Q. Can the term "physician support staff"-- the staff who can assist the physician in drafting the narrative be further defined?

Transcription

1 From: CMS F2F FAQs Q. Can the term "physician support staff"-- the staff who can assist the physician in drafting the narrative be further defined? A. Yes. Physician support staff are those staff who work with or for the physician on a regular basis, and, as part of their job duties regularly perform documentation, take dictation from the physician and/or extract from the physician's medical records to support the physician in a variety of ways. We note that HHA staff cannot assist the physician in drafting the narrative. The statute requires that the physician must document the face-to-face encounter. As we describe in our final rule, the HHA staff cannot draft the narrative documentation for the physician to sign as this would violate the statutory requirement Mary Did CMS define "physician support staff"?? From: NAHC Regulatory Affairs We redirected this question to CMS and they are adamant that the physician must extract the information for F2F encounter documentation from the NPs clinical documentation. NPs may not extract from their own clinical documentation of the encounter. CMS rationale is that, according to the statute, the physician must document the encounter. Mary, Forgive me, but I must argue this illogical CMS response. If the f2f encounter is done by the NP, the resulting information (whether it's in the patient's chart or on the encounter form) DOES originate from the NP! It can never originate from the physician. How insane is it to require the physician to transfer the NP's information to the encounter form??? Could this question be redirected back to CMS in hopes of a more reality based response? Very frustrated..

2 From NAHC, Regulatory Affairs CMS maintains that a NPP documenting his/ her encounter findings for the physician to sign would not be permitted since that information would have originated from the NPP and not the physician. When supporting personnel extract information from the physician's entry, it s the physician's original documentation. The Affordable Care Act mandates that the certifying physician for home health service be enrolled in Medicare. There is no requirement at this time that the certifying physician be enrolled in PECOS. If a physician has been successfully billing Medicare they are enrolled in Medicare. Mary, Several more questions: 1) If a "physician's own support staff can help the physician draft the f2f encounter narrative", then why can't the NP or PA (who TRULY are the physician's support staff, and actually have first hand information of the f2f encounter because they did it) draft the f2f encounter narrative for the physician to review and sign? It is very much a waste of their time if the NP doing the f2f encounter documents separately in the medical record, but then the physician or his support staff must use precious time to extract and re write this on our form. In the real world, I know that the NPs are indeed completing the form after their f2f encounter and the doc is reviewing and signing. It's the only logical/reasonable use of time to get it done. 2) We understand that the f2f certifying physician must be PECOS enrolled. April 1 was our date for total f2f mandate compliance with full fiscal ramifications. Yet, the physicians have been given an extension (beyond our April date) to complete their enrollment and be on the list. How do we reconcile these differences? Are we able to utilize a certifying physician and complete our final billing at this time if the patient's physician is not yet on the PECOS enrolled list? The discharge summary/form may be used to document the F2F encounter as long as there is a titled section on the form and the information meets the F2F documentation requirements. Q.Can documentation requirements for the face-to-face encounter be satisfied if the certifying physician s staff complete the document as part, or addendum to the certification using the patient s medical record & physician reviews and signs?

3 A.The statute requires that the certifying physician document the encounter as part of the certification. A physician's own support staff can help the physician draft the face-to-face encounter documentation narrative in a number of ways which include but are not limited to: the certifying physician can dictate the narrative to the physician's support staff, the support staff can extract the narrative from the physician's own medical record documentation of the encounter, or the support staff can generate the narrative from the physician's electronic medical record software. Such are examples of common practice for physicians to document their patient encounters, and all would meet the statutory requirement that the certifying physician must document the encounter as part of the certification. CMS expects that because this same information is often present on the discharge summary and/or physician orders for home health services, the face to face encounter documentation narrative may satisfy multiple purposes. A physician's orders for home health services or an acute/post-acute discharge summary can be used to satisfy the face-to-face documentation narrative, if they reflect the clinical condition of the patient as seen during the encounter, they are drafted by the physician or the physician's support personnel, and they meet these requirements: Hospitals are asking if they can change their interagency discharge form so it would encompass the pertinent info for the face to face encounter, Would this satisfy the face to face rule, or do we need a separate certification form Original Message To: "NAHC Member Network" <homecare@news.nahc.org> Yes, that s correct. CMS clarified which physician may bill for the certification in the following Q&A Q. If a facility physician completes the encounter documentation and the community physician completes the plan of care, which of the two may bill Medicare for physician certification? A. The physician who certifies may bill Medicare for physician certification. If a physician that follows the patient while in the facility completes the f2f encounter, certifies the patient meets criteria, and then transfers the care of the patient to a community physician (who doesn't have a F2F encounter)...which physician is able to bill for G0180(certification) and which physician is able to bill for G0181(Care plan oversight)? Would the facility physician be able to bill for G0180 and then the following physician only be able to bill for G0181 since they didn't have the f2f encounter?

