Home Health & Hospice Week

Watch out if you carry a heavy managed care patient load.

How you currently handle hospitalizations, PEPs and readmissions will determine how much a new F2F clarification burdens you in the new year.

In the 2015 home health prospective payment system final rule, the Centers for Medicare & Medicaid Services makes a change to when it re-quires face-to-face physician encounters for home health patients.

Old way: In its 2011 PPS final rule, CMS explained that Medicare required F2Fs only for certifications — not recertifications. In later guidance, CMS detailed that it required F2Fs for “initial epi-sodes” only. That means when an agency discharged a patient with goals met, but then readmitted the patient within 60 days, Medicare did not require a new F2F for the second episode.

New way: Now, “the face-to-face encounter requirement is applicable for certifications (not recertifications), rather than initial episodes,” CMS says in the 2015 rule published in the Nov. 6 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.

Why? Many episodes that occur within 60 days of a previous one are due to a hospitalization of the patient and have a different reason for home care, CMS notes in the rule (see related story, p. 347). “Equating a certification with any time a SOC OASIS is completed to initiate care will further en-courage physician accountability in certifying a pa-tient’s eligibility for the Medicare home health benefit and in establishing and overseeing the patient’s plan of care,” CMS says.

Rule Takes Aim At Frequent Fliers

This change affects episodes that start after a partial episode payment (PEP) episode too, CMS explains. But the provision really “was intended to mostly respond to instances of patients being discharged after the end of a 60-day episode of care and then readmitted without a 60-day gap in care before the start of the next episode,” CMS says in the final rule. “For claims processing purposes (to categorize episodes into ‘early’ versus ‘late’ for case-mix ad-justment), these episodes are considered subsequent episodes rather than initial episodes of care.”

Background: “We received several questions from the MACs and providers asking whether the face-to-face encounter was required for instances where the patient was discharged at the end of a 60-day episode of care and then re-admitted, sometimes up to 50 days later and for reasons completely unrelated to the previous episode of care,” CMS explains. “This prompted us to propose a clarification … that would make it clear that documentation of a face-to-face encounter is required for each certification and a certification is any time a SOC OASIS is completed to initiate care.”

Result: This change could translate into an additional 800,000 F2Fs per year, CMS says in the rule. Of the 6,562,856 home health episodes in 2012, HHAs performed 3,096,680 SOC assessments on initial home health episodes, CMS points out. Under the initial-to-SOC definition change, “an additional 830,287 episodes would require documentation of a face-to-face encounter for subsequent episodes that were initiated with a new SOC OASIS assessment,” CMS notes.

“The switch from initial to certification epi-sodes will be a big deal,” foresees clinical consultant Judy Adams with Adams Home Care Consulting in Asheville, N.C. “It will mean obtaining face-to-face documentation more frequently.”

“It is difficult for HHAs to get this documentation from the physicians at all,” Adams tells Eli. “To have to have more of them will add significantly to the agency’s workload — requesting them, tracking them, reviewing them and trying to get the forms edited. Many HHAs have had to assign a staff member specifically to obtaining and reviewing F2F documentation.”

Bottom line: “This is another element that more than likely will not make physicians very happy — more paper work,” Adams emphasizes.

Impact Will Vary Depending On Practices

While CMS concedes that it will require more F2F documentation under this rule, the impact may not be as great as you think. For one, new F2F documentation doesn’t necessarily mean a new F2F visit. A qualifying F2F visit may occur up to 90 days before an episode starts. “Depending on when the face-to-face encounter occurred, the face-to-face encounter from the PEP episode could be used for the new certification as long as it was performed within the required timeframe and is still related to the primary reason the patient requires home health services,” the agency points out in the rule.

The definition change “may cause some confusion but I do not think it will have a significant impact on the number of F2F encounters,” expects consultant Patricia Jump with Acorn’s End Train-ing & Consulting in Rice Lake, Wis.

Plus: A number of agencies already follow this policy, CMS maintains. “We have heard, anecdotally, from several HHAs that they are already in compliance with this proposed clarification and, as such, this clarification will pose no additional burden for those HHAs.”

The 800,000 figure is “a ‘worst-case’ scenario as it does not account for instances where HHAs already consider anytime a new SOC OASIS is completed as a certification and are thus already in compliance,” CMS adds later in the rule.

Watch out: One place where the new policy may be particularly burdensome is with managed care patients, worries Chicago-based regulatory consultant Rebecca Friedman Zuber. “It may case some problems for patients who are being re-admitted because of a change in payer — something we are seeing more with increased movement between managed care and fee-for-service payers.”

Another problem area is with referral sources. “The initial-to-certification episode change will create a lot of confusion and more frustration for physicians,” Zuber predicts. That will happen at a time when agencies are already trying to educate docs on the new switch from furnishing a physician narrative to furnishing their own clinical records for medical review support (see Eli’s HCW, Vol. XXIII, No. 43).

Consider OASIS Transfer Option, CMS Suggests

Commenters on the proposed rule suggested that subsequent episodes that meet the new SOC definition should be exempt from the requirement when the patient is back in home care for the same reason as in the first episode. One commenter suggested that CMS require a new F2F only when the certifying physician changes.

Those episodes still require a new F2F, CMS confirmed.

This change will increase agencies’ burdens without any direct benefit, another commenter said.

“If the patient is hospitalized during a 60-day episode of care and is expected to return to home health during the same 60-day episode of care, the HHA has the option to complete a transfer OASIS without discharging the patient,” CMS responds in the rule. “If the patient returns to home heath during that same 60-day home health episode, a resumption of care OASIS would be completed upon return, and … (t)he subsequent episode would be considered continuous for recertification purposes and documentation of a face-to-face encounter would not be required.”

Justification: “More often than not, the primary reason for home care is changing between episodes of care when the subsequent episode of care is initiated with a SOC OASIS, regardless of whether the patient remains with the same HHA or is receiving care from another HHA,” CMS says (see stats, p. 347). 

Note: The old F2F question-and-answer that contains the old “initial” definition is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Home-Health-Questions-Answers.pdf — see Q&A #11.