CMS Proposes Changes to Medicare Home Health Benefit Face-to-Face Encounter Requirement

Multiple Patient Record

(July 18, 2014):The Centers for Medicare & Medicaid Services (CMS) has proposed several changes to the Medicare Home Health Prospective Payment System (HH PPS). Medicare pays Home Health Agencies (HHAs) through the PPS and pays higher rates for services furnished to beneficiaries with greater needs. One of the proposed changes to the HH PPS involves the face-to-face encounter requirements.

I. Requirement of a Face-to-Face Encounter

The Affordable Care Act (ACA) requires that a certifying physician or allowed non-physician provider (NPP) must have a face-to-face encounter with a patient before certifying the beneficiary’s eligibility for the home health benefit. The face-to-face encounter has to happen 90 days before care begins or up to 30 days after care began. The certification needs to be accompanied by documentation of the encounter, and this documentation has had to include a narrative explaining why the clinical findings of the encounter support that the patient is homebound and in need of skilled services. CMS is proposing three changes to the face-to-face encounter requirements:

  1. Eliminating the narrative requirement. The certifying physician would still be required to certify that a face-to-face patient encounter occurred. The physician will also still need to document the date of the encounter as part of the certification of eligibility, but a narrative justifying the patient’s need for home services will no longer be necessary.
  2. Only considering medical records from the patient’s certifying physician or discharging facility. In determining initial eligibility for the Medicare home health benefit, documentation will be limited to records from the beneficiary’s certifying physician or discharging facility.
  3. Considering the physician claim for certification/re-certification a non-covered service. If the HHA claim was non-covered because the patient was ineligible for the home health benefit, the physician claim for certification/re-certification of eligibility for home health services (not the face-to-face encounter visit) will be considered a non-covered service.

II. Documenting Requirements from Medical Records

The second proposal addresses questions which have been raised regarding which documents can be used to document a patient’s eligibility for the Medicare home health benefit. The new rule would only consider medical records from the patient’s certifying physician or discharging facility. Previously, face-to-face encounter documentation could include notes from multiple encounters that took place with multiple physicians and NPPs during an acute stay. It is uncertain how the new proposal will change this as the proposal does not specify what will constitute sufficient documentation. CMS does not require a specific form or format for the communication or documentation of the face-to-face encounter, regardless if a NPP, certifying physician, or the physician who cared for the patient in the acute or post-acute setting had the face-to-face encounter. What CMS does need to see is that the clinical findings that support the eligibility of the patient for home health are reflective of the patient’s condition upon discharge. Previously, a certifying physician could use documentation from the informing physician or NPP as his or her documentation of the face-to-face encounter, as long as he signed and dated the documentation, representing that he received that information from the physician who performed the face-to-face encounter, and that he is using that discharge summary or documentation as his documentation of the face-to-face encounter. It is unclear whether this process will be sufficient under the proposed rule.

III. Conclusion

In 2013, home health services cost Medicare approximately $18 billion. The goal of the proposed rule is to reduce payments for home health services. In addition to lowering costs and simplifying the face-to-face encounter regulatory requirements, other proposed changes include updating the HH PPS case-mix weights, revising the home health quality reporting program requirements, simplifying the therapy reassessment timeframes, revising the Speech-Language Pathology (SLP) personnel qualifications, and limiting the reviewability of the civil monetary penalty provisions. CMS will accept comments on the proposed rule until Sept. 2, 2014, and if adopted the rule will take effect next year.

Robert Liles represents health care providers in RAC and ZPIC appeals.

Robert W. Liles, Esq., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Liles Parker attorneys represent dentists, orthodontists, and other health care providers around the country in connection with both regulatory and transactional legal projects. For a free consultation, call Robert at 1 (800) 475-1906.