Home Health & Hospice Week

Warning: Other two contractors probably aren’t far behind.

Scrutiny of your face-to-face documentation won’t just be limited to certification episodes anymore — at least at one Medicare Administrative Contractor.

“For home health claims with a Start of Care on or after January 1, 2015, CGS will begin reviewing the face-to-face (FTF) encounter documentation for all home health episodes, including the initial (Start of Care) and subsequent episodes for appropriateness,” the MAC says in a new message to providers. “Previously, CGS only reviewed the FTF documentation when reviewing initial (Start of Care) claims. However, because the FTF documentation is a requirement for Medicare payment, all additional development requests (ADRs) for home health claims must include the FTF documentation.”

Warning: “Claims may be denied if the FTF documentation is not submitted or is incomplete,” CGS stresses.

CGS had announced the change back in early December, but then put the move on hold “pending further clarification” from the Centers for Medicare & Medicaid Services (see Eli’s HCW, Vol. XXIV, No. 1). Now the change is back on.

Reimbursement expert M. Aaron Little with BKD is “surprised to see the announcement, given the limited guidance CMS has offered for the 2015 FTF requirement,” he says. 

Watch out: Agencies served by Palmetto GBA or National Government Services shouldn’t feel safe. “Historical trends suggest that the MACs tend to follow similar procedures,” Little tells Eli. “It’s certainly reasonable to conjecture that a similar initiative could be forthcoming from the other two MACs.”

This added review will come on top of the additional 800,000 or so F2Fs CMS is requiring under new guidance published in the 2015 HH PPS final rule. “The face-to-face encounter requirement is applicable for certifications (not recertifications), rather than initial episodes,” CMS said in the rule published in the Nov. 6, 2014, Federal Register. In other words, when an episode requires a new OASIS Start of Care assessment, it’s a certification that requires a F2F, CMS explains in the rule. That’s true even if the second episode occurs within 60 days of the first one, and even if it’s considered a “subsequent” episode for PPS billing purposes (see Eli’s HCW, Vol. XXIII, No. 44). 

Note: See CGS’s announcement at http://cgsmedicare.com/hhh/pubs/news/2015/0215/cope28466.html.