Medicare Home Health & Hospice Changes

A webinar for Medicare Home Health & Hospice Changes Physician Face-to-Face Encounters M. Aaron Little, CPA Senior Managing Consultant mlittle@bkd.com

LeadingAge Information Available Peter Notarstefano, Director of Home and Community-Based Services LeadingAge Website LeadingAge.org 202 508-9406 pnotarstefano@leadingage.org March 9, 2011 LeadingAge 2

Agenda Medicare physician face-to-face (FTF) encounters Home health Review regulations & requirements Offer process implementation strategies Provide sample implementation tools Hospice Review summary of regulations & requirements March 9, 2011 LeadingAge 3

Home Health FTF Encounters March 9, 2011 LeadingAge 4

New Legal Statute Physician FTF encounters required by law effective January 1, 2011 Patient Protection and Affordable Care Act http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf Federal Register dated November 17, 2010 http://edocket.access.gpo.gov/2010/pdf/2010-27778.pdf Documents establish requirements for both home health & hospice March 9, 2011 LeadingAge 5

New Legal Statute Centers for Medicare & Medicaid Services (CMS) instructed regional home health intermediaries (RHHIs)/Medicare administrative contractors (MACs) to delay enforcement of FTF requirements for both home health & hospice until April 1, 2011 https://www.cms.gov/homehealthpps/downloads/hill_ notification_face_to_face.pdf March 9, 2011 LeadingAge 6

Resources CMS Change Request 7329, dated February 16, 2011 https://www.cms.gov/transmittals/downloads/r139bp. pdf MLN Matters Article SE1038 http://www.cms.gov/mlnmattersarticles/downloads/se 1038.pdf March 9, 2011 LeadingAge 7

Resources Questions & answers (Q&As) CMS Home health Q&As Physician Q&As https://www.cms.gov/center/hha.asp Cahaba GBA https://www.cahabagba.com/rhhi/faqs/hh_face.htm CMS PowerPoint guidance https://www.cms.gov/homehealthpps/downloads/fac e-to-face-requirement-powerpoint.pdf March 9, 2011 LeadingAge 8

Qualifying Condition of Coverage FTF encounter required on all start of care episodes beginning January 1, 2011, & thereafter Encounters not required for recertification episodes Encounter required as Medicare home health qualifying condition Service eligibility Payment Requirements establish specific qualifying physician roles & activities March 9, 2011 LeadingAge 9

Qualifying Roles Qualified certifying physician1 Qualifying Activities Referring/ordering services1 Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) 3 Performing FTF encounter Signing & dating FTF encounter certification Signing & dating plan of care (POC) 3 March 9, 2011 LeadingAge 10

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) 1 3 Physicians & NPPs cannot have financial relationship with home health agency Must observe Stark laws & requirements Medical directors may perform encounters if serving as qualified certifying physician Cannot be paid by home health agency to perform encounters Must be doctor of medicine, osteopathy, or podiatric medicine March 9, 2011 LeadingAge 11

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) Could be either community physician or inpatient facility physician, i.e., hospitalist Attending physician, primary care physician, etc. Responsible for performing qualifying FTF encounter or supervising NPP encounter Responsible for certifying eligibility by signing & dating home health qualifying FTF encounter certification documentation March 9, 2011 LeadingAge 12

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) Typically performs all qualifying activities Refers/orders services Performs/supervises FTF encounter Signs/dates encounter certification documentation Signs/dates POC March 9, 2011 LeadingAge 13

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) 1 Non-inpatient facility physician Attending physician, primary care physician, etc. Serves as qualified certifying physician & performs all qualifying activities if referring/ordering home health Refers/orders services Performs/supervises FTF encounter Signs/dates encounter certification documentation Signs/dates POC March 9, 2011 LeadingAge 14

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility facility physician Qualified nonphysician practitioner (NPP) 1 3 If referring/ordering home health & willing to accept responsibility for patient after inpatient facility discharge then serves as qualified certifying physician & performs all qualifying activities Refers/orders services Performs/supervises FTF encounter Signs/dates encounter certification documentation Signs/dates POC March 9, 2011 LeadingAge 15

