Home Health & Hospice Week

The other shoe has dropped for this burdensome regulatory requirement.

You can watch your Medicare reimbursement circle the drain if your patients’ face-to-face physician encounter documentation isn’t meeting exacting standards.

Earlier this year, the Comprehensive Error Rate Testing (CERT) program began denying an increasing number of home health claims for not meeting face-to-face documentation requirements, report HHH Medicare Administrative Contractors Palmetto GBA, CGS and NHIC. "The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show: the encounter was related to the primary reason for home care; how the patient’s condition supports the patient’s homebound status; or how the patient’s condition supports the need for skilled services," CGS explains in a post on its website.

Consultant Pam Warmack with Clinic Connections in Ruston, La., has seen the latter two reasons cited most frequently, she relates. And often the denials are based solely on F2F reasons.

Now CGS is launching a widespread probe aimed specifically at F2F problems, it says. Home health agencies served by Palmetto already have seen lots of Additional Development Requests and denials based on this issue, experts tell Eli. "There’s a tremendous amount of ADR out there," observes clinical consultant Betty Gordon with Simione Consultants in Hamden, Conn.

And despite earlier statements to the contrary, all the HHH MACs now agree that they will be requiring F2F documentation for all home health episodes, not just initial episodes. "The face-to-face document needed may be for an earlier certification period," MAC NHIC clarifies in a message to providers. "Both the certification and the face-to-face encounter documentation are required."

Watch out: Expect to see F2F-related de-nials increase further as review on this issue ramps up, says Lynda Laff with Laff Associates in Hilton Head Island, S.C.

MACs Sow Confusion About F2F Requirements

Reviewers are shooting down claims that have inadequate F2F documentation, for reasons ranging from listing diagnoses only to vague wording (see box, p. 170, for examples of inadequate documentation).

But HHAs, not to mention physicians, are still confused about exactly what is and isn’t acceptable. And sometimes MACs are compounding the problem.

For example: "Some procedures like total knee replacement can demonstrate the homebound status and the need for skilled therapy services," NHIC says in its article for providers. "Other diagnoses like diabetes need additional explanation as to why the person is homebound."

But in its provider article, Palmetto lists "recent procedures alone, such as total knee replacement," as an example of inadequate documentation for supporting homebound status.

Extra F2F Documentation Stops Referrals

Increasing review for F2F is galling, because HHAs’ reimbursement hangs in the balance, but the physician’s documentation that will make or break it is out of agencies’ hands.

"It is so unfair that providers are being denied entire episodes of care on the basis of documentation that they have no control over," Warmack tells Eli. "They have no skin in this game so they have no incentive to be in compliance."

"Why should home care be penalized?" Gordon asks. "We’re being held accountable for somebody else’s practice."

Bottom line: Many physicians "simply don’t care enough to document as is necessary," Warmack laments.

Many providers believe the Centers for Medicare & Medicaid Services far exceeded congressional intent when it required the narrative documenting the reasons for homebound and medical necessity. Just proving the encounter took place and that the physician certifies the patient for home care should be enough, they fume. Agencies and their representatives continue to lobby Congress for legislation that would make that explicit.

Impact: "Many physicians have stopped referring to home care because of this documentation requirement," Warmack says.