4 Thanks. Date: Thu, 7 Apr :49: A physician that follows the patient while in the facility may complete the f2f encounter, certify the patient, and transfer the care of the patient to a community physician. The regulation does not define hospital physician nor does it limit the hospital physician to a hospitalist. Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Rules and Regulations, page Where the patient is admitted to HH from the hospital, we believe that current practice associated with the HH certification would apply to the face-to face encounter as well. In most cases, we would expect the same physician to refer the patient to HH, order the HH services, certify the beneficiary s eligibility to receive Medicare HH services, and sign the plan of care. It would be this physician who would be responsible for documenting on the certification that he or she, or a specified NPP working in collaboration with the certifying physician, had a face-to-face encounter with the patient. However, we recognize that, in certain scenarios, one physician performing all of these functions may not always be feasible. An example of such a scenario would be a patient who is admitted to HH upon hospital discharge. While we would still expect that in most cases, a patient s primary care physician would be the physician who refers and orders HH services, documents the face-to-face encounter, certifies eligibility, and signs the plan of care, there are valid circumstances when this is not feasible for the post-acute patient. For example, as several commenters pointed out, some post-acute HH patients have no primary care physician. In other cases, the hospital physician assumes primary responsibility for the patient s care during the acute stay, and may (or may not) follow the patient for a period of time post-acute. In circumstances such as these, it is not uncommon practice for the hospital physician to refer a patient to HH, initiate orders and a plan of care, and certify the patient s eligibility for HH services. In the patient s hospital discharge plan, we would expect the hospital physician to describe the community physician who would be assuming primary care responsibility for the patient upon discharge. It would be appropriate for the physician who assumes responsibility for the patient post-acute to sign the plan of care and thus be considered under the care of that community/personal physician throughout the time the patient is receiving HH services. In a scenario such as this, if the hospital physician certifies the patient s HH eligibility and initiates the orders for services, the hospital physician could document that a face-to-face encounter occurred and how the findings of that encounter, which in this scenario would have occurred during the patient s acute stay, support HH eligibility. The community physician designated on the discharge plan would assume responsibility for the patient at some point after acute discharge, updating orders, signing the From: NAHC Report Article, Monday, December 6, 2010 CMS responded to this inquiry in an message: (a)(1)(iii) states "A plan for furnishing the services has been established and is periodically reviewed by a physician." "As we discussed yesterday, currently, many hospital docs sign the cert and the plan of care for their patients, prior to acute discharge. In this case, long standing practice has allowed the hospital physician's referral to home care orders to satisfy the establishment of a care plan, and the combination of the hospital doc's attending role during the remaining acute stay, coupled with the discharge plan which transfers the patient's care to the patient's community PCP satisfies the 'under the care of" requirement. We believe that in the (hopefully rare) scenario where a hospital doc would sign the cert but wouldn't (for whatever reason) sign the plan of care, as long as the hospital doc has ordered HH services, we would consider the POC to be initiated. As above, if the hospital doc describes in the discharge plan that the patient will be under the care of a PCP physician at discharge, we would consider the patient to be under the care of a physician at the time of the certification signing. We will allow the doc described in the discharge plan to sign the plan of care in such a case. I note that "services were furnished while the patient was under the care of a physician" is a longstanding certification requirement. Long standing practice should ease your concerns here. We've never enforced a policy which precluded the certifying physician from transferring care of the patient to another physician. And, we've never precluded a hospital physician who was attending to the patient during the acute stay from certifying HH or establishing the care plan. Longstanding practice

5 has allowed the hospital docs referral orders and acute discharge plan which described the patient's transfer to the PCP physician for continuing care to satisfy the "under the care of' cert reqmt. We have then looked to the HHA to ensure that the patient remains under the care of a physician during the episode." Subject: Re: Face-toFace Encounter rule Can a physician who is not a hospitalist sign the F2F if he or she will not be the primary MD signing the care plan if he or she saw the patient in the hospital? My scenario is: the internist and cardiologist both made rounds on the day of d/c from the hospital. The internist wrote the discharge order for home health and wants the patient to be followed by cardioligist, so asked that we sned all POC and verbal orders to the cardiologist. The case manager said to send the F2F to the internist when we asked her to conplete it and have either doctor sign it. Help?????