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility facility physician Qualified nonphysician practitioner (NPP) 1 3 If referring/ordering home health but unwilling to accept responsibility for patient after inpatient facility discharge then performs only some qualifying activities Refers/orders services Performs/supervises FTF encounter Signs/dates encounter certification documentation Community physician signs/dates POC March 9, 2011 LeadingAge 16

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) 1 3 Qualified NPPs include Nurse practitioner, clinical nurse specialist, or certified nurse-midwife working in collaboration with qualified certifying physician, or Physician assistant working under supervision of qualified certifying physician March 9, 2011 LeadingAge 17

Qualifying Physician Roles Qualified certifying physician Community physician Inpatient facility physician Qualified nonphysician practitioner (NPP) 1 3 May perform qualifying FTF encounter Must document & communicate findings from encounter to qualified certifying physician Qualified certifying physician must then sign & date home health qualifying encounter certification documentation March 9, 2011 LeadingAge 18

Qualifying Physician Activities Referring/ordering services 1 Performing FTF encounter Signing & dating FTF encounter certification 3 Activities may be performed wholly by qualified certifying physician Activities may be shared between community physician & inpatient facility physician Signing & dating plan of care (POC) March 9, 2011 LeadingAge 19

Qualifying Physician Activities Referring/ordering services1 Performing FTF encounter 3 Must be performed by qualified certifying physician performing FTF encounter Signing & dating FTF encounter certification Signing & dating plan of care (POC) March 9, 2011 LeadingAge 20

Qualifying Physician Activities Referring/ordering services Performing FTF encounter 1 3 Must be performed by qualified certifying physician referring/ordering home health services Signing & dating FTF encounter certification Signing & dating plan of care (POC) March 9, 2011 LeadingAge 21

Qualifying Physician Activities Referring/ordering services Performing FTF encounter Signing & dating FTF encounter certification Signing & dating plan of care (POC) 1 3 Must be performed by qualified certifying physician referring/ordering home health services & performing/supervising FTF encounter March 9, 2011 LeadingAge 22

Qualifying Physician Activities Referring/ordering services Performing FTF encounter Signing & dating FTF encounter certification Signing & dating plan of of care (POC) 1 3 Typically performed by qualified certifying physician referring/ordering home health services, performing/ supervising FTF encounter, & signing & dating FTF encounter documentation May be performed by community physician if inpatient facility physician unwilling to accept responsibility for patient after inpatient facility discharge March 9, 2011 LeadingAge 23

Attachment A March 9, 2011 LeadingAge 24

Payers Encounter required as new condition of both eligibility & payment but only for some payers Traditional Medicare primary Traditional Medicare secondary regardless of primary payer Ohio Medicaid Ohio-specific encounter requirements Does not apply to Medicare advantage or other payers yet Medicaid requirement forthcoming March 9, 2011 LeadingAge 25

Timing Encounter must occur within 90 days prior to or 30 days after admission All recertification episodes excluded from requirement March 9, 2011 LeadingAge 26

Timing Exception If patient dies during admission before FTF encounter occurs then certification is deemed to be complete If documentation substantiates to the satisfaction of the Medicare administrative contractor that the provider exercised a good faith effort to facilitate & coordinate the encounter, and If all other certification requirements are met March 9, 2011 LeadingAge 27

Timing Noncompliance If patient does not receive FTF encounter by day 30 Coverage requirements are not met & episode cannot be billed Patient may be discharged but cannot be held financially responsible Expedited Determination Notice & Home Health Advance Beneficiary Notice (HHABN) must be issued New start of care for billing is required once qualifying encounter has occurred Visits provided prior to qualifying encounter date can not be billed March 9, 2011 LeadingAge 28

