Certification/Recertification Michigan Home Care & Hospice Association May 3, 2017
Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at https://www.cms.gov. 2
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Acronyms Acronyms used in this presentation can be viewed on the NGSMedicare.com website. On the Welcome page, click on Provider Resources > Acronyms. 4
JK/J6 Territories Jurisdiction K Jurisdiction 6 Maine New Hampshire Vermont Rhode Island Massachusetts Connecticut New York New Jersey Michigan Wisconsin Minnesota Idaho Nevada Washington Oregon California Arizona Alaska Hawaii Puerto Rico Mariana Islands American Samoa Virgin Islands Guam 5
Objectives To further the understanding of the documentation that supports home health certification and recertification To learn how to avoid errors from the top denials from the first round of the Probe & Educate Endeavor To provide the latest information about the Pre- Claim Review Demonstration 6
Agenda Overview of the Medicare FFS HH Benefit Five elements of certifying/recertifying HH Probe & Educate Endeavor and the Top Reasons for Denial Pre-Claim Review Demonstration Update References & Resources, and CERT 7
Medicare HH Benefit Services that the Medicare beneficiary may receive at home include: Skilled nursing services Home health aide services Physical therapy Speech-language pathology services Occupational therapy services Medical social services 8
Patient/Beneficiary Eligibility CMS regulations state that when the physician refers a patient to home health, the patient must: Be confined to the home Need skilled services Be under the care of a physician Receive services under POC established and reviewed by a physician Have a FTF encounter for their current diagnosis with a physician or allowed NPP 9
Medicare HH Benefit For purposes of benefit eligibility, intermittent means: Skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable) 10
Homebound Status Criteria One One Standard Must Be Met 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 to leave their place of residence. Criteria Two Both Standards Must Be Met There must exist a normal inability to leave home. AND Leaving home must require a considerable and taxing effort. OR Have a condition such that leaving his or her is medically contraindicated. 11
Homebound Status Declaring any portion of the regulation as a blanket statement copied from the CMS manual is vague ( It s a taxing effort for the patient to leave home ). Documentation must: Include information about the injury/illness & the type of support and/or supportive device/assistance required for illness/injury to assist the patient in leaving home Or explain in detail how the patient s current condition makes leaving home medically contraindicated Clarify exactly the distinct difference in the patients normal ability versus their normal inability Describe exactly what effects are causing the considerable and taxing effort for this patients when leaving home 12
Homebound Status If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. For religious services For other unique or infrequent events Funeral, graduation, hair care 13
Need for Skilled Services Documenting the need for all skilled services requested (including SN, PT/OT/SLP, SW): Distinguish exactly what services are going to be provided by the skilled professional in the patients home Explain why a skilled professional is required to provide the HH care services requested Disclose clinical information (beyond a list of recent diagnoses, injury, or procedure) that is individual and specific to the patient 14
Plan of Care A plan of care has been established and is periodically reviewed by a physician. As per CR 9189: The referring/certifying physician s initial order for home health services initiates the establishment of a POC (for example: discharge plan) as part of the certification of patient eligibility The physician s initial order must specify the medical treatments to be furnished and does not eliminate the need for the POC 15
Plan of Care CMS Form 485 is no longer an up-to-date or CMS endorsed document because the certification statement does not encompass all five requirements of certification. It doesn t reference the fact that a F2F encounter was performed: 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 have authorized the services on this plan of care and will periodically review the plan. 16
Example of a Complete Certification Statement I certify 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. This patient is under my care, and I have authorized the services on this plan of care, and will periodically review the plan. I further certify this patient had a face-to-face encounter that was performed on xx/xx/xxxx by a physician or Medicare allowed non-physician practitioner that was related to the primary reason the patient requires home health services. 17
Example of a Complete Certification Statement Ordering IS Certifying but NOT following care I certify 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. I have authorized the services on this initial plan of care which will be further developed by Dr. XXX who is overseeing the home health services. I further certify this patient had a faceto-face encounter that was performed on xx/xx/xxxx by a physician or Medicare allowed non-physician practitioner that was related to the primary reason the patient requires home health services. 18
Face to Face Encounter DOS Eff 1/1/15 Documentation from the medical record that a visit occurred to ensure that the beneficiary was seen for the reasons (diagnosis) for which home care is being ordered. Timeframe: A face-to-face encounter can occur 90 days prior to the start of care or within 30 days after the start of home health care. Can be performed by a MD, NP, PA, CNM, CNS The face-to-face encounter does NOT have to include information about homebound status or the need for skilled services 19
FTF Encounter 2015 Changes 2014 FTF Encounter Form Narrative mandatory regarding: Need for skilled services, and Homebound status 2015 FTF Encounter Documentation from the patient s medical record providing proof that a visit occurred for same reason (primary diagnosis) that home care is being ordered Example: discharge summary or office progress note 20
Required Elements of the Certification Physicians or non-physician practitioners are required to have face-to-face encounters with beneficiaries before they certify eligibility for the home health benefit. One aspect of the certification is for the certifying physician to certify (attest) that the face-to-face encounter occurred and document the date of the encounter. 21
