Home Health & Hospice Week

Are you trading F2F narrative dependence on physicians for an even harder doc standard?

Elimination of the despised physician narrative for face-to-face encounters may not be a clear-cut victory. In conjunction with the change, the Centers for Medicare & Medicaid Services proposes to revise how it assesses the patient’s eligibility for the home health benefit.

“In determining whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care, we would review only the medical record for the patient from the certifying physician or the acute/post-acute care facility (if the patient in that setting was directly admitted to home health) used to support the physician’s certification of patient eligibility,” CMS says in the 2015 home health prospective payment system proposed rule. “If the patient’s medical record, used by the physician in certifying eligibility, was not sufficient to demonstrate that the patient was eligible to receive services under the Medicare home health benefit, payment would not be rendered for home health services provided.”

That will once again put agencies in the position of having their reimbursement dependent on another provider with no skin in the game, reimbursement-wise, experts worry.

CMS doesn’t “trust the home health record to justify the delivery of services,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. “They don’t trust their own required assessment tool to support the delivery of skilled care or make the case for homebound status.”

Warning: “If they review the physician’s or hospital’s record and don’t find justification for home care, our episode will be denied,” Zuber laments. “Plus, we won’t be able to see this documentation,” she adds. “At least now we see what they are using to make the determination.”

Relying on the physician’s patient record for documentation supporting the need for skilled services and homebound status “may be less do-able for home health,” worries Mark Sharp with BKD in Spring-field, Mo. Agencies will have difficulty making sure there is sufficient documentation in the physician’s records to support payments under review. At least with the current F2F requirement, agencies could obtain — and check — the documentation from the physicians.

However: At least some of the physicians’ reimbursement may be affected if reviewers find the docs’ records don’t support home care eligibility. “Physician claims for certification/recertification of eligibility for home health services (G0180 and G0179, respectively) would not be covered if the HHA claim itself was non-covered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit,” CMS says in the rule. “However, rather than specify this in our regulations, this proposal would be implemented through future sub-regulatory guidance.”