Home Health & Hospice Week

Not sure if your certifying physicians should use templates to support your patients’ home care? A new Program Integrity Manual indicates it’s OK — sometimes.

The PI Manual already indicated that the Centers for Medicare & Medicaid Services “does not prohibit the use of templates to facilitate recordkeeping,” notes CR 10930 issued Oct. 12. But the change adds this italicized phrase: “CMS also does not endorse or approve any particular templates except for the clinical templates it publishes on its website.” CMS also adds this italicized phrase directly after: “A physician/LCMP may choose any template to assist in documenting medical information. Contractors shall consider information captured in templates when conducting medical review.”

The National Association for Home Care & Hospice double-checked with CMS, and confirmed that using templates is fine — if it’s the right template. The CR and manual change “reminds review contractors they must review the information contained in templates along with any other documentation they receive in response to an additional documentation request,” CMS told NAHC.

But CMS also told NAHC that “some [templates] may encourage sufficient information/documentation, while others may not,” the trade group says in its member newsletter. “For example, if a face to face visit is required and the date of the face to face visit is simply noted in a template, we would expect additional documentation of the visit in the medical records. However, if the practitioner has chosen to use a template and sufficiently documented the visit in the template, we would not expect duplicative documentation in another format.”

The CR is at www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/2018Downloads/R833PI.pdf.