face-to-face f2f · § answer: if the f2f does not occur within 90 days prior to or within 30 days...

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home health 1 FACE-TO-FACE (F2F) A Retrospective Review

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  • home health

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    FACE-TO-FACE (F2F) A Retrospective Review

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    OBJECTIVES: §  Attendees will be able to verbalize the components of the F2F §  Attendees will recognize who may complete the F2F §  Attendees will recognize documentation strategies for the F2F §  Attendees will be able to prepare a MCR compliant F2F statement

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    1.  Be confined to the home 2.  Under the care of a physician 3.  Services are provided under a plan of care established and periodically reviewed by

    a physician

    4.  Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy

    5.  Have a documented F2F encounter with physician or allowed non-physician practitioner (NPP)

    Certifying physician must certify that Medicare HH eligibility has been met to include the following:

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    F2F OVERVIEW §  Mandated by the Affordable Care Act (2010) §  Required for SOC home health certifications on or after Jan. 1, 2011 §  F2F is condition of payment, NOT a condition of participation

    •  Agency can be denied payment even if all other conditions are met

    §  The F2F requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

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    Nomorethan90daysprior Within30days

    of

    SOC

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    If the F2F encounter occurs within 90 days of SOC BUT is not related to the primary reason for home health, there must be another F2F encounter within 30 days after the SOC

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    EXCEPTIONS TO THE F2F REQUIREMENT §  If a home health patient dies shortly after admission before the F2F encounter occurs

    and it can be determined a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete

    §  DOCUMENT, DOCUMENT, DOCUMENT!!!

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    REQUIRED COMPONENTS OF THE F2F §  Documentation of the name of the MD or NPP who saw the patient and the date of the

    encounter

    §  Clinical condition that supports homebound status §  Need for skilled services

    •  Supports primary reason the patient required home health

    §  Reason for home health referral §  MD name, signature and date §  Items must come directly from MD

    Additional items may be located throughout the medical record, but must be clearly identifiable

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    DOCUMENTATION REQUIREMENTS §  F2F information must be based on MD medical records and/or acute/post-acute care

    facility’s medical records

    §  MD or facility medical record must include the actual clinical note for the F2F encounter visit that supports the required components

    §  Information from the HH records can be incorporated into the certifying physician’s medical record and be used to support homebound status and need for skilled care •  Cannot be used as the sole basis to support HH and must corroborate other MD or facility

    records

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    EXAMPLES OF APPROPRIATE DOCUMENTS §  Discharge summary §  MD office visit note §  Progress note from acute/post-acute facility §  Note on MD letterhead summarizing the required information §  Clinical summary §  Admission summary §  History & Physical

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    EXAMPLES OF INADEQUATE DOCUMENTATION •  Diagnosis list alone •  Recent procedures alone •  Recent injuries alone •  Generic statement without specific clinical finding to indicate what makes the patient

    homebound: •  “taxing effort to leave home” •  “gait abnormality” •  “weakness/muscle weakness”

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    WHO MAY COMPLETE THE F2F? §  Certifying physician §  Physician who cared for patient in acute/post-acute facility §  Nurse practitioner §  Clinical Nurse Specialist §  Certified nurse-midwife §  Physician Assistant

    *But remember, only an MD (doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license) can order home health and sign the Plan of Care*

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    The entity performing the F2F encounter CANNOT be employed by or have a financial relationship with the HH agency as defined by 42CFR 424.22(d)

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    FLEXIBILITY FOR PHYSICIANS §  Physician who cared for patient in acute or post-acute setting may complete the F2F, and:

    •  Establish and sign the plan of care then “hand off” to primary care physician (PCP) OR

    •  Initiate home health order and then “hand off” to PCP to review and sign the plan of care §  NPP in an acute care setting can complete the F2F and notify the PCP of the encounter who must

    then document the encounter based on this information §  Need documentation that this “hand off” of information occurred §  If the certifying physician chooses to use the encounter documentation from the informing

    physician or NPP as his or her documentation of the F2F encounter, the certifying physician must sign and date the documentation, demonstrating that the certifying physician received that information from the physician who performed the F2F encounter, and that the certifying physician is using that discharge summary or documentation as his or her documentation of the F2F encounter

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    FLEXIBILITY FOR PHYSICIANS (CONT.) §  F2F may occur via telehealth in rural areas in an approved originating site which include:

    •  Office of a physician/NPP •  Hospitals •  Critical Access Hospitals (CAH) •  Rural Health Clinics (RHC) •  Federally Qualified Health Centers (FQHC) •  Hospital-based or CAH-based Renal Dialysis Centers (including satellites) •  Skilled Nursing Facilities (SNF) •  Community Mental Health Centers (CMHC)

    §  Originating sites must be located in: •  County outside a metropolitan statistical area (MSA)

    OR •  Rural health professional shortage area (HPSA) in a rural census tract

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    F2F OCCURS OUTSIDE TIME FRAME §  QUESTION: If the F2F does not occur within 30 days after SOC but it does occur, for

    example, on the 35th day, how should the OASIS data be collected and submitted?

    §  ANSWER: If the F2F does not occur within 90 days prior to or within 30 days after the SOC, then MCR HH eligibility criteria have not been met and episode is not covered or billable. A F2F occurring on day 35 would represent a pay source change and therefore, a new SOC would be generated. The new SOC OASIS could be completed based on data from the prior OASIS in this instance. The new SOC would have a start of episode date 30 days prior to F2F and may not have a visit associated with that date. The (M0090) date assessment completed would be reported as the actual date of the new OASIS assessment even if no visit provided. M0110 and M2200 would need to be adjusted to reflect the new episode and should exclude any visits provided prior to date of eligibility. If the prior SOC has been submitted, it will need to be deleted and the new SOC submitted.

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    F2F OCCURS OUTSIDE TIME FRAME (CONT.) §  No mandated F2F form or template §  Whether the F2F documentation is on the certification form itself or is an addendum to

    it, it must be separate and distinct and must include the necessary components

    §  Should be clearly titled and as such be easily recognizable as documentation of the F2F encounter

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    F2F OCCURS OUTSIDE TIME FRAME (CONT.) §  Different physicians may be involved in the care of the patient: the certifying physician,

    the MD who provided care in the acute/sub-acute facility, and possibly a specialist who prepared a pre-op history and physical. Additionally, there are Home Care Medicine practices consisting of physicians who provide home based care for homebound patients. Any one of these entities may have prepared a document that is a valid F2F encounter

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    F2F OCCURS OUTSIDE TIME FRAME (CONT.) §  Among the documents that may be utilized: a History and Physical, Progress Notes from

    an office visit, a specialist’s consultation, or a Discharge Summary. The documents must be signed and dated by the MD who prepared the F2F encounter to be valid. These are not the only appropriate documents. Documents need to contain the elements directly pertaining to the referral for home health services. The F2F encounter date (if performed by a different MD) must be acknowledged by the certifying physician on a signed Attestation, a signed communication, a signed Addendum, or on the signed Plan of Care (POC).  Any document utilized must be dated by the certifying physician along with their signature

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    F2F OCCURS OUTSIDE TIME FRAME (CONT.) §  The inclusion of a F2F encounter document is a requirement. It is also required that

    recognition is provided by the certifying physician that an alternate MD created the F2F record on a specific date. There are multiple options that satisfy this requirement.  The mechanism to 'connect the dots' is often likely to be provided by the HHA.

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    F2F OCCURS OUTSIDE TIME FRAME (CONT.) §  Important points:

    •  All documents must be signed and dated. A physician-signed document without a date accompanying the signature is not complete. Evaluate electronic signatures for validity

    •  Any document that needs to be validated for Home Health needs to have the signature with an appropriate date by the certifying physician

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    CGS DENIALS

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    PALMETTODENIALS10/18

    THROUGH12/18

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    REASON FOR DENIALS §  Actual F2F visit date doesn’t match the date on the F2F form or statement §  Referral diagnosis doesn’t match primary reason for home health care §  Documentation does not support homebound status or need for skilled service

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    HOMEBOUND STATUS AND SKILLED NEED

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    §  “The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen”

    NARRATIVE EXAMPLE: HOMEBOUND STATUS & NEED FOR SKILLED SERVICE

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    HomeboundStatus

    • FuncMonaldecline• DemenMaorconfusion• DifficulttotraveltoMDoffice• Unabletoleavehome/drive• Weak• StatuspostTHA