Face-to-Face Encounters must be conducted FTF by qualified certifying physician or NPP Telehealth acceptable for FTF encounter If conducted at Medicare qualifying originating site Rural health professional shortage area, county outside of a metropolitan statistical area, or federal demonstration project site Office of a physician or practitioner Hospital Critical access hospital (CAH) Rural health clinic Federally qualified health center Hospital-based or CAH-based renal dialysis center Skilled nursing facility Community mental health center March 9, 2011 LeadingAge 29

Encounter Purpose Encounters must be related to primary reason patient admitted to home health If physician orders home health based on a new condition not evident during original encounter then a new encounter is required If standards of practice indicate that physician or NPP should examine the patient in order to establish an effective treatment plan March 9, 2011 LeadingAge 30

Physician Reimbursement Physicians & NPPs cannot be paid by home health agencies to conduct required encounters Administrative responsibility of qualified certifying physician or qualified NPP Home health agency not responsible for determining whether encounter is billable by physician to Medicare Part B Encounters performed only to satisfy home health requirement not billable by physician to Medicare Part B Encounters billable by physician to Medicare Part B if medically necessary covered service provided during encounter No changes to physician care plan oversight documentation requirements or reimbursement March 9, 2011 LeadingAge 31

Documentation Encounter documentation required to be incorporated into home health medical record Providers held responsible for qualified certifying physician s documentation that is incorporated into home health medical record Providers not held responsible for qualified certifying physician s documentation of encounter in physician s medical record Obtaining copies of physician encounter documentation is not sufficient to satisfy requirement Providers required to obtain documentation as a separate & distinctly identifiable section of home health certification or certification addendum Requires use of new certification addendum form March 9, 2011 LeadingAge 32

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Documentation Certification/addendum documentation must Be clearly titled, dated & signed by qualified certifying physician Include qualifying FTF encounter date Include clinical findings from qualifying encounter explaining why findings support Encounter was related to primary reason for home health Patient needs intermittent skilled nursing &/or therapy services Patient is homebound March 9, 2011 LeadingAge 34

Documentation Clinical findings must be composed by qualified certifying physician NPP cannot compose home health qualifying encounter certification documentation even if NPP performed FTF encounter NPP must document & communicate clinical findings to qualified certifying physician Qualified certifying physician may dictate documentation content to physician support personnel March 9, 2011 LeadingAge 35

Documentation Physician s support personnel may compile FTF encounter certification/addendum content by extracting information from physician s medical record entries Includes electronic health record entries Content must signed & dated by qualified certifying physician on certification/addendum Physician may not verbally communicate FTF encounter certification/addendum content to home health personnel to incorporate into certification/addendum Physicians may utilize their own electronic medical record s prepared descriptive language Use of home health agency s standardized language is not permitted March 9, 2011 LeadingAge 36

Documentation Documentation may be composed by qualified certifying physician using physician s medical record if Actual encounter date occurred within 90 days prior to or 30 days after home health start of care Documentation is received by home health prior to billing final claims Electronic documentation & signatures allowed If documentation is composed by qualified certifying physician If documentation is part of certification itself or addendum to it March 9, 2011 LeadingAge 37

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Documentation Receipt of documentation must correspond with timing of billing Requests for anticipated payment (RAPs) can be billed while agency waits for receipt of qualified certifying physician encounter documentation Final claims cannot be billed until after qualified physician certification encounter documentation received March 9, 2011 LeadingAge 39

Documentation Forthcoming program integrity instructions expected To instruct Medicare contractors responsible for medical review To instruct state surveyors with guidance on monitoring compliance Other program integrity oversight efforts will be used as vehicles to monitor compliance Office of Inspector General? Zone Program Integrity Contractors? Recovery Audit Contractors? Other? March 9, 2011 LeadingAge 40

Process Implementation Strategies Educate strategically Adapt intake documentation processes Adapt compliance processes March 9, 2011 LeadingAge 41

Educate Strategically 1 Internal personnel Intake & clinical personnel Administrative & marketing personnel Financial & billing personnel March 9, 2011 LeadingAge 42

