Home Health & Hospice Week

Tip: If you have to appeal, use the physician’s visit note for support.

With medical review for face-to-face physician encounter documentation kicking into high gear, now’s the time to beef up your F2F policies and procedures.

Consider this advice from experts on how to make your F2F documentation and practices the best they can be:

1. Educate yourself. If you’ve been letting F2F requirements slide because sloppy documentation didn’t seem to bring any consequences, now’s the time to go back and brush up on face-to-face basics. Resources including Centers for Medicare & Medicaid Services Q&As, a MLN Matters article, and more are at www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html — scroll down to the "Home Health Face-to-Face" section in the Spotlights box.

2. Educate physicians. Once you’ve got a good grasp of the requirements — including when nonphysician practitioners can conduct the F2F and when a facility physician can conduct the F2F but a community physician can document it — reach out to referring physicians to make sure they understand the Medicare requirements clearly.

"It is really important that agencies develop relationships with hospitalists and physician groups to educate them about the requirement," Lynda Laff with Laff Associates in Hilton Head Island, S.C. urges. "The CMS information on the physician’s ability to bill for F2F is an important feature to discuss with them."

Earlier education efforts may have focused on introducing the new requirement and scheduling the necessary physician visits. Now’s time to get into documentation details. "My clients have intensified efforts to educate physicians in the completion of the forms," relates consultant Pam Warmack with Clinic Connections in Ruston, La.

3. Train your own staff. Docs aren’t the only ones who don’t know the ins and outs of F2F. Your own staffers may need updating. That includes all staff who perform duties related to the documentation — marketing and clerical employees in addition to clinicians, Warmack suggests.

4. Use