Home Health & Hospice Week

Ring in the New Year with more documentation requests for referring physicians.

While home health agencies will happily bid goodbye to the face-to-face physician narrative requirement in 2015, they will not welcome the stipulation taking its place — medical review of the certifying physician’s medical record to prove eligibility for home care.

When the Centers for Medicare & Med-icaid Services proposed nixing the narrative this summer, HHAs were overjoyed. The narrative has caused sky-high denial rates for claims reviewed in a wide range of probes, including review for the CERT program.

But agencies were disappointed to see the replacement for the standard. CMS proposed to “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,” according to the 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.”

Scores of agencies blasted the proposed requirement in their comments on the rule (see Eli’s HCW, Vol. XXIII, No. 32). But in the final rule published in the Nov. 6 Federal Register, CMS stuck to its guns on the mandate (see Eli’s HCW, Vol. XXIII, No. 39).

Same old, same old: Clinical expert Judy Adams wasn’t surprised to see CMS retain the proposed requirement. “It was pretty clear all along that the F2F would continue and the requirement for physicians to document the reason a patient is confined to their home and requires skilled services would continue,” laments Adams, with Adams Home Care Consulting in Asheville, N.C. “The language was changed to delete the requirement for a narrative, but essentially there are the same expectations for physician documentation as previously.”

Money talks: “I do not believe CMS is going to be willing to give up their home health ‘cash cow’ any time soon,” Adams continues. “They have been able to save thousands of dollars through denials of the F2F for insufficient documentation.”

Getting the new F2F requirements nixed was a long shot, notes Patricia Jump with Acorn’s End Training & Consulting in Rice Lake, Wis. “It is and always has been difficult to change what CMS believes to be the best strategy. While I believe CMS considers comments from providers, they seldom make major changes to proposed rules.”

Despite the change from the narrative to the medical record requirement, “I still think it is going to be trouble,” worries Chicago-based regulatory consultant Rebecca Friedman Zuber. “It is important to remember that CMS will no longer be seeking physician certification of home health eligibility in the home health record — they will be looking in the physician’s record instead. I don’t think a lot of agencies fully grasp this yet.”

F2F For Every Claim 

CMS requires F2F only for certification epi-sodes (changed from “initial” episodes in the final rule, see Eli’s HCW, Vol. XXIII, No. 39). But new medical review rules will require you to request physician documentation for any claim reviewed.

“For home health claims reviewed on or after January 1, 2015, [Medicare Administrative Con-tractor] 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 explains on its website. “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.”

So while the F2F might not be for the episode addressed in the claim under review, reviewers still will want to look at the relevant certification episode’s F2F to determine eligibility for all its subsequent claims.

One Final Rule Concession May Help 

CMS did throw agencies a bone in the final rule. “We would expect that the findings from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician. The certifying physician can incorporate this information into his/her medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility,” the final rule says. “The certifying physician must review and sign off on anything incorporated ... into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.”

“It may help a little that the HHA is now allowed to send the physician information on the reason the patient is confined to home and needs skilled services,” Adams allows. “But the overall expectation for the physician to document the reasons for both is essentially the same.”

“Allowing agencies to submit documentation to physicians that can be included in the physician’s record as support could be helpful, as long as the agencies prepare the material clearly and the physicians do whatever CMS wants them to do to ‘review and sign off,’” Zuber predicts. (For more on furnishing material to the doc, see story, this page).

Docs Balk At Shifting F2F Demands

While furnishing info to the certifying physicians is a small benefit, it won’t alleviate most of agencies’ problems in securing doc compliance with this mandate, experts believe.

“Physicians will continue to resist the F2F requirements and resent the HHA for bringing more ‘paperwork’ to them,” Adams forecasts. “Many physicians have already stopped or limited referrals to home health because they do not want to be bothered with these ‘unending F2F requirements.’”

“Requiring providers to obtain any documentation from physicians is always problematic,” Jump points out. It is “sometimes quite difficult to obtain the documentation, requiring multiple requests from the provider. This is time-consuming and costly for the provider. While seamless communication and documentation between physicians and home health providers would be ideal, we are simply not there yet and CMS needs to recognize this when mandating the sharing of documentation between the physician and home care providers.”

“Some physicians will balk at giving agencies their documentation — some won’t even do the documentation, much less share it with the agency,” Zuber relates.

Taking its toll: “The constant changes in approach are really causing a lot of wear and tear on agency/physician relationships,” Zuber believes. “Physicians are rightfully complaining about how the whole issue has been a constantly moving target, and it has been,” she continues. “CMS’ requirements and how they are applied by the RHHIs have been in flux ever since this began. The fear is that this change just represents another three to four years of constantly shifting demands.”

“It will continue to be a challenge for physicians to refer to home health,” Adams predicts. “Many will decide this is too much work and choose not to bother with the extra documentation. Physi-cians are already being saddled with the need for more documentation to meet their requirements for meaningful use and outcomes.”

Bottom line: “Providers have no control over or knowledge of the content of a physician’s patient record,” Jump protests. “Claim determination should not be based on documentation that is out of the jurisdiction of the home care provider. It is unreasonable that the home care provider carries the burden of the risk of liability with little or no control.”