Home Health & Hospice Week

Sharpen your ADR tracking process.

You must kick your face-to-face processes and documentation into gear as Medicare’s “Probe & Educate” campaign cranks up, or you could face denials and never-ending prepay medical review.

Reminder: The Centers for Medicare & Medicaid Services announced the P&E program focused on F2F in early summer, and released details in an MLN Matters article last month (see Eli’s HCW, Vol. XXIV, No. 40). The P&E initiative aims “to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements,” CMS says in MLN Matters No. SE1524. Specifically, CMS highlights the requirement that took effect Jan. 1: “documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) is to be used as the basis for certification of home health eligibility,” the article notes.

Confusion about the F2F requirements that took effect this year continues to abound, amongst both HHAs and referring physicians. To master the new F2F rules and ward off expanded medical review based on P&E results, heed this advice from MACs and industry veterans:

• Know the rules. Under the requirements that took effect Jan. 1, the physician’s record must prove a patient’s home health eligibility. However, “the certifying physician can incorporate information obtained from or generated by the HHA into his or her medical record, to support the patient’s homebound status and need for skilled care, by including it in his or her documentation and signing and dating to demonstrate review and concurrence,” CMS allows in the MLN Matters article.

But there are certain elements that the physician record must contain on its own, HHH Medicare Administrative Contractor Palmetto GBA notes in a new F2F article on its website. “The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain the actual clinical note for the F2F encounter visit that demonstrates that the encounter: Occurred within the required timeframe; Was related to the primary reason the patient requires home health services; and Was performed by an allowed provider type,” Palmetto reminds agencies.

The Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2 specifies that the record must also “contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: Need for the skilled services; and Homebound status,” Palmetto notes.

But agencies are allowed to assist with that piece. “Information from the HHA, such as the initial and/or comprehensive assessment of the patient … can be incorporated into the certifying physician’s medical record for the patient and used to support the patient’s homebound status and need for skilled care,” Palmetto allows. “However, this information must be corroborated by other medical record entries in the certifying physician’s and/or the acute/postacute care facility’s medical record for the patient.” Palmetto also specifies that agencies can’t complete any F2F forms for the physician (see related story, p. 330).

• Educate your staff. Once you’ve got the basics of the new rules down, educate your staff on them, experts advise. Include information that CMS and its contractors have issued throughout the year, from manual updates to transmittals to MLN Matters articles.
• Educate your physicians. Docs are certainly tired of the byzantine and ever-changing rules for the F2F encounter, but they’ll need to comply with them if they want their patients to receive home care services. Fill them in on what’s required and how you can help them plug any documentation holes with your own information to be signed and dated into the record.
• Nail down policies. If you have docs who won’t furnish the required documentation, you’ll likely have to make the tough decision to cut them loose as referral sources, experts recommend. Update your policies and procedures to reflect this process.
• Watch for ADRs. As specified in last month’s MLN Matters article No. SE1524, HHH MACs will select five claims for pre-payment review under the P&E program. If as few as two claims get denied (based either on F2F or other reasons), the agencies will be subject to five more claims reviews, and so on. MACs will furnish results letters with detailed information on denials and offer one-on-one educational calls (see Eli’s HCW, Vol. XXIV, No. 40).

HHH MAC CGS will attach edit code 5013W to claims suspended under the program, it says in a new article on the process. “Depending on your daily billing volume, more than five claims may initially suspend for this probe,” the MAC tells agencies. “Any suspended claims, over the required five, with edit code 5013W, will be released by CGS to continue processing within 24-48 business hours.”

Deadline: If you overlook ADRs under the P&E program, you’ll be subject to denials and yet more cycles of review. Be sure to keep an eye out for the record requests so you can respond to them within the 45-day time limit, CGS says on its website.

• Do your own review. “Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency,” the MAC advises.

Smart agencies will ask for F2F documentation from docs up front, so they merely have to assemble the documents and submit the response. If you have to scramble to get your clinical information signed into the physician record, and to secure the clinical note indicating the three elements required to be furnished by the physician, you’ll be hard pressed to meet the deadline, experts warn.

Note: CGS’s article is at www.cgsmedicare.com/hhh/pubs/news/2015/1115/cope30934.html. CMS’s P&E MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1524.pdf.