FREE YOUR AGENCY OF FACE-TO-FACE DENIALS

FREE YOUR AGENCY OF F2F DENIALS F2F Background & Context Homebound F2F Denials Intermediary Perspectives Good vs. Bad Narratives Q & A s 3 F2F BACKGROUND AND CONTEXT Where did F2F come from? Affordable Care Act Section 6407 The Affordable Care Act mandates that, prior to certifying a patient s eligibility for the HH benefit, the physician must document that the physician or a permitted non-physician practitioner (NPP) has had a face-to-face encounter with the patient. Regulatory Amendment 42CFR 424.22 4

F2F BACKGROUND AND CONTEXT CMS Manual Update https://www.cms.gov/transmittals/downloads/r139bp.pdf Pub 100-02 Medicare Benefit Policy Chapter 7 was revised to incorporate the new face-toface encounters with a physician due to the provisions mandated by the Affordable Care Act. 5 F2F BACKGROUND AND CONTEXT Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1 - Face-to-Face Encounter 6 Parts to this section: Certifying Physician Documentation Requirements* Timeframe Exceptional Circumstances Acute & Post Acute Stay Requirements Telehealth 6

F2F BACKGROUND AND CONTEXT The Certifying Physician The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. Certain NPPs may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. NPPs Nurse Practitioner & Clinical Nurse Specialist working with the physician in accordance with State Law Physician Assistant under the supervision of the physician Certified Nurse-Midwife 7 F2F BACKGROUND AND CONTEXT Documentation Requirements The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient s clinical condition as seen during that encounter supports the patient s homebound status and need for skilled services. 8

F2F BACKGROUND AND CONTEXT Documentation Requirements The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed. It is acceptable for the certifying physician to dictate the documentation content to one of the physician s support personnel to type. It is also acceptable for the documentation to be generated from a physician s electronic health record. It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign. 9 F2F BACKGROUND AND CONTEXT Timeframe Requirements The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed NPP must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patient s condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan. 10

F2F BACKGROUND AND CONTEXT Acute and Post Acute Stay Requirements A physician who attended to the patient in an acute or postacute setting, but does not follow the patient in the community (such as a hospitalist) may certify the need for home health care based on his/her contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then transfer/hand off the patient s care to a designated community-based physician who assumes care for the patient. Or; A physician who attended to the patient in an acute or postacute setting may certify the need for home health care based on his/her contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care. 11 F2F BACKGROUND AND CONTEXT Clinical Conditions = Primary Reason for HHC CMS believes these goals can be achieved better if the faceto-face encounter occurs closer to the HH start of care, increasing the likelihood that the clinical conditions exhibited by the patient during the encounter are related to the primary reason the patient comes to need HH care. Related Reason Encounter must be related to primary reason for home health* What does CMS want physicians to do? Understand current clinical needs Establish effective plan of care Ensure homebound status Ensure skilled need 12

F2F BACKGROUND AND CONTEXT Timeframes 90 Days CMS proposed that the encounter occur within the 90 days preceding the start of HH care, if the reason for the encounter is related to primary reason the patient requires home care. 30 Days If no such encounter occurred prior to the start of HH care, they proposed that the encounter must occur within 30 days after the start of care. 13 F2F BACKGROUND AND CONTEXT 2 Ways to Document Upstream Completed at time of referral 90 days before SOC Downstream To be completed after referral as addendum 30 days after SOC 14

F2F BACKGROUND AND CONTEXT Certifications, Homebound & Skilled Need As part of the Affordable Care Act mandated encounter documentation, CMS proposed that the physician document on the certification how the clinical findings of the encounter support the eligibility requirements that a patient be homebound and need intermittent skilled nursing or therapy. 15 HOMEBOUND Medicare Benefit Policy Manual, Chapter 7, Section 30.1.1 Patient Confined to Home In order for a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated. 16

