Home Health & Hospice Week

MAC calls out agencies for not including physician records in ADR responses.

Medicare officials are trying to fine-tune their voluntary “Clinical Template” for the physician face-to-face encounter, but many home health agencies and certifying physicians are missing the entire concept — and that’s leading to claims denials.

How it’s supposed to work: Under the rules that were finalized in the 2015 HH PPS final rule and took effect Jan. 1, 2015, the Centers for Medicare & Medicaid Services scrapped the much-hated physician narrative requirement for F2F. Instead, however, a physician’s own record must substantiate the patient’s home care eligibility — and agencies must obtain and then submit those records for medical review when they receive an ADR.

One saving grace is that the physician can sign agency-furnished documentation into her own record, CMS has allowed. The physician still must have — and the agency must obtain and send to the HHH Medicare Administrative Contractor — her own clinical note for the F2F encounter which 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, MAC Palmetto GBA tells agencies on its website.

What’s really happening: Many HHAs are still using their old F2F forms and not obtaining and sending in doc records for ADRs. “Through review of the Comprehensive Error Rate Testing (CERT) error report and claims selected for the probe and educate project, [MAC] CGS has seen that home health providers are not sending the actual face-toface (FTF) encounter note in response to requests for medical documentation,” CGS says in a new post on its website. “Most often, providers are sending a form that includes the date the FTF took place.” The Medicare Benefit Policy Manual says “home health agencies must be able to provide supporting documentation to review entities, upon request. The documentation must support the certification of home health eligibility,” CGS explains.

“The documentation from the certifying physician’s and/or the acute/post-acute care facility’s medical records must contain the actual clinical note for the FTF encounter visit to demonstrate that the encounter occurred timely, was related to the primary reason the patient required home health care, and was performed by an allowed provider type.”

Bottom line: “To avoid denial of home health services, when medical documentation is requested by CGS or other review entities, such as the CERT Documentation Contractor (CDC), please ensure the medical records you submit include the actual clinical note from the FTF encounter,” the MAC instructs.

F2F Reckoning Coming

MAC medical reviewers took it relatively easy on HHAs for F2F last year. But now that the Probe & Educate reviews for F2F are cranking up, you can expect to see a lot more denials.

The changes CMS has made to the F2F Clinical Template have improved it a bit, allows nurse consultant Pam Warmack with Clinic Connections in Ruston, La. (see related story, p. 19). But “I seriously doubt [the template] will be successful in achieving the intent of CMS,” Warmack says. “The problem has never been the form itself. The problem is that physicians have no intention of completing any form to the degree that will satisfy the demands of CMS.”

Physicians document visits in their own records — usually electronic — for their own purposes, notes attorney Robert Markette Jr. With Hall Render in Indianapolis. Most docs are unlikely to use CMS’s form as a template to make their visit notes — particularly since it asks physicians to document items in much more detail than is usual in a physician visit note.

Template Isn’t A Home Health Form

HHAs have no control over whether physicians use this form, stresses Judy Adams with Adams Home Care Consulting in Asheville, N.C. “The bottom line is that it is not a form for home health agencies to use, it is a form for physicians to use,” Adams notes. “Agencies can accept and promote the form to their physicians, they cannot ‘use’ the form.”

Many HHAs that have adopted CMS’s Clinical Template form are likely using it as they did their old F2F form — as a document request for physicians to fill out after the visit occurs, not as a guide for how physicians should complete their own records. As an F2F form, this document “requires far too much documentation from the MD and he/she will not complete it,” Warmack expects.

As CGS’s notice shows, many HHAs simply do not understand how the new F2F rules work and don’t obtain/submit physician records for an ADR as required. And if they don’t understand the process, they can hardly educate their referring physicians on it properly, Markette tells Eli.

And as usual, CMS has not been doing much educating of physicians on the process either, industry veterans criticize.

With so much confusion around the F2F requirement, HHA claims under review don’t stand a fighting chance against denials. The new F2F rules are like “a de facto rate cut” for agencies, Markette contends.

Learn The Ropes Before It’s Too Late

Hopefully, agencies and referring physicians can work together to learn the new system. CMS has made clear that while the original physician visit note must include the date, provider type, and reason for visit (which must be the same as the reason for home care), the HHAs can furnish to the physician information that supports the rest of the F2F requirement — eligibility documentation regarding homebound and skilled service need.

Markette suggests doing away with F2F forms altogether, and instead implementing a system where you furnish the physician with a clinical summary or similar that covers the eligibility bases.

The catch: The physician must sign that agency document into her own clinical record with a date and signature, Markette emphasizes. That means for agencies, it’s not enough to provide the summary — they have to be sure it makes it into the physician record.

Another catch: And the physician must fork over that note and signed-in documentation when you need it to respond to an ADR. The original physician encounter note with the required elements, plus the agency summary with the eligibility information, “together may get us to something that looks like” CMS’s Clinical Template, Markette suggests.

But many agencies and their referring physicians are a heck of a long way from that process working — or even being initiated.

“After almost five years of working with physicians to educate them and even giving them examples of appropriate documentation, we are still struggling with this issue,” Warmack laments. “Quite a few physicians have stopped referring to home care because of this requirement and others simply don’t care if they complete the form [or other documentation] correctly or not.”

Alternative: The only other way an F2F clinical template will work is if CMS changes the form to checkboxes only, or if the HHA fills in the narrative portions of the form for the physician to sign, Warmack expects.

CMS could make the template mandatory for physicians after obtaining OMB approval, Adams muses. But that would lead to reduced home health referrals and widespread physician noncompliance, observers predict.