(February 6, 2014): Before a Medicare beneficiary may be deemed eligible for home health services, a provider must perform a face-to-face encounter with the patient and certify that he or she is eligible for care. More importantly, the certifying physician must properly document this encounter. However, practitioners are commonly finding that their documentation do not include all of the statutory requirements. As a result, practitioners are seeing their claims for reimbursement denied as not medically necessary. Effective January 1, 2011, the Affordable Care Act directs that prior to certifying a beneficiary’s eligibility for home health benefits, the certifying physician must document that he or she – or a qualified non-physician practitioner (NPP) – performed a face-to-face encounter with the beneficiary. In order to be reimbursed for home health services, this encounter must occur within 90 days prior to the start of care or up to 30 days after the start of care. More importantly, the documentation of the encounter must include specific elements in order be considered valid. The encounter form should be titled Home Health Face-to-Face Encounter. The encounter form must include
“…an explanation of why the clinical findings of such an encounter support that the patient is homebound and in need of either intermittent skilled nursing services or physical therapy services.”
This is commonly known as the “narrative” portion of the documentation. The certifying practitioner must then sign and date the form.
I. Common Mistakes on Home Health Face-to-Face Documentation:
A majority of home health claims are denied due to “insufficient documentation” errors. These errors generally occur where the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation requirement is missing. Frequently, “insufficient documentation” errors result in claims where the narrative section of the face-to-face encounter form fails to sufficiently describe how the practitioner’s clinical findings during the encounter support the patient’s homebound status and need for skilled services.
For example, many denied claims present documentation with very little clinical information beyond a simple list of diagnoses, recent injuries, and / or procedures. This insufficient documentation will include instances where the need for skilled nursing services is justified only by a list of diagnoses. Additionally, some denied claims will document a beneficiary’s homebound status only with a general notation such as “gait abnormality” or “taxing effort.”
These two examples reflect information that is insufficient to support a reimbursable claim. The face-to-face encounter form must EXPLAIN WHY the findings from the encounter support the medical necessity of the services ordered, as well as the beneficiary’s homebound status. Furthermore, the Medicare Benefit Policy Manual Chapter 7 § 188.8.131.52, requires the documentation for a face-to-face encounter to include a brief narrative that “describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.”
II. Requirements for the Narrative Section:
So what must the brief narrative section of the face-to-face encounter form include? There are two required elements:
1. CONFINED TO THE HOME
The certifying practitioner must describe why the beneficiary is homebound. A patient is considered “confined to the home” (i.e., homebound) if both of the following two criteria are met:
i. The beneficiary must either:
a. Because of illness or injury; or need the aid of a supportive device (e.g., crutch, cane, wheelchair, walker), the use of special transportation, or the assistance of another person, in order to leave his or her place of residence.
b. Have a condition where leaving his or her home is medically contraindicated.
1) Patient ambulates a limited distance of 75’ with assistance of a walker due to recent acute stroke;
2) Patient has poor endurance, shortness of breath with minimal exertion due to congestive heart failure (CHF) and needs assistance to leave his home.
ii. There must exist:
a. A normal inability to leave home; AND
b. Leaving home must require a considerable and taxing effort.
1) Patient has a poor, deteriorating mental status and is unable to leave the home unsupervised;
2) Patient has frequent seizures and requires supervision / assistance of another person.
To qualify for home health services, the beneficiary must need intermittent skilled nursing services (SN), physical therapy (PT), occupational therapy (OT), or speech language pathology (SLP) services. More importantly, the certifying practitioner must describe what the SN, PT, OT, or SLP and other services will be doing within the beneficiary’s home. For example, “a skilled nurse is required to assess and manage the patient’s new sliding scale diabetic regimen.
· Skilled nursing services– Skilled nursing services must be reasonable and necessary for the treatment of the patient’s illness or injury. These services include, but are not limited to:
o Teaching / training;
o Observation and assessment;
o Complex care management;
o Administration of certain medication (primarily where beneficiary is unable to);
o Tube feedings;
o Wound care, catheters, and ostomy care;
o Nasogastric(NG) tube and tracheostomy aspiration / care
o Psychiatric evaluation and therapy; and
· PT, OT, SLP– These therapy services must be reasonable and necessary for the treatment of the patient’s illness or injury or to the restoration or mainteancne of function affected by the patient’s illness or injry within the context of his or her unique medical condition. If all other Medicare eligibility and coverage requirements are met, one of the following three conditions must be met for these therapy services to be covered:
1. The skills of a qualified therapist are needed to restore patient function;
2. The skills of a qualified therapist are needed to design or establish a maintenance program; or
3. The skills of a qualified therapist (NOT AN ASSISTANT) are needed to perform maintenance therapy.
Mr. John Doe is a 95 year old male hospitalized with congestive heart failure (CHF) exacerbation. His co-morbidities include asthma and poor / low vision. He is going home and needs skilled nursing services due to a new medication regimen and the high potential for a re-admission to inpatient care. He also needs PT services for strength training due to debilitation during his CHF exacerbation and safety assessment because he is at risk for falls. He is unable to leave his home without a walker.
Element 1: “Confined to the Home” status due to debilitation, CHF, low / poor vision.
Element 2: “Skilled Nursing Services” required due to medication regimen change. PT is required for strength training and home assessment due to patient’s fall risk.
III. Concluding Remarks:
These examples reflect the basic requirements that are needed to support proper face-to-face encounter documentation. A failure on behalf of the practitioner to include the requirements will result in a claim that is denied. Moreover, all of the skilled nursing, physical therapy, occupational therapy, or speech pathology services that have all been provided during the certification period will be considered not medically necessary. More importantly, the practitioner will not be reimbursed for those services. It is therefore important that every required element be included in the face-to-face documentation. For more detailed examples, please refer to the following Medicare Learning Network article provided by CMS.
Now, more than ever before, it is essential that home health providers ensure that their practices fully comply with these face-to-face encounter documentation requirements, as well as other applicable regulatory requirements. To do so, it is recommended that organizations regularly review their documentation, coding and billing practices. When conducting internal reviews, it is recommended that you discuss the approach to be taken with legal counsel prior to initiating such a review. As a final point, should you identify an overpayment, pursuant to another mandate under the ACA, the identified overpayment must be repaid to the government within 60 days. Failure to do so will constitute a violation of the False Claims Act.
In light of these new considerations and mandates, all home health agencies should review their current Compliance Plan to verify that these new risk issues have been incorporated into the plan. If you have not developed and implemented an effective Compliance Plan, we recommend that you immediately contact qualified legal counsel and engage them to prepare an effective Compliance Plan which takes your organization’s specific risks into account.
Robert W. Liles, Esq., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Liles Parker attorneys represent health care providers and suppliers around the country in connection with Medicare audits by ZPICs and other CMS program integrity contractors. The firm also represents health care providers in HIPAA Omnibus Rule risk assessments, privacy breach matters, State Medical Board inquiries and regulatory compliance reviews. For a free consultation, call Robert at: 1 (800) 475-1906.