HOMEBOUND Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be: A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk; A patient who is blind or senile and requires the assistance of another person in leaving their place of residence; A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence; A patient who has just returned from a hospital stay involving surgery who may be suffering from resultant weakness and pain and, therefore, their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.; 17 HOMEBOUND Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be (cont.): A patient in the late stages of ALS or neurodegenerative disabilities. A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity; and A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations. 18

HOMEBOUND SOC OASIS(C): Vision: M1200 Severely Impaired: Cannot see objects without hearing or touching them or patient non-responsive Pain: M1240 Severe Pain M1242 Pain is daily or all of the time Made worse by movement/ambulation 19 HOMEBOUND SOC OASIS(C): Respiratory: M1400 (dyspnea) minimal exertion (eg. Eating, talking, ADLs) or at rest Neuro/Emotional/Behavioral Status: M1700 Requires considerable assistance in routine situations or Totally dependent due to disturbances M1710 confused in new/complex situations or during day/evening M1720 Anxious all the time M1740 Memory deficit; Impaired decision making; Physical Aggression; combative to self and others; delusional, hallucinatory, or paranoid behavior M1745 Frequency; At least daily 20

HOMEBOUND SOC OASIS(C): ADLs: M1850 able to bear weight and pivot, but unable to transfer self; unable to transfer self, unable to bear weight and pivot; bedfast M1860 requires two-handed device to walk alone and/or requires human supervision; able to walk only with supervision; chairfast Falls: M1910 Falls Risk Functional Limitations: Relevant to M-Locators above (dyspnea, endurance, ambulation, transfer, pain, vision, etc.) 21 HOMEBOUND What doesn t support homebound? Check Boxes for Homebound Reason: Reviewers and ALJ s place very little weight on these Ex. Confusion, unable to get out of home alone Unable to safely leave home unassisted Dependent upon adaptive devices(s) Medical Restrictions Severe SOB, SOB upon exertion Requires assistance to ambulate Other 22

HOMEBOUND What doesn t support homebound? Circular logic Ex. They re homebound because they re homebound Documentation in the record of: Frequent absences from home for non-medical reasons Beneficiary is working a regular job Beneficiary is working out and/or walking out of the home regularly 23 HOMEBOUND What are acceptable reasons for leaving the home? To attend an adult day care program (licensed or certified by a state or accredited) To attend a religious service Any other absence shall not so disqualify an individual if the absence is of infrequent or of relatively short duration 24

F2F DENIALS Each intermediary, relative to your geographic location, has a different approach on their evaluation of F2F, this is reflected by their denials: CGS National Government Services (NGS) Palmetto GBA Most harsh view on F2F documentation MAXIMUS QIC Panel always issues your Reconsideration Decision regardless of your Intermediary 25 F2F DENIALS - CGS CGS Denial Examples Initial Determination Ex. 1 The FTF encounter submitted does not contain a narrative composed by the physician describing how the Pt s clinical cond., as seen during the encounter, supports the need for skilled services. Ex. 2 No clinical findings to support primary reason for HHC. Doc must include a brief narrative by certifying physician who describes how the clinical condition as seen during the encounter supports Pts homebound status and need for skilled services. 26

F2F DENIALS - CGS CGS Denial Examples - Redetermination Ex. 1 Medicare requires that a valid physician certification be submitted for all home health care services. Home Health agencies are required to have a face-to-face encounter (FTF) as part of the certification on the Start of Care certifications. The FTF must: Describe how the patient s clinical condition as seen during that encounter supports the patient s homebound status and need for skilled services; Show that the certifying physician or allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient; Include the date of the encounter; and, demonstrate that the FTF took place prior to billing. The physician narrative on the face to face encounter submitted does not describe how the patient s clinical condition supports the need for skilled services. 27 F2F DENIALS - CGS CGS Denial Examples - Redetermination (Cont.) Ex. 2 The FTF sent with the claim was signed by the certifying physician. However, the FTF did not contain specific patient clinical findings to support the medical necessity of the skilled nurse. It just listed the patient s diagnoses. It was also noted that the homebound status was not specific as to why it was a considerable and taxing effort to leave home. 28