Certification Per CR 9189: The certifying physician must also document the date of the face-to-face encounter as part of the certification There is no specific form or format for the certification, as long as the five certification requirements are met The HHA s generated medical record documentation for the patient, by itself, is not sufficient in demonstrating the patient s eligibility for Medicare home health services. It is the patient s medical record held by the referring certifying physician and/or the acute/post-acute care facility that must support the patient s eligibility for home health services. 22
Recertification Recertification is required at least every 60 days Medicare does not limit the number of continuous episode recertifications for patients who continue to be eligible for the HH benefit. The physician recertifying the patients eligibility is the physician that has been monitoring the POC and providing oversight of HH Services 23
Recertification Per CR 9189 - For all medical necessity reviews, the Medicare review contractors shall: Determine whether the supporting documentation addresses each of the 5 certification criteria. Review the certification documentation for any episode initiated with the completion of a home health agency start of care assessment. This means that if the subject claim is for a subsequent episode of home health service, the home health agency must submit all initial certification documentation as well as recertification documentation. 24
Recertification Recertification must : Be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of the plan. Include an estimate of how much longer the skilled services will be required measurable and pt specific Be signed & dated by the physician who reviews the plan of care 25
Collaboration of Supporting Documentation Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered. Information from the HHA can be incorporated into the certifying referring physician s and/or the community physician s medical record for the patient. The certifying physician must review and sign any documentation incorporated into the patient s medical record that is used to support the certification. If this documentation is to be used for verification of the eligibility criteria, it must be dated prior to submission of the claim. 26
MLN SE 1524 Probe & Educate CMS implemented a Probe and Educate medical review strategy to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements. 27
MLN SE 1524 Probe & Educate MLN SE 1524 First Round: Episodes beginning on or after August 1, 2015 https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1524.pdf 28
MLN SE 1524 Probe & Educate CMS has directed contractors to select a sample of FIVE (5) claims for pre-payment review. Review will focus on HHA compliance with CMS 1611-F and the new regulations highlighted in CR 9119 and 9189 29
MLN SE 1524 Probe & Educate Contractors have been advised by CMS to repeat the probe & educate process for providers found to have moderate to major concerns with claim/medical record review. ADRs began to be sent January 2017 If the HHA fails to submit five claims, the provider will be considered moderate concern (unless four claims were reviewed and the contractor approved all four). 30
MLN SE 1524 Probe & Educate Top Reasons for Denial: The actual clinical note for the face-to-face encounter visit (physician s progress note or the facility s discharge summary) is not being submitted by the HHA when responding to the ADR. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2 indicates that documentation from the certifying physician s medical records and/or the acute/post-acute care facility s medical records are to be used to determine eligibility for the Medicare home health benefit. It further states that this medical record must contain the actual clinical note for the face-to-face encounter visit. Make sure to submit the actual medical record of the face-to-face encounter with your records for NGS to review. This information can be found most often in clinical and progress notes and discharge summaries. 31
MLN SE 1524 Probe & Educate Top Reasons for Denial: The eligibility requirements to substantiate that the patient has the need for skilled home health services and is homebound must be justified by the documentation in the certifying physician s and/or the acute/post-acute care facility records. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2, The certifying physician and/or the acute/post-acute care facility medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient s need for the skilled services and homebound status. Examples of documentation to support the need for skilled services and homebound status may include: facility therapy notes, social work or discharge planning records, history and physicals, and other clinical progress notes. 32
MLN SE 1524 Probe & Educate Top Reasons for Denial: When the physician from the acute/post-acute care setting is certifying the patient s eligibility for home health services but will not be following the patient after discharge, there is no documentation of the community physician who will be following the patient after discharge. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2, One of the criteria that must be met for a patient to be considered eligible for the home health benefit is that the patient must be under the care of a physician. Otherwise, the certification is not valid. This requirement only applies when the facility/referring physician is the certifying physician. If the facility physician or a hospitalist is providing the certification of the five required elements, confirm that the community physician is identified by the certifying physician. 33
MLN SE 1524 Probe & Educate Top Reasons for Denial: CMS has instructed that the MACs assure that the beneficiary meet all certification requirements at the start of care. The HHA is not providing the certification and face-to-face encounter documentation from the start of care (SOC) episode when the claim under review is a recertification claim. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.2, The reviewer will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid. Supply all of the documentation relating to the certification requirements and the faceto-face encounter for the SOC episode even on claims that apply to a recertification period. It is helpful to include the SOC POC with the recertification document, a physician s certification form if used, any of which can help support the physician certification for the initial episode. 34