Educate Strategically Internal personnel Intake & clinical personnel Administrative & marketing personnel Financial & billing personnel 2 Referral sources Key administrative & business office personnel Key inpatient facility discharge personnel Key referring physicians March 9, 2011 LeadingAge 43

Educate Strategically Internal personnel Intake & clinical personnel Administrative & marketing personnel Financial & billing personnel Referral sources Key administrative & business office personnel Key inpatient facility discharge personnel Key referring physicians 3 Patients Educate at time of admission Add as bullet discussion item to admission checklist Incorporate key language into existing admission documents March 9, 2011 LeadingAge 44

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Adapt Intake Documentation Process 1 Answer three key questions Who is home health referring physician? What physician will be signing POC? What physician is performing/overseeing qualifying FTF encounter? March 9, 2011 LeadingAge 46

Attachment B March 9, 2011 LeadingAge 47

Adapt Intake Documentation Process Answer three key questions Who is home health referring physician? What physician will be signing POC? What physician is performing/overseeing qualifying FTF encounter? 2 Determine physician(s) responsible for qualifying activities Community physician only Inpatient facility physician only Inpatient facility physician & community physician March 9, 2011 LeadingAge 48

Attachment B March 9, 2011 LeadingAge 49

Adapt Intake Documentation Process Answer three key questions Who is home health referring physician? What physician will be signing POC? What physician is performing/overseeing qualifying FTF encounter? Determine physician(s) responsible for qualifying activities Community physician only Inpatient facility physician only Inpatient facility physician & community physician 3 Submit documentation to physicians Adapt existing documentation tracking & follow-up processes Evaluate received documentation for content, signature & date Incorporate documentation verification into prebilling audit March 9, 2011 LeadingAge 50

Attachment C March 9, 2011 LeadingAge 51

Attachment D March 9, 2011 LeadingAge 52

Attachment E March 9, 2011 LeadingAge 53

Examples Scenario One March 9, 2011 LeadingAge 54

Examples: Scenario One Faxed referral received from community physician office Call placed to referring community physician business office to verify key referral information Community physician referring home health also performed qualifying FTF encounter March 9, 2011 LeadingAge 55

Attachment F Scenario One March 9, 2011 LeadingAge 56

Examples: Scenario One Faxed referral received from community physician office Call placed to referring community physician business office to verify key referral information Community physician referring home health also performed qualifying FTF encounter Community physician to sign FTF encounter certification & POC March 9, 2011 LeadingAge 57

Attachment F Scenario One March 9, 2011 LeadingAge 58

Attachment F Scenario One March 9, 2011 LeadingAge 59

Examples Scenario Two March 9, 2011 LeadingAge 60

Examples: Scenario Two Faxed referral received from hospital discharge planner Call placed to hospital discharge planner by intake department to verify key referral information Hospitalist referring home health also performed qualifying FTF encounter & willing to follow patient after hospital discharge until patient can be handed off to community physician March 9, 2011 LeadingAge 61

Attachment G Scenario Two March 9, 2011 LeadingAge 62

Examples: Scenario Two Faxed referral received from hospital discharge planner Call placed to hospital discharge planner by intake department to verify key physician information Hospitalist referring home health performed FTF encounter & willing to follow patient after hospital discharge until patient can be handed off to community physician Hospitalist to sign FTF encounter certification & POC March 9, 2011 LeadingAge 63

Attachment G Scenario Two March 9, 2011 LeadingAge 64

Attachment G Scenario Two March 9, 2011 LeadingAge 65

Examples Scenario Three March 9, 2011 LeadingAge 66

Examples: Scenario Three Faxed referral received from hospital discharge planner Call placed to hospital discharge planner by intake department to verify key referral information Hospitalist referring home health also performed qualifying FTF encounter but not willing to follow patient after hospital discharge Community physician identified to accept patient after hospital discharge March 9, 2011 LeadingAge 67

Attachment H Scenario Three March 9, 2011 LeadingAge 68

Examples: Scenario Three Faxed referral received from hospital discharge planner Call placed to hospital discharge planner by intake department to verify key physician information Hospitalist referring home health performed FTF encounter but not willing to follow patient after hospital discharge Community physician identified to accept patient after hospital discharge Hospitalist to sign FTF encounter certification Community physician to sign POC March 9, 2011 LeadingAge 69

