to home health services

The hospitalist is seeing patient while in the hospital


CR 9119

Scenario #2 Patient admitted to home health, not resulting from acute/post-acute discharge

Community physician is seeing patient in physician’s office with no hospitalization


CR 9119 Scenario #1: Patient discharged from acute/post-acute facility directly to home health services Hospitalist sees patient & performs FTF encounter

Community physician will follow patient after discharge and certifies HH services • HH criteria requires patient to be under care of physician

• Certifying physician must document the date of the FTF encounter

• NOTE: If hospitalist performs FTF encounter and also certifies patient for home health, the hospitalist must identify the community physician who will follow the patient


CR 9119 Scenario #2: Patient admitted to home health, not resulting

from acute/post-acute discharge

Community physician has in-person visit (FTF) with patient 90 days before or 30 days after 1st HHA visit (and the in-person visit is related to the reason for home health services)

Documents FTF encounter in medical record, and certifies patient’s eligibility for home health by the physician certification


MLN Matters® SE1436

“Certifying Patients for the Medicare Home Health Benefit” SE1436.

Important information plus document examples

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1436.pdf



















Face-to-Face Documents

To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and: 1. Be confined to the home;

2. Need skilled services;

3. Be under the care of a physician;

4. Receive services under a plan of care established and reviewed by a physician; and

5. Have a face-to-face encounter performed by: Certifying physician (must be Medicare enrolled) Non-physician practitioner (NPP) in collaboration with the

certifying physician

Physician who cared for the patient in an acute/post-acute facility during a recent stay and has privileges in that facility


Face-to-Face Documents

Information from the HHA can be incorporated into the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.

Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.

The certifying physician must review and sign off on anything incorporated into the patient’s medical record that is used to support the certification of patient eligibility.


When? Certifying physician must document FTF took place within 90 days prior to start of care (SOC), or

30 days after SOC

Reminder: FTF must be related to primary reason for home health admission

Exceptional circumstance: Patient death before FTF can be performed


Face-to-Face

The physician who cared for the patient in an acute or post-acute facility may choose to use documentation from the patient’s medical record, (such as a discharge summary) to inform the certifying physician of the clinical findings from the face-to-face encounter.

IF The compiled documentation is reflective of the clinical findings of the face-to-face encounter

AND

Serves as that physician’s communication to the certifying physician July 21, 2015 © 2015 Copyright, CGS Administrators, LLC. 33

Face-to-Face Signatures

The document from the acute or post-acute facility record

Must be signed and dated by the certifying physician,

Must indicate the certifying physician received the information from

the physician who performed the face-to-face encounter, and

Must show the certifying physician is using that documentation as

his/her documentation of the face-to-face encounter


Documentation

Does the documentation clearly answer “why home health and why now?”

Reminder: Good documentation should address: Objective clinical evidence of patient’s individual need for care

Progress or lack of progress

Medical condition

Functional losses


Examples of FTF Documentation “Don’ts” Insufficient documentation – Miscellaneous

The following may cause a claim to NOT BE PAID: Diagnoses/clinical findings on FTF not related to home care ordered

Altered documentation without acceptable notations for changes

FTF signed by Non Physician Practitioner (NPP) only

No date of FTF encounter

Not clearly titled as face-to-face encounter


FTF Documentation: Important Reminders FTF is requirement for Medicare payment

Missing/incomplete documentation results in entire claim being denied

As the billing entity, the home health agency’s (HHA’s) responsibilities include: Facilitating and coordinating between patient and physician to

ensure FTF occurs timely

Ensuring all FTF requirements are met

Ensuring physician’s documentation is complete

Delaying submission of claim until documentation complete


Medical Necessity

All services (even skilled) must be reasonable and medically necessary related to the patient’s condition. Does the documentation clearly answer “why home health and why now?”

