Health Information Compliance Alert

Published on Sun Jun 10, 2012 PDF

Beware the fine print, however.

Medicare has finally loosened up on some unnecessarily strict documentation requirements for face-to-face encounters with physicians. But just how loose the rules have gotten is under debate.

In a new MLN Matters article, "A Physician's Guide to Medicare's Home Health Certification, including the Face-to-Face Encounter," the Centers for Medicare & Medicaid Services for the first time gave its official approval to physicians using checkboxes in their documentation of the F2F encounter. "The face-to-face documentation can include, or exist as, checkboxes so long as it comes from the certifying physician," CMS clarifies in the education document.

This is an about-face from earlier CMS statements, which said checkboxes were not allowed and that physicians must write a narrative in their own words.

Reminder: "For initial home health certifications, the certifying physician must document that the physician himself or herself, an allowed NPP, or a physician caring for the patient in an acute or post-acute facility who has privileges at the facility had a face-to-face encounter with the patient," CMS explains in the article. The encounter must occur up to 90 days before or 30 days after the start of care.

"The article provides relief to home health agencies and physicians in the change in CMS policy to allow for the use of checkboxes," cheers the National Association for Home Care & Hospice.

Consider Carefully Before Using Checkboxes

But CMS's communication about checkboxes isn't entirely clear, leaving some providers reluctant to encourage referral sources to use them.

The MLN Matters article still also says that "documentation includes a brief narrative which describes how the patient's clinical condition, as seen during that encounter, supports the patient's homebound status and need for skilled services."

And in a new set of questions-and-answers about F2F topics, CMS replies "it depends," when asked whether referral sources can use F2F forms that utilize checkboxes. "We would not allow a form created by the HHA, which contained only checkboxes for the certifying physician to check off, to satisfy the requirement," the agency warns.

However: "We accept documentation which was generated and/or extracted from a physician's medical record by the physician's support staff, assuming it contains all the required content, regardless of what format it is in," CMS continues. "As long as it comes from the certifying physician, checkboxes either generated from a physician's electronic health records, or more simply created and used by a physician for documentation purposes, are allowable."

In a separate Q&A, CMS says it's OK for physicians to "use their own electronic medical records with drop down menus to select from prepared descriptive language when completing the face-to-face encounter documentation."

"This allows the sort of flexibility where such documentation could be dictated by the physician to one of his support personnel, or to allow it to be generated by the physician's electronic medical record software," CMS explains. "Such is common practice for physicians to document their patient encounters."

Bottom Line: Documentation Content Is Key

"The information from CMS on this point seems inconsistent," rues Washington, D.C.-based health care attorney Elizabeth Hogue.

However, home health agencies probably shouldn't worry too much about it. "In my communications with the staff at CMS regarding the documentation requirements, the staff has stated that it doesn't matter how the required elements of documentation are presented, including the use of boxes to check, so long as all of the information is there," Hogue tells Eli. "I have even submitted proposed forms to the staff at CMS that providers want to use that include boxes to check off and the staff has stated that the use of these forms will meet applicable requirements."

Remember: F2F documentation must include these five elements, CMS reiterates in the new Q&As:

1) the patient's name;

2) date of the encounter;

3) how the patient's clinical condition as seen during the encounter supports homebound status and the need for skilled services;

4) the certifying physician's signature (original signature, a faxed copy, copy of original document with signature or electronic signature -- but not stamped signature); and

5) date of the certifying physician's signature.

Remaining flexible on the documentation format, as long as it includes the necessary elements, "seems like a very sensible approach to the issue of what constitutes adequate documentation in a process that is otherwise difficult to square," Hogue concludes.

Note: The new MLN Matters article is online at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1219.pdf. The Q&As are at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/QandAsFull-5-4-12.pdf.