Attachment H Scenario Three March 9, 2011 LeadingAge 70

Attachment H Scenario Three March 9, 2011 LeadingAge 71

Adapt Compliance Processes Establish admission policies Admit patients if qualifying encounter has not yet occurred? Establish discharge policies Continue services if qualifying encounter does not occur? Discharge patients once qualifying encounter window of time has passed? March 9, 2011 LeadingAge 72

Adapt Compliance Processes Utilize HHABN in appropriate situations To notify patient if discharging due to lack of qualifying encounter Must use new HHABN effective April 1, 2011, Option Box 2 https://www.cms.gov/bni/03_hhabn.asp Prior versions of HHABNs issued on and after April 1, 2011, for any purpose considered invalid Patient not financially liable for lack of qualifying encounter Change of care notice with no bearing on financial liability May deliver in advance of actual discharge date to allow patient additional time to meet requirement March 9, 2011 LeadingAge 73

Attachment I March 9, 2011 LeadingAge 74

Attachment I You have not had a face-toface visit with your physician within 30 days of your admission to this home health agency, as is required by Medicare. March 9, 2011 LeadingAge 75

Adapt Compliance Processes Adapt compliance monitoring Incorporate into existing routine documentation followup & tracking processes Incorporate into prebilling audits Incorporate into quarterly compliance chart audits March 9, 2011 LeadingAge 76

Hospice FTF Encounters March 9, 2011 LeadingAge 77

Hospice FTF Encounters Physician FTF encounters required by law effective January 1, 2011 CMS instructed RHHIs/MACs to delay enforcement of FTF requirements until April 1, 2011 March 9, 2011 LeadingAge 78

Hospice FTF Encounters CMS Change Request 7337, dated March 2, 2011 https://www.cms.gov/transmittals/downloads/r141bp. pdf Q&As National Hospice & Palliative Care Organization (NHPCO) Offered to NHPCO members only Cahaba GBA https://www.cahabagba.com/rhhi/faqs/hospice_face.htm March 9, 2011 LeadingAge 79

Hospice FTF Encounters Encounter must be FTF by hospice physician or nurse practitioner (NP) who is directly employed by the hospice or working under contract with hospice Applies to all patients whose total stay across all hospices reaches the third benefit period March 9, 2011 LeadingAge 80

Hospice FTF Encounters Failure to meet FTF encounter requirements results in failure to meet patient eligibility requirements Must occur no more than 30 calendar days prior to the third benefit period & no more than 30 calendar days prior to every benefit period recertification thereafter March 9, 2011 LeadingAge 81

Hospice FTF Encounters Timing exceptions If patient is new hospice admission & entering third or later benefit period then encounter can occur within two days of admission If patient is an emergency admission & physician can not perform encounter prior to admission If admission occurs at time when Medicare common working file is unavailable If patient dies during period of exception then encounter is deemed as complete All exceptional circumstances must be documented March 9, 2011 LeadingAge 82

Hospice FTF Encounters Documentation requirements Must be separate & distinct section of, or addendum to, recertification form Hospice physician or NP must attest in writing that he/she performed FTF encounter & must include date of encounter If encounter performed by NP then NP attestation must state that the clinical findings of that encounter were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less if the illness runs its normal course March 9, 2011 LeadingAge 83

Physician Dates 84

Physician Dates Physicians must date all signatures Home health plans of care, verbal orders, & certifications Hospice certifications/recertifications Date received stamps no longer acceptable Effective January 1, 2011 Cahaba GBA Effective for all claims submitted on or after January 1, 2011 Palmetto GBA Effective for all documents signed on or after January 1, 2011 March 9, 2011 LeadingAge 85

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M. Aaron Little, CPA Senior Managing Consultant mlittle@bkd.com www.bkd.com March 9, 2011 LeadingAge 87