WEBINAR: Navigating the Face-to-Face Home Health Documentation in the Physician Office December 6 @ 12:00 pm - 1:00 pm Good afternoon everyone. I am Olivia Henze from the New England QIO. I am your moderator for this webinar. The quality innovation network quality improvement organization works with healthcare providers stakeholders and communities across New England on data-driven quality initiatives. Thank you for joining us for today's webinar. Before we get started, this call is recorded for training purposes, I will provide you with details on accessing the recording at the end. The phone lines are on Mute and we will take questions at the end. I will provide instructions. At this time I would to pass over to Brenda Jenkins. Thank you Olivia. I am a senior program administrator here at the New England QIN- QIO. We are fortunate to have a couple of VNA nurses from Rhode Island. We have Mary Biello an RN, she serves as the cochair of the greater Providence transition coalition she has over 25 years experience in homecare providing care to vulnerable and chronically ill populations, or focus as the liaison is to support safe transition of patience and export evidence based innovative methods that become the foundation of best practices. She is involved in several collaborations to set standards for the improvement of the quality of care and recognized for making recommendations for evidence-based clinical measures. We also have Charlene Eggeman who is an RN VS and certified diabetes educator and certified cardiovascular disease outpatient educator, with over 29 years experience of nursing including critical care and care in the community. She has served as the case manager for a practice where she is assisting the practice to be the first in Rhode Island to achieve level III recognition, currently she serves as the quality compliance clinical supervisor in Newport. Finally we have Doctor Christopher Campanile who is a family practice physician at coastal Hillside medicine and also a clinical consultant here at the New England QIN- QIO. Without further ado we will move on to our first question. How confident are you in your knowledge of Medicare's acceptable five criteria language on the face-to-face home health document? Very confident, confident, somewhat confident, not at all confident, or it is not applicable. You have 30 seconds to answer the question.
We have somewhat confident as the first and there is just a spread from being very confident to not confident at all. We will try to answer any of those questions that are outstanding for the criteria today. Homecare has been an important resource today we're speaking up a collaborative process that we took in Rhode Island, this provides background on my home health face-to-face certification is out the country, it's a national issue because we are all health physicians there were 3.5 minute where is he from healthcare Services provided by approximately 12,000 homecare agencies, at a cost to Medicare of $18 billion. Which is a lot of money but in comparison to other healthcare providers it's actually a pretty cost-effective homecare is a service that takes care of people and individuals who are functionally and cognitively disabled or to have an acute exacerbation of an illness, and are unable to care for themselves. Face-to-face came into being in 2011. Anyone who is receiving home care services must have the required documentation in place, the encounter can take place in a hospital, a skilled nursing facility, physician's office or a rehab facility, typically it is at the time of the patient's discharge but can also be during a routine office visit with a PCP or with a special practitioner, a patient must be homebound in order to receive homecare services. We have found that this is not a well understood requirement by committee visits but by Medicare definition this does not necessarily mean that a person is confined to their home. One can still be considered to drive and two and the appointment to get there prescription and then in addition to that they can attend religious services, special occasions, and the hairdresser. Typically they require assistance of either a person or device to help them so that clarifies the a little bit. Another important component that CMS is looking for is what is the skill, home health can provides intermittent care to patients specifically geared toward whatever there facing, we will give later information about what skills are needed, who can complete the face-to-face. Face-to-face encounter can occur between a nurse practitioner, physician assistant, or the physician. That could be a resident. It must be signed by a PECOS. PECOS is an acronym for provider enrollment chain and ownership system. Which means that you can bill Medicare for your services. When we receive referral we need to confirm that the physician is in fact PECOS certified, because unfortunately some unknown to them and unknown to the referral entity has had the certification lapse. So this removes them as eligible to sign our orders or complete the face-to-face documentation.