    NeedforSkilledService

    • Familyaskingforhelp• ConMnuestohaveproblems• Listoftasksfornursestocomplete

    • PaMentunabletodowoundcare• Diabetes

    EXAMPLES OF INAPPROPRIATE DOCUMENTATION OF HOMEBOUND STATUS & SKILLED NEED

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    Would not be sufficient to

    just use diagnosis or problem list

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    EXAMPLE §  Example:

    •  Agency provides first skilled visit January 1 •  F2F encounter occurs February 4 (Day 35) •  Date when all Medicare eligibility was established January 6th (30 days prior to the F2F

    encounter, with F2F encounter date counted as "day 1") •  Non-covered visit period (January 1-5) •  (M0030) SOC Date on generated OASIS (The date of the first visit on or after January 6) •  (M0090) Date Assessment Completed on generated OASIS (The actual date new assessment is

    generated – on or after the February 4 F2F encounter.)

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    EXAMPLES—SOC 1/30 Oasisassessmentcompleted.Rxregimenreviewed.ERplan/POCestablishedAgency24h#/CHAPHotline#providedInstonHIPPA,PrivacyAct,AdvancedDirecMves,Ptsrights/responsibiliMesPaMent'sDiagnosis:CHFClinicalSummaryNeededforalldisciplines:89yrs.oldwithhistorySOB,dizzinesswithfalls,CHF,anxiety,HTN,andDM.SNtomonitorBP,andcompliancewithmedicaMon.PaMentisonconMnuousoxygentohelpincontrollingSOB.Inst.willbegivenonmeasurestoconserveenergy.Inst.willbegivenondiettohelpwithherDM.ThepaMentisHomeboundbecauseoftheseenvironmentalandorPhysicalCondiMons:COPD,CHF,unabletoleavehomeunassisted,SOBwithmin.exerMon.SNobtainedvitalsignsincludingpulseoxasindicated,instructedinmedicaMons,dietanddiseaseprocess,s/sofcomplicaMons&homesafety.SNperformedheadtotoeassessmentasindicated.WNL

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    CLINICAL NOTE

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    EXAMPLE #2

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    EXAMPLE—SOC 3/14

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    Agency Supporting Documentation for Home Health Eligibility: I certify that this patient had a F2F Encounter performed by a physician or allowed non-physician practitioner that was related to the primary reason the patient requires Home Health Services on (Date of F2F Encounter) _____________________

    Patient's Diagnosis:

    Clinical Summary Needed for all disciplines:

    The patient is Homebound because of these environmental and or Physical Conditions:

    Excerpts from Agency OASIS on _________________

    I certify that the handoff physician was _______________________ and handed off communication and care to me.

    Signed and dated by certifying physician indicating review and incorporation into the patient’s medical record.

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    STRATEGIES FOR F2F SUCCESS §  Contact the MD for an attestation statement to update the F2F information if

    documentation does not match primary reason for home care •  Example: MD F2F states muscle weakness, recurrent falls. Comprehensive assessment reveals

    patient has Parkinson’s disease and neuropathy.

    §  Notify MD of need for additional services that may not be included on the F2F and generate a verbal order updating the primary reason for home care •  Example: PT only ordered at SOC but found the have unstable blood sugars with multiple new

    meds

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    STRATEGIES FOR F2F SUCCESS (CONT.) §  Make sure dates on F2F are congruent with actual visit note date

    •  If dates do not match, claim can be denied §  Start with an effective referral

    •  Order for HH services •  Verify who will be the certifying physician

    •  Documentation supporting the need for skilled service and homebound status •  F2F encounter documentation

    §  Have a process in place to monitor for pending F2F visits •  Also have a policy to assess for scheduled F2F visits and have agency assist patient/CG with

    making appointments if not scheduled

    §  Don’t wait until the last minute!!!

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    LINKS §  https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/

    downloads/qandasfull-revised-062712.pdf

    §  https://www.palmettogba.com/Palmetto/Providers.Nsf/files/F2F_Physician_Letter_09042014.pdf/$File/F2F_Physician_Letter_09042014.pdf

    §  https://www.cgsmedicare.com/hhh/education/materials/pdf/ftf.pdf

  • home health

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    QUESTIONS?

    J’non Griffin, RN, WCC, MHA, HCS-D, COS-C, HCS-H Home Health Solutions, LLC 888-418-6970 | homehealthsolutionsllc.com