F2F DENIALS - NGS NGS Denial Examples - Initial Determination Ex. 1 No Physician s certification F2F does not meet requirement. Ex. 2 No Physician s certification-f2f not valid. Ex. 3 No MD cert. Ex. 4 No physician s certification; Face to face requirements not met. Date of encounter not present on physician attestation. Therefore, invalid FTF/cert. 29 F2F DENIALS - NGS NGS Denial Examples - Redetermination Ex. 1 Mr. X was admitted to home health services. The patient received skilled nurse services during this home care episode. The patient has congestive heart failure. Effective April 01, 2011, CMS requires home health agencies to comply with the face to face encounter requirements mandated by the Affordable Care Act for the purposes of certification of a beneficiary s eligibility for Medicare home health services. The certifying physician s face to face encounter should include a brief narrative describing the beneficiary s clinical condition and how the beneficiary s condition supports homebound status and the need for skilled services. The face to face lacks sufficient documentation and a narrative of clinical findings in support of homebound status. The face to face encounter did not meet these requirements therefore the services remain denied. 30

F2F DENIALS - NGS NGS Denial Examples - Redetermination (Cont.) Ex. 2 Mrs. X was admitted to home health services The provider did not submit a completed face to face encounter. The face to face encounter is part of the home care certification. Without a completed face to face encounter there is no valid certification. The home care services are denied as there is no valid certification. 31 F2F DENIALS PALMETTO Palmetto Denial Examples - Initial Determination Ex. 1 Face to Face requirements not met Ex. 2 Full denial as face to face requirements not met. Documentation does not support patient s homebound status or need for skilled services Ex. 3 Documentation does not meet the requirements specified in the Medicare guidelines for a face to face encounter for dates of service. The face to face encounter lacks a narrative explanation describing how the patient s clinical finding documented as S/P pneumonia, poor endurance, unsteady gait support the patient s homebound status and need for skilled services. The corresponding progress note is not titled face to face, and lacks 32

F2F DENIALS PALMETTO Palmetto Denial Examples - Redetermination Ex. 1 - This review finds the HIPPS (Health Insurance Prospective Payment System) code 1CGK1 for twelve physical therapy visits and one hundred and twenty skilled nurse visits for the dates of service October 3, 2012 to December 1, 2012 must be denied as the face to face encounter was not valid as it did not include clinical findings to support the homebound status and need for skilled services. The documentation did not show patient s clinical condition as seen during the encounter to support the patient s homebound status and need for skilled services. 33 F2F DENIALS PALMETTO Palmetto Denial Examples - Redetermination (Cont.) Ex. 2 the face to face encounter form was found to be invalid as it was not signed or dated by the physician. Therefore as a result the episode will be fully denied as face to face encounter requirements not met. Ex. 3 Upon review of the face to face encounter it was determined the documentation failed [to] contain a brief narrative describing how the patient s clinical condition as seen during that encounter supports the patient s homebound status. 34

F2F DENIALS MAXIMUS MAXIMUS QIC Panel Reconsideration Ex. 1 A panel of licensed healthcare professionals reviewed this case and determined that the services at issue did not meet Medicare coverage criteria. The beneficiary was admitted to home care services on August 20, 2011 with a primary diagnosis of congestive heart failure and secondary diagnoses of hypertension and ambulatory dysfunction. The 17 physical therapy visits, 12 skilled nursing visits and 1 occupational therapy visits in this appeal remained denied based on the Face to Face Encounter. The Face to Face Encounter did not provided specific clinical indicators to support the beneficiary s homebound status. The Face to Face Encounter that was submitted with this appeal was not fully completed. The physician did not include functional limitations, homebound status and clinical findings which make the Face to Face Encounter invalid and the visits denied. 35 F2F DENIALS MAXIMUS MAXIMUS QIC Panel Reconsideration (Cont.) Ex. 2 Invalid face to face, there was no date of the encounter. Without a valid face to face we cannot find the services favorable. 36