We need to determine if there is a colleague in the practice will sign for them or specialist also involved in the patient's care that could sign in their place. The face-to-face encounter is in a counter that is time sensitive must be 90 days prior or within 30 days of the start of home care services. This should have been great and a good thing for home health, we are increasing the communication, unfortunately there were some unintended consequences from this, the hospital initially up until a year ago felt as though with the responsibility of the community physician to fill it out because they were the most familiar, and the community physician felt it was a responsibility of the hospital, because they impact the services, so we were caught in the middle. A year ago we work with us in the hospital and now the information has been added to the EMR and for the most part we can get the documentation that we need. The impact on home health has management as we had to sign people clinicians, to obtain this information to make sure all the criteria is present so we are able to file our claims. Why the chase? Information that is lacking is important so we can bill for services, so that puts the agency in a difficult position of being 100% dependent on other clinicians for documentation that they have zero incentive to provide, so That's not really been a good position to be in so why would we take the referrals when we don't have the information. When you recognize at the end of the referral there's a person who typically has comorbidities or psychosocial issues, etc., we feel a sense of accountability in this transition of process we want to be good partners we want to prevent the unnecessary emergency revisits and the hospitalization. We recognize the vulnerable patients that we take care of and we want to make sure that we keep them in the home which is where they want to be. Unfortunately we don't want to talk about money as clinicians but there is a financial uncertainty when we don't have this documentation in place. It is important that we all work together because the solvency of the agency serving the beneficiaries is at stake. If we start closing agencies because they don't have money it will decrease the access for people in the committee to have home health and we don't want to see that happen. The solution, Charlene and I got together and we collaborated to create a tool that was standard, and inform physicians what the five criteria are so we could make it easier instead of having 27 different home health agencies, Surrey Medicare, maybe if we had one tool it would simplify it and make it easier. The goal is to minimize time spent by all clinicians.
So we can go about the business of taking care of the patients. So we will talk about the tool, and what we created. We attempted to create the fastest way to correct the certification, no longer a specific reform is required and CMS changed the requirements to no longer meet the merit of what Medicare wants is a statement certifying that five criteria for home health have been that, for hospitals this documentation can be found in the discharge summary or in the COC. When the patients and physicians are in the office, the progress note is the best way to find this and that makes it easier for us. The certifying statement must be dated and signed, it cannot be signed by a PA NPR resident. Previously mid-level practitioners can complete the face-to-face but they cannot sign the statement with red medical records that must be documentation to support each criterion and we will go over that later. National government services, this is the CMS agent, this is a super busy slide, take away is really positive for home health aides in a nutshell of documentation is missing to support skills, CMS is allowing a home health agency to provide the physician with the information, if there is areas in the clinical therapy or occupational therapy, we can gather those notes for skilled nursing and we can add that along with some information from the oasis and put that together as an addendum and we fax that to the physician. What we were doing is taking those pages and numbering them and stamping the back with our stamp that says that I review the information and will incorporate it into the patient's record. The physicians are signing, dating and faxing back the last page. To remember, most important thing is this documentation is going to be used for verification of eligibility criteria it has to be signed and dated prior to the claim. The following slides will review the five elements of eligibility criteria, it will be followed by the cheat sheet which will be available at the end of the webinar. The first criteria is the homebound status. The definition from Medicare, patient either needs support of devices with the help of another person or a condition which makes leaving a medically inadvisable, leaving home without the assistance requires considerable effort, the patient is still considered homebound if they can leave home easily with caregiver support. So the patient is unable to leave their home independently, and safely, these patients are homebound. This documentation should be found anywhere in the patient's record from the certifying physician. Criteria number two the need for skilled services. The physicians need to be specific as to what services they are being ordered and why, on the backside will give several
examples, acceptable reasons, physically the doctors ordering the skilled nursing they need to write the reason why so if a patient is going to need skilled nursing for cardiopulmonary, they need to write that or it could be for medication reconciliation, education or whatever. Criteria number three the plan of care, the facility that discharges plan is usually spells out the plan of care nicely and it's by the referring certifying physician and that's the doctor that prompted the home health referral to begin with. The physician office got the plane of care written in the progress note so within the face-to-face progress note at the time of the office visit the plan is written beautifully and those are usually very easy to meet the criteria. Criteria number four physician oversight of home health services, the certifying physician must name the physician was agreed to monitor the home health services at the time of the referral. No longer is it sufficient to write that the patient is going to follow up with her PCP. That position has to be written in the discharge plan. As you can see this reinforces transitions of care throughout the continuum. Now we come to criteria number five. The physician needs to have the patient visit within 90 days prior to the home health referral or within 30 days afterwards. The encounter could have been done by a resident and still count. The face-to-face encounter must be for the same reason the patient being referred to for home health services. If a patient is referred due to a COPD exacerbation to visit has to include that in his documentation for the face-to-face progress note. Now we will look at the Cici. This is a two-sided one page document, this is the front and everything we have just addressed is on this front page if we go to the next slide, these are the examples of some of the reasons why the physicians would order the skilled care, some physicians are putting these in their exam rooms and what they do if you look at it closely, if you or occupational therapy, it has to be for the reason of an increased independence of ADLs or instruct and train, or recent such as that things like physical therapy, skilled nursing, it is all listed here, some examples of what CMS will consider skilled needs. We will go over a sample of the acceptable documentation. This is a patient who is a 79-year-old female who presents to the office with her daughter they reporting a noted increase in caregiver need due to weakness and fatigue. No longer able to manage her ADLs without assistance. She has increased gait disturbance with reported recent falls in the home, although this patient refused the assistant device in the past she is willing to discuss now.
