Home Health & Hospice Week

Quick documentation retrieval will boost your claims success.

Home health agencies have yet to see their claims tested under the new face-to-face encoun-ter physician rules that took effect Jan. 1, but that day is coming soon. Will your claims stand up to the scrutiny of your referring physicians’ documentation?

Recap: Starting for episodes in 2015, medical reviewers will look to certifying physicians’ records to prove a patient’s eligibility for the Medicare home care benefit, the Centers for Medicare & Medicaid Services reviewed in a December National Provider Call, “Certifying Pa-tients for the Medicare Home Health Benefit.” (see Eli’s HCW, Vol. XXIV, No. 3). Physicians must show these three elements in their visit note for the F2F encounter without any help from the home health agency — the visit:

1. Occurred within the required timeframe,

2. Was related to the primary reason the patient requires home health services; and

3. Was performed by an allowed provider.

The physician record must also show these two elements, but the physician can merely sign off on an HHA summary substantiating these items:

4. Need for skilled services, and

5. Homebound status.

Don’t Dilly-Dally

Industry veterans and even CMS itself all agree on the best strategy to ensure compliance with the new F2F rules — asking for physician documentation from the get-go.

Under the new rules, HHAs must submit the physician’s substantiating documentation to the Medicare contractor reviewing the claim, reviewed CMS’s Jill Nicolaisen in the call. But “the home health agency is not required to have a copy of the physician’s documentation prior to submitting a claim for reimbursement,” Nicolais-en acknowledged.

However: “Because eligibility for home health services is established by the physicians in the patient’s medical record, the home health agency may want to consider obtaining this documentation as early in the home health episode as possible to assure themselves that the Medicare home health patient eligibility criteria has been met,” Nicolaisen said. “While not a Medicare requirement, the home health agency may implement such a procedure as a sound business practice.”

The Illinois Homecare & Hospice Coun-cil recommends that “the agency ask for the physician’s note on the face-to-face encounter or the hospital/nursing home’s discharge summary at referral so that they get this documentation on every patient as early as possible,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. “In this way, they will be able to assess their liability.”

It’s on you: “The HHA is the one responsible for furnishing information on F2F if requested by CMS or one of the review groups,” stresses Judy Adams with Adams Home Care Consult-ing in Asheville, N.C. “The only way they will be able to do that is to request the physician documentation up front.”

Take The Next Step

Just collecting the visit note isn’t enough to ward off F2F denials. You need to check it for the required five elements, Adams says.

If the note is missing the three elements required to be furnished by the physician, you must send it back for correction by the doctor, Zuber directs. Do so “before the final claim is filed,” she urges.

Possible option: Agencies could also “include a statement on the POC or documentation that is sent to the physician that serves as an attestation that a F2F encounter was conducted within the required time frame, the encounter was related to the primary reason for home health services, and the encounter was conducted by the physician or an allowed NPP,” suggests the Na-tional Association for Home Care & Hospice.

But CMS officials emphasized in the forum that the doc’s own visit note needed to contain that information, so you may be risking the entire episode payment if you use such an attestation statement, experts caution. Watch for forthcoming guidance from CMS to shed light on this evolving issue.

On the other hand: If the note is missing information substantiating homebound status or skilled need, CMS has made it clear you can “assist with additional documentation back to the physician,” Adams says. You can submit information for the physician to sign off on (date and signature) and include in his medical record (see Eli’s HCW, Vol. XXIV, No. 3).

Proactively Head Off Denials By Sending Clinical Summary

Rather than dealing with missing documentation on a case-by-case basis, many experts recommended establishing a procedure to include the necessary visit, homebound and skilled need information in every certifying physician’s record.

IHHC “is recommending that our members use an addendum to the plan of care to share information from the assessment that will support the physician’s certification of homebound status and need for skilled care,” Zuber says. “This would mean that no extra signature would be required since the physician must sign the plan of care anyway.”

Whether as a separate form or combined with the POC, HHAs need to “send a clinical summary and make every effort to have the MD sign it and send it back,” urges Lynda Laff with Laff Associates in Hilton Head Island, S.C.

Don’t miss: “Include a statement at the end of the summary that will serve as an attestation that the physician agrees with the summary and is incorporating the information into his/her medical record,” NAHC advises.

Agencies that skip over the essential step of sending a summary are leaving themselves wide open to denials, Laff warns. “My fear is many will only do the bare minimum and completely rely on not having ADRs and not having to prove the MD has documented supportive information for the need for home care in his/her files,” Laff tells Eli.

Whether you use a blanket procedure for every referral or base requests on the physician note contents, “agencies should still obtain as much information from the physician as soon as possible,” NAHC urges.

Tip: And don’t trust the physician to sign and date your documentation and file it neatly with her record, ready for you to request if you receive an ADR. Request a returned, signed and dated copy of your summary, POC with addendum, or other documentation, NAHC recommends. v

Note: See resources from the call, including an audio recording, transcript, slides, and documentation examples, at www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-12-16-Home-Health-Benefit.html.