Home Health & Hospice Week

A seemingly new face-to-face interpretation by the feds could cut your Medicare payments even further.

The Centers for Medicare & Medicaid Services issues quarterly question-and-answer sets regarding OASIS via contractor OCCB. In its most recent set, the Q&As address what to do when the F2F encounter doesn't occur until the 35th day.

"The previous 34 days of skilled care are not reimbursable by a Medicare payer which means OASIS data collection/submission for that previous episode of care was not required," says the Q&A issued in July.

In a F2F question-and-answer set updated Aug. 10 on the CMS website, the agency tells home health agencies how to handle amending start of care dates when the F2F encounter is missed. "Once the encounter has occurred, the agency would delete the original OASIS submission (Medicare was not the payer when that OASIS was done), establish a new start of care date, and complete a new OASIS," CMS directs.

The implications of these Q&As is troubling, Mary St. Pierre of the National Association for Home Care & Hospice said in the latest home health Open Door Forum. CMS had previously issued informal guidance telling agencies that if a F2F encounter occurred on day 35, the new SOC could begin on day 5, causing the agency to lose reimbursement for only a handful of days in the episode. (F2F regulations require the encounter occur within 30 days of the SOC.) If the new SOC due to the missed encounter must occur when the new OASIS SOC is filled out, that will cause agencies to take a much steeper payment hit for the F2F delay.

The Q&As aim to tell HHAs that their OASIS requirements haven't changed under the F2F rule, said CMS's Lori Anderson in the forum held Aug. 17. "Existing OASIS completion requirements remain the same," Anderson told attendees. "OASIS has to be completed within a certain timeframe of the SOC date."

But the policy would be a change, since agencies have always been able to complete a new SOC OASIS if they found out later that the patient has Medicare as a payer, St. Pierre maintained.

CMS will look into the matter and provide clarification, Anderson said.

Confusion also persists about just what is acceptable for physician documentation of the F2F encounter. A caller who said she was from Apple Home Health in Chicago questioned whether a checkbox form drawn up by a local orthopedic physician group would suffice for the F2F documentation. The form includes a space for the narrative.

Anderson indicated the form might be OK, depending on how it fulfilled the content requirements for the documentation.

St. Pierre questioned Anderson's guidance, since CMS has made clear in its regulations and Q&As that checkboxes will not meet the documentation requirement.

The key is that the physician provide his "synthesis as to how the findings of the encounter support the patient's need for skilled services and their homebound status," Anderson stressed. A narrative of a simple sentence or two can easily fulfill the requirement, she indicated. And if the physician wants to support that statement with checkboxes, that would be fine, she indicated.

Bottom line: "We've been very clear that there can't just be checkboxes that a physician signs," Anderson told forum participants. The physician must include his justification for the patient's home care eligibility.

Agencies at least can catch a break on billing if the physician doesn't fill out the F2F documentation at the time of the encounter. This is a problem when an agency thinks a patient is a Medicare managed care patient at admission, then finds out quite a while after that the patient actually reverted to traditional Medicare, noted one HHA caller in the forum.

Often, the patient has actually had a doctor visit with the physician who signed the plan of care, the HHA rep said. But can the physician fill out the documentation 90 days later?

That should be fine, Anderson responded. As with other home health certification require ments, as long as the agency has the complete documentation in place before billing, it's acceptable.

Watch for: Physicians are still in need of education from Medicare on the F2F requirements, agencies say. CMS is working on that issue, with a physician-specific MLN Matters article on the topic coming out soon, Anderson promised. Physician education "hasn't stopped," she reported. "We are continuing to reach out and refine our educational materials and to communicate with the physician groups."