F2F DENIALS MAXIMUS MAXIMUS QIC Panel Reconsideration (Cont.) Ex. 3 There was a Face to Face document submitted However, it lacked a sufficient narrative summary to support the clinical need for home health services and homebound status making the form invalid. There is no documentation on the form with specific clinical findings of the encounter and how these findings support medical necessity for home health services and homebound status. There are diagnoses listed, but there was no specific information describing the need for home care services or homebound status. In addition, physical and occupational therapy services were not indicated as required services on the Face to Face encounter form. 37 F2F DENIALS - REVIEW Denial Reasons Review: Physician Signature Dates Primary reason for home health is inconsistent with F2F documentation Homebound not supported Insufficient Narrative Listing Diagnosis Only Blank Document Addendum not clearly identified 38

INTERMEDIARY PERSPECTIVES - PALMETTO Jurisdiction 11 Home Health Medical Review: Top Denial Reason Codes 5FF2F Face to Face Requirements Not Met 49.9% (for bill type 32X) 5FF2F - Face to Face Requirements Not Met 45.4% (for bill type 33X) Face to Face Requirements Not Met: The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter. Let s see what Palmetto recommends to avoid this denial reason 39 INTERMEDIARY PERSPECTIVES - PALMETTO To prevent this denial: The face-to-face encounter must occur no more than 90 days prior to the home health start of acre or within 30 days after the start of care. Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following: The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient's clinical condition as observed during that encounter supports the patient s homebound status and need for skilled services The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification The certifying physician may dictate the face-to-face encounter documentation content to one of the physician s support personnel to type. The documentation may also be generated from a physician s electronic health record 40

INTERMEDIARY PERSPECTIVES - PALMETTO Medical Review Requirements For Home Health Face-to-Face Documentation F2F is top reason for overpayments More comprehensive review of F2F effective 5.20.2013 Focus = Homebound 41 INTERMEDIARY PERSPECTIVES - PALMETTO Medical Review Requirements For Home Health Face-to-Face Documentation (cont.) Examples of inadequate documentation include the following: Dx alone, such as osteoarthritis Recent procedures alone, such as total knee replacement Recent injuries alone, such as hip fracture Statement, taxing effort to leave home without specific clinical findings to indicate what makes the beneficiary homebound Gait abnormality without specific clinical findings Weakness without specific clinical findings 42

INTERMEDIARY PERSPECTIVES - PALMETTO MLN Matters (SE1219) A Physician s Guide to Medicare s Home Health Certification, including the F2F Recertifications: Face-to-face encounter documentation is only required for the initial certification At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for a subsequent 60-day episode. 43 INTERMEDIARY PERSPECTIVES - PALMETTO Going Beyond Diagnosis: Efficiently and Effectively Communicating Information to Satisfy Home Health Face-to Face Requirement Step 1: Identify relevant structural and functional impairments and their severity. Step 2: Identify relevant activity limitations/participation restrictions and their severity. Step 3: Identify relevant environmental factors and their impact. Describe how the specific impairments of structure and function, activity limitations/participation restrictions, and environmental factors identified in steps 1-3 combined contribute to the beneficiary being homebound and to the need for skilled services. 44

INTERMEDIARY PERSPECTIVES - NGS NGS on Narratives: The brief narrative needs to include more than the diagnosis being treated or the surgical procedure performed. Information describing why the patient needs the skilled nursing and/or skilled therapy services and why the patient is homebound must also be included. The clinical information should describe the unique needs of the patient. It is not appropriate to quote sections of the CMS manual. The narrative needs to be the physician s assessment of why the patient meets the Medicare home health requirements. Often the forms have this information in separate sections but it could be in one section as long as the homebound status as well as the patient s clinical condition is documented supporting the need for home health services. 45 INTERMEDIARY PERSPECTIVES - NGS NGS on Narratives (Cont.): Overall NGS narrative examples via their website are fairly brief, more so than other intermediaries, however reviewers are still denying for short narratives There is an obvious disconnect between the educational content and the denials, and because of this, narratives need to be descriptive, lengthy and have quality content 46