In that note, homebound status is in that note, even note it is not spelled out you can infer from the note that this patient is homebound by looking at her gait disturbances, her weakness, fatigue etc. She needs more help. The doctor nicely wrote out the plan which is having VNA for skilled nursing, medication reconciliation, and increased independence with ADLs. As you can look at this note you see the five criteria, because this position is also the one place in the referral, for a visit, therefore the physician is overseeing the plan of care, so all five elements of eligibility are nicely written. This is an example of follow-up visits to the doctor after a skilled nursing facility stay, to this particular patient was hospitalized with congestive heart failure, then went from the hospital to the facility, for rehab, the patient is currently followed by VNS, this is acknowledging that there was a transition and that they are aware at the primary care office that the patient is currently receiving services and why they are receiving them. It gives CMS an example of the care continuum that has preceded and everybody was taking care of the patient is acknowledging that so they also would like us to have the doctors acknowledge that they have received the CSA and they are currently going to be managing, no longer will the patient be managed by the hospitalist or medical director. Now we will ask only question number two, in regards to the information that was shared, we recognize that it was difficult to see the Cici on the slide but we will provide that to everyone at the end of the webinar. The question is how likely are you to reference the five criteria cheat sheet review in this discussion by completing your face-to-face home health documentation? You have 30 seconds to answer, please hit the submit button once you have selected your answer. It looks like the majority are very likely to use the documentation. That was the goal of sharing. We will share a quote that sums up everything, "the greatest opportunities for improving care transitions center around improving communication, building cross setting relationships and redesigning workflow." Now I want to turn it over to Doctor Christopher Campanile for his perspective Thank you I could not agree more with the quote, I think of this as a referral in essence and it's just a referral that requires a little more documentation than the referral and make to the orthopedist for shoulder tendinitis. Certainly from a provider perspective, I want to minimize the time and effort that's needed to provide the
documentation that is needed actually want to see the services provided to the patients that need them I want to see the home health agencies reimbursed. It seems to me, is that it is requirement from the CMS that the documentation to be included in the progress note, my experience is that I would receive a form that I would have to fill out even worse, right on and that I would have to do a mini chart audit for visits that already happened and that's really not ideal in many ways, the fact that we are really moving to document it in the progress note I think that could be a silver lining to this whole metamorphosis, I think what is needed is for me as a provider, to be able to do the documentation in the progress note, would first be to know which patient I am seeing that is the hospital follow-up were SNF discharge follow-up it someone who is receiving home health services, I don't see lots of people that come out of the hospital but they are doing fine for it just wasn't a situation where they needed any home health services after but I need to know which ones are patient that have needed or will be needing a referral documentation for home health services. For that to occur in my setting, I need my buddy to know about that because she does previsit planning, she sets up a visit for me, she does standing immunization she puts in appointment notes that tells me I need to do a urine tox screen for someone on chronic pain medication in that same appointment note, I need to see something that just says, F-2-F home health. Something like that. And in that regard I know that part of that visit because a visit is going to cover a lot of different things, part of the visit I need to make sure there is proper documentation for a home health referral. I think, that for the moment we use electronic health records we use eclinical works, which seems to be amenable to modification, we use templates that we use as a whole notes or the push and as a part of a note, with almost every visit, for the moment while I am working with IT people at my practice, I would be using the guidance cheat sheet to make sure I am covering all the bases for proper documentation. I think also in that appointment note if I know the name of the home health agency and the fax number once I have signed and lock my note, I can easily send the note back from the computer straight to the home health agency so that really closes the loop it ensures I have a note that has all the document patient and I have instantly transmitted it back and I don't have any work to do tomorrow for what happened today. Other than that, I think if there are people that are still using paper records they could use a form and really put that form into the paper record and consider it part of that note.