Reminder: Good documentation should address: Objective clinical evidence of patient’s individual need for care

Progress or lack of progress

Medical condition

Functional losses

Treatment goals

Discharge planning


Medical Necessity

Covers all disciplines

Nursing

Physical therapy

Occupational therapy

Speech language pathology


Medical Necessity Additional information http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guid

elines/1E.html


http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1E.html

http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1E.html

Medical Necessity - “Do’s”

Identify skilled service, and reason skilled service is necessary for beneficiary in objective terms

Examples of good documentation:

“Wound care completed per POC to left great toe. No s/s of

infection, but patient remains at risk due to diabetic status.”

“Range of motion (ROM) is tolerated to lower extremities. Unsafe to teach caregiver ROM due to displaced fracture.”


Medical Necessity – “Do’s”

Demonstrate medical necessity of skilled observation and assessment by documenting complexity of beneficiary’s condition and co-morbidities affecting outcomes.

Examples of good documentation:

“Lungs sound coarse throughout. Patient finished antibiotic therapy today for pneumonia, and seeing pulmonologist tomorrow for follow up to due to COPD and emphysema.”

“Stasis wound on LLE continues to show 50% granulation and moderate serous drainage. Instructed patient on need to elevate legs and exercises related to peripheral vascular disease.”


Medical Necessity – “Don’ts”

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, §40.1 and §40.2 lists requirements in order for a service to be covered by Medicare as “skilled.” The service must:

Require the skills of a nurse or qualified therapist

• Service is NOT skilled because it is performed by a nurse or qualified therapist

• Service does NOT become unskilled because it is taught

Be reasonable and necessary to treat patient’s illness or injury

• Patient’s condition warrants the skilled care

• MUST BE evident in documentation


Homebound Criteria http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1C.html


http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1C.html

http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1C.html

Homebound Criteria http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8444.pdf





Homebound Criteria MLN Matters Home Health – Clarification to Benefit Policy Manual Language on “Confined to the Home” Definition

Clarifies definition of patient being “confined to home”

Reflects definition in Social Security Act (Section 1835(a))

Removes vague terms to ensure clear and specific definition

Not a change in homebound definition


Homebound Criteria Two criteria are used to determine homebound status

Criteria-One:

The patient must either: Because of illness or injury, need the aid of supportive devices such

as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.

OR Have a condition such that leaving his or her home is medically

contraindicated.


Homebound Criteria Two criteria are used to determine homebound status (continued)

Criteria-Two:

There must exist a normal inability to leave home

AND Leaving home must require a considerable and taxing effort


Homebound Criteria

The patient may be considered homebound (confined to the home) if absences from the home are:

infrequent; for periods of relatively short duration;

for the need to receive health care treatment;

for religious services;

to attend adult daycare programs; or

for other unique or infrequent events

the patient may have more than one home

• vacation home, home of caregiver, seasonal home


Homebound Criteria

Documentation must support homebound status throughout

Beware of vague descriptions: “taxing effort”, “unable to leave home”

Utilize objective, measurable language Examples of good documentation: “After ambulating 20 feet, patient has increased dyspnea and

complains of back pain.”

“Patient has unsteady gait, and must sit to rest after 20 feet of ambulation due to uncontrolled dyspnea.”


CGS Home Health Denial Fact Sheets http://www.cgsmedicare.com/hhh/education/materials/HH_QRT.html


http://www.cgsmedicare.com/hhh/education/materials/HH_QRT.html

http://www.cgsmedicare.com/hhh/education/materials/HH_QRT.html

CGS Home Health Denial Fact Sheets 5HHBD – Homebound Status http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhbd_factsheet.pdf


http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhbd_factsheet.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhbd_factsheet.pdf

CGS Home Health Denial Fact Sheets 5HMED – Medical Necessity http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HMED_FactSheet.pdf


http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HMED_FactSheet.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HMED_FactSheet.pdf

2015 MAC Satisfaction Indicator (MSI) Survey

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