INTERMEDIARY PERSPECTIVES - NGS Certifying Physician s Partner: It is not acceptable for a physician partner of the certifying physician to sign a face-to-face encounter document for the partner while the certifying physician is out of town or otherwise unavailable. The face-to-face must be signed by the certifying physician. Electronic signatures are acceptable but it must be noted that it is an electronic signature. 47 INTERMEDIARY PERSPECTIVES - CGS Widespread Home Health Probe F2F Documentation As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. 48

INTERMEDIARY PERSPECTIVES - CGS Widespread Home Health Probe F2F Documentation (Cont.) The most common errors identified by the CERT contractor regarding FTF encounter documentation are insufficient documentation of clinical findings by the physician/nonphysician-practitioner (NPP) to show the encounter was related to the primary reason for home care, and a description of why the patient was homebound and in need of Medicare covered home health skilled services. 49 INTERMEDIARY PERSPECTIVES - CGS Widespread Home Health Probe F2F Documentation (Cont.) In some cases, the FTF documentation only provided a diagnosis, or the frequency and duration of services to be provided. Below is a list of statements or items frequently used that, alone, would be considered insufficient for documentation of the homebound status and need for skilled services: Homebound: functional decline, dementia, confusion, travel difficulty, unable to leave home, weak, unable to drive Need for skilled services: family asking for help, continues to have problems, patient unable to do wound care, diabetes, list of tasks for nurse to do 50

CURRENT EVENTS Provider Frustration Erupts at PGBA Education Session If the physician's documentation is inadequate (e.g. naming the diagnosis is not sufficient; a full narrative must be written by the physician, new for each patient and never copied from boilerplate text), the home care agency will not be paid for the entire PPS episode. But the physician who wrote the faulty F2F document is unaffected. Medicare Administrative Contractors, such as PGBA, provide educational opportunities to their Medicare Part A and B constituents but they are contracted to serve different states for home care than for physicians. PGBA serves 16 states for home care but only four of those states for physicians. They are powerless to control what happens with physician education in the other 12 states. 51 CURRENT EVENTS Provider Frustration Erupts at PGBA Education Session Cont. Palmetto admits being unaware of the nature or existence of any such educational efforts. When asked, "Do you talk with or coordinate educational efforts with your counterparts responsible for physician Medicare billing in those other 12 states?" Mr. Canaan replied, "That is a great idea. We should do that. I will look into it. The net effect of such an administrative disconnect is that hundreds, if not thousands, if not all, honest, motivated, hard-working home healthcare agencies have begun to receive payment denials after providng 60 days of excellent, well-documented care, care that helps prevent hospital readmissions and consequently saves Medicare millions of dollars. These are denials that did not occur prior to the advent of the F2F rule and are only happening now because of a document wording error that is entirely beyond the home care agency's control, and entirely unrelated to the quality of care provided. 52

CURRENT EVENTS Provider Frustration Erupts at PGBA Education Session Cont. Until Congress acts, it appears your only choice is to strengthen your physician relationships to the point where they will accept a little F2F training of your own. They see F2F as a burden, an unfunded mandate if you will, and they have no incentive to take the time to design a unique, original paragraph or two for every patient. Cajoling and pleading and bringing a box of doughnuts may seem beneath your dignity, but the alternative is an unending string of payment denials that, by design, will always be unfair. 53 GOOD VS. BAD NARRATIVES The Bad: Ex. 1 - I certify my clinical findings support that this patient is homebound per CMS guidelines due to: Patient unable to leave home unattended and continues to require assistance with ADLs. Ex. 2 I certify my clinical findings support that this patient is homebound per CMS guidelines due to: s/p left hip fracture surgery Ex. 3 My clinical findings support the need for home health services as follows: skilled nursing, home health aide, physical therapy. I certify my clinical findings support that this patient is homebound per CMS guidelines due to: poor ambulation, risk for falls. Ex. 4 My clinical findings support the need for home health services as follows: physical therapy. I certify my clinical findings support that this patient is homebound per CMS guidelines due to: dementia, CVA, expressive aphagia 54

GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 5 My clinical findings support the need for home health services because: Per record review she was admitted to LUMC (hospital) for intertrochanteric fracture Ex. 6 My clinical findings support the need for the above services because: Patient referred to skilled nursing for monitoring [and] insulin administration. Patient with very physically limited unable to perform BS test or administer insulin. Poor eye and hand coordination Patient is homebound due to his physical and mental condition. Patient unable to get out of house with out assistance wheelchair 55 GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 7 Primary diagnosis & reason for home health care: Atrial fibrillation, hypertensive heart disease, long term use of anticoagulants, gout NOS. Additional clinical findings that support the need for home health services: anticoagulant medication education and monitoring. The physician also attests that My findings support the fact the patient is homebound as defined in CMS chapter 7 Medicare Benefit Manual 30.1.1. In addition, The condition of the patient is such that there exists a normal inability to leave home and consequently, leaving home would require a considerable and taxing effort. 56

GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 8 Primary diagnosis & reason for home health care: COPD, HTN The physician also attests that My findings support the fact the patient is homebound as defined in CMS chapter 7 Medicare Benefit Manual 30.1.1. In addition, The condition of the patient is such that there exists a normal inability to leave home and consequently, leaving home would require a considerable and taxing effort. 57 GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 9 The medical reason, diagnosis, or condition related to the primary reason for home healthcare for the encounter was exacerbation of COPD, generalized weakness, unstable gait. It also has, Clinical findings that support the medical need for home health services and support home patient s homebound status are as follows: Pt needs further assistance w/ distance condition teaching, increased weakness and unstable gait. 58

GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 10 The encounter with the patient was in whole, or in part, for the following medical condition. Which the primary reason for home health care (list medical condition): OA, spondylosis, muscle weakness My clinical findings support the need for the above services because: due to conditions [noted] above Further, I certify that my clinical findings support that this patient is homebound (ie. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons because: patient is homebound due to condition [noted] above. 59 GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 11 The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care (list medical condition): hemiplegia affecting dominant side, cerebrovascular accident, hypertension, and history of falls. The physician also attests that My clinical findings support the need for the above services because: cannot drive. Lastly, the physician states I certify that my clinical findings support that this patient is homebound (ie. absences from home require considerable and taxing effort and are for medical reasons or religious services of infrequently or of short duration when for other reasons) because: difficulty in walking. 60

GOOD VS. BAD NARRATIVES The Bad (Cont.): Ex. 12 Please describe why this patient requires home health services: Mobility impairment, partial visual impairment, teaching on diabetic care and insulin administration. Eval and asses, teaching how to use sliding scale Diagnosis: hypothyroid, IDDM, renal insufficiency. Further, the Encounter identifies: Please describe what functional limitations identify the patient as homebound: Renal insufficiency, mobility impaired, due to DM and hypertension. 61 GOOD VS. BAD NARRATIVES The Good Clinical Findings/Skilled Need: Patient currently has several unhealed/complicated surgical wounds that require skilled nursing to provide wound care and education on integumentary status. They are newly diagnosed with Diabetes and require insulin administration and teaching due to limiting cognitive and physical impairments resulting in a complicated treatment plan. Further, patient is at a high risk for re-hospitalization and skilled nursing is needed for observation and assessment for signs of decomposition or adverse events from the new medical regimen. 62

GOOD VS. BAD NARRATIVES The Good Homebound: Patient paralyzed from a recent stroke and is unable to ambulate safely, requires wheelchair for home mobility and is unable to drive. Transfer and self care ADLs require assistance from another person and patient is limited by low back pain rated 9/10. Patient also experiences dyspnea with minimal exertion. Further, when out of the home without supervision the patient's safety is an issue to due to diagnosis of dementia. The totality of of these findings support a considerable and taxing effort to leave home by way of mobility, pain, mobility and altered mental status. 63 GOOD VS. BAD NARRATIVES The Good CMS Example Homebound and Clinical Findings/Skilled Need 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. 64