At this point I really want to pursue this because I see it as a real practice improvement opportunity, and I'm always open to further transformation to improve performance in our practice, and what I would think would be for my practice, taking myself as a physician champion and my NA, to meet with home health agency representatives and my practice manager, and start working on a revised workflow where the home health agency notifies us of an coming visit that will require face-toface documentation, they know to put that in my note and I am using the paper guide to make sure I include everything or I got to the point where I'm just pushing in a template that allows me to do it electronically and I faxed it back. So that's what I see as a male fix-it approach to this problem that I'm sure has a lot of unseen details to work out but that is what I would think of as an approach to this problem. It sounds like that type of workflow is minimized to delay services or lack of services for the patient and for the home health agency the risk of denial of claims. Now we can open up for questions. If you want to ask a question you can type in the chat box, or you can ask your question via the telephone, press pound six. While we are waiting, perhaps we could ask Mary if you have any recommendations for the physician's practice is to adopt. I think the approach is good, they are willing to let us come to speak with them, home health is willing to do anything, I can speak on behalf of all of us, and say, we will provide some laminated sheets, we will talk to your manager, we are available by phone, fax, or a visit to the office, whatever works best, is a collaboration between the settings that is going to take this away from being a problem and making it a standard of practice. The goal is to take the clinicians that we have assigned in home health, we are spending valuable time working on getting this information and putting them back out to taking care of patients, all of them, it would be better if we were improving our practice and providing standards of care versus chasing documentation that we need to bill for our services. There are a couple of comments in the chat box. According to Shelley, you can sign the document without a counter signature. Yes. We were talking about the certification. Can you provide clarity?
The face-to-face is the visit, and the nurse practitioner or mid-level practitioner can find a face-to-face but they cannot sign for the five elements of care. If the five elements are in the progress note, then the empty has to sign. That's another workflow issue, we have a new nurse practitioner and we cosign for notes for credentialing but she we need to know when she did a face-to-face, she does push it over to whoever the PC fee for the patient is. They cosign it electronically. We have another question, in the past homebound status have to be stated and not implied, your knowledge now stating CMS will accept implied homebound status rather than stated? Yes. That can be anywhere in the medical record. From the episode. It doesn't have to be homebound because of, but if you're stating all of the reasons why patients homebound, it can be inferred. When I read the second note that you reviewed, I was thinking to myself, what in this note from the hospital SNF discharge example really set that person was homebound. That would have come from the referral, the skilled nursing facility or hospital would have addressed the status in the referral, you are doing a follow-up visit so it's just your getting the warm handle so to speak from the referral, if during the period of time that a patient is on service they no longer are homebound, home health will not continue to service them, it is difficult to service people who are not home but we also want to be providing care that is something that CMS recognizes is necessary so if they are not homebound we would call you and say this patient is no longer homebound, we're going to be discharging them. Is the one have an opinion with the new presidency of the face-to-face regulation will it go away? I don't think we have enough knowledge to speculate on that topic. What do you do if you haven't seen a patient in the time frame is 90 days before or 30 days after? I had a patient who had not seen since spring they sent me the face-to-face but we haven't seen him and now he is back in the hospital. Yes beginning services but we have not signed. We have had that issue come up, from physician referrals, it is difficult if they have not been seen and we accept these referrals in good faith because the patient will have
a scheduled follow-up visit. Unfortunately, patients that have not seen her doctor 90 days fire to the start usually have significant barriers to getting to the doctor's office so have a scheduled appointment within 30 days is a start, that is great but what is the likelihood of being able to keep the appointment and that has been a problem. We've had some positions -we continue with services, we have eaten a lot of those bills because the patient hasn't been able to keep the appointment, so this is an issue we try very hard patient was hospitalized, you should be able to get face-to-face information from the hospital referral I don't know if that would cover you for the visits you made previously. It sounds like the patient was actually in the hospital prior to the face-to-face. Somebody had to have referred the patient to home healthcare. It sounds like he was seen at home and then sent back to the hospital so it's unclear. Any other questions? This has been a good discussion. I appreciate you taking the time to share your expertise with the participants. Hopefully folks will be coming away with some new understanding of what the criteria is, and what the acceptable language is in terms of what they are expecting to be incorporated into the progress notes. We will send out an evaluation to everyone that participated on the call. With that we will also be sending you out a copy of the cheat sheet. If there are no other questions, we can give you back 20 minutes of your day. Thank you. I want to let you know, the presentation has been sent out and the cheat sheet In the email that went out and we will send the information in a thank you evaluation. I want to thank you for a great discussion. When you close out of the webinar, the evaluation will pop up on your screen, please fill it out. If you don't have time to fill it out right now, or you are currently sharing a computer, you will receive the email tomorrow with a link to the evaluation. As well as the link to the events page. In a few days the website will have a recording and a transcript of the webinar. Thank you for everyone for attending. Thank you to the presenters. Have a great day. Thank you. [ Event concluded ]