MLN SE 1524 Probe & Educate Top Reasons for Denial: The recertification does not include an estimate by the physician of how much longer the skilled services will be required. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.2, The physician must include an estimate of how much longer the skilled services will be required. The HHA should review all recertification forms for the estimate of how much longer the skilled services will be required; if missing, obtain documented clarification from the physician before the services are billed to Medicare. 35
Pre Claim Review Demonstration The Centers for Medicare & Medicaid Services (CMS) plans to implement a three-year Medicare pre-claim review demonstration for home health services in the states of Illinois, Florida, Texas, Michigan, and Massachusetts. The demonstration began in Illinois on August 3, 2016. 36
Pre Claim Review Demonstration As of April 1, 2017, the Pre-Claim Review demonstration was paused for at least 30 days in Illinois. The demonstration will not expand to Florida on April 1, 2017. After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre- Claim Review requests. During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration. 37
Pre Claim Review Demonstration CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care. 38
Pre Claim Demonstration This demonstration could also: Reduce home health expenditures by avoiding the delivery of services that are not medically necessary or otherwise do not meet Medicare coverage requirements. Reduce burden on Agency providers by allowing them assurance that a claim is likely to be paid. 39
Pre Claim Review Demonstration The pre-claim review demonstration does not create new clinical documentation requirements. HHAs will submit the same information they currently submit for payment, but will do so earlier in the process. 40
Pre Claim Review Demonstration More information: www.cms.gov www.ngsmedicare.com From the home page, Medical Policy & Review, then Medical Review. Click on the blue box: 41
Educational Opportunities Educational Opportunities Go to www.ngsmedicare.com, click on the Education Tab, then hit the green Register button for any available events Bi-monthly webinar, Ordering & Certifying Medicare HH Services Bi-monthly on Tuesday 30 min webinars which focus on one or two pieces of HH eligibility YouTube Channel CBTs at Medicare University 42
Computer Based Training Sessions Clinical Education: CBTs at Medicare University To register and complete CBT courses you must log into Medicare University. If you do not have a Medicare University account, you can create one on the MU login page for free. Qualifying Criteria Face-to-Face Encounters & the Plan of Care Homebound Status & the Need for Skilled Services Certification & Recertification Documentation & the Additional Development Request (ADR) 43
Ask the Contractor Teleconferences JK/J6 2017 ACTs 2017 J6 Dates: 2/23/17 and 8/24/17 CMS Updates (CRs, MLM Articles, regulatory changes) NGS Updates (Articles, Educational Sessions) Questions Answered Live Generate Dialogue with Peers Minutes published on ngsmedicare.com 44
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References & Resources 47
2015 Federal Register Reference Federal Register Vol. 79, No. 215 Released: Thursday, November 6, 2014 Page 66117 http://www.gpo.gov/fdsys/pkg/fr-2014-11-06/pdf/2014-26057.pdf 48
Clinical Resources CMS Medicare Learning Network Article SE 9119 Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Services http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM9119. pdf In accordance with its references to Transmittal 92 & 208 in the CMS IOM Publications Manual 100-01 and 100-02
Clinical Resources CMS Change Request 9189 The purpose of this Change Request (CR) is to manualize policies in the calendar year 2015 Prospective Payment System Final Rule published on November 6, 2014, in which the CMS finalized clarifications and revisions to policies regarding physician certification and recertification of patient eligibility for Medicare home health services. https://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads /R602PI.pdf
Clinical Resources CMS Medicare Learning Network Article SE 1524 Selecting Claims for Probe & Educate Review: Episodes that Begin on or After August 1, 2015 https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE152 4.pdf
Clinical Resources CMS Medicare Learning Network Article SE 1436 Certifying Patients for the Medicare Benefit https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE143 6.pdf
CMS References & Resources CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6 https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/pim83c06.pdf CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10 https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c10.pdf 53
Resources Pre-Claim Review Demo Pre-Claim Review Fact Sheet https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs- Compliance- Programs/Pre-Claim-Review-Initiatives/Downloads/Pre_Claim_Review_Fact_Sheet.pdf Pre-Claim Review Demonstration for Services https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs- Compliance- Programs/Pre-Claim-Review-Initiatives/Overview.html Pre-Claim Review Demonstration for Services Operational Guide https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs- Compliance- Programs/Pre-Claim-Review-Initiatives/Downloads/PCRD_HH_Operational_Guide.pdf Pre-claim Review Demonstration for Services Frequently Asked Questions https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffscomplianceprograms/pre-claim-review-initiatives/downloads/faq.pdf
CERT A/B MAC Outreach & Education Task Force The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate. 55
CERT A/B MAC Outreach & Education Task Force CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT A/B MAC Outreach & Education Task Force https://www.cms.gov/medicare/medicare- Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task- Force.html NGS CERT Task Force Web Page Go to our website, https://www.ngsmedicare.com; in the About Me drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page. 56
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