Q/A S Q: Is it allowable for a HHA to provide a certifying physician and his or her office support staff, a completed sample face-to-face encounter documentation to use as a guide for how to complete actual face-to-face documentation? 65 Q/A S A: To clarify, CMS does not require a specific form for face-to-face documentation. Moreover, CMS does not require that the certification, which includes the face-toface documentation, to be in a specific format or on a specific form. Rather, CMS requires that the content requirements of the face-to-face documentation are met. The face-to-face documentation must reflect the certifying physician s, allowed NPP s, or for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in that acute or post-acute facility and who has privileges at the facility, experience with the patient.. (Cont. slide 67) 66

Q/A S (CONT) An HHA providing physicians with sample face-to-face documentation as a guide to what would be considered acceptable face-to-face documentation to assist them in preparing their particular face-to-face documentation for a patient, would be allowable. The HHA cannot provide the specific clinical details from the patient s face-to-face encounter in a document, call it a sample, with the expectation, possibility, or probability that the physician would have all the information he o rshe would need to document the face-to-face for that particular individual and thus simply sign it as the official face-to-face documentation 67 Q/A S Q: Will subsequent episodes be covered if face-toface requirements are not met timely during the first episode? 68

Q/A S A: The face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes. 69 IMPROVING YOUR F2F FORM Amount of content written by physician MORE Make sure you have enough space on the form to get MORE content Narratives SEPARATE 2 Narratives eliminate confusion Quality Content Make sure to guide physicians if they give you insufficient narratives QA F2F before submitting final bill YOUR responsibility AD Maxim has F2F Encounter forms available Upstream and Downstream Physician relationships Good physician/support staff relationships are now more important than ever 70

RESOURCES MLN Matters A Physician s Guide to Medicare s Home Health Certification, including Face-to-Face Encounter, http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1219.pdf (Last accessed September 9, 2013) Medical Review Requirements for Home Health Face-to-Face Documentation, http://www.palmettogba.com/palmetto/providers.nsf/ls/jurisdiction%2011%2 0Home%20Health%20and%20Hospice~97VQKU0732?opendocument (Last accessed September 9, 2013) Efficiently and Effectively Communicating Information to Satisfy the HH Faceto0Face Requirement, http://palmgba.com/gbd/2013/05/efficiently-andeffectively-communicating-information-to-satisfy-the-home-health-face-toface-requirement/ (Last accessed September 9, 2013) Provider Frustration Erupts at PGBA Education Session, http://homecaretechreport.com/print_article.asp?id=1773 (Last accessed September 9, 2013) Home Health Face to Face Encountr,ehttp://www.ngsmedicare.com/ngs/portal/ngsmedicare (Last accessed September 9, 2013) 71 RESOURCES Widespread Home Health Probe F2F Encounter Documentation, http://www.cgsmedicare.com/hhh/pubs/news/2013/0613/cope2239 3.html (Last accessed September 10, 2013) Home Health FTF FAQs, https://www.cgsmedicare.com/hhh/education/faqs/ftf_faqs.html (Last accessed September 10, 2013) Home Health F2F Q/A,http://www.cms.gov/Medicare/Medicare-Fee- for-service-payment/homehealthpps/downloads/home-health- Questions-Answers.pdf (Last accessed September 10, 2013) CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1 CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.1 Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22 72

DISCLAIMER This educational presentation is only an overview. It is not intended to be a comprehensive authority of the subject. Further, this presentation provides information about the law designed to help viewers more effectively handle their own legal needs as they pertain to regulatory compliance in the health care field. Please note that legal information is not the same as legal advice - the application of law to an individual's specific circumstances. Although we go to great lengths to make sure our information is accurate and useful, we recommend you consult a lawyer if you want professional assurance that our information, and your interpretation of it, is appropriate to your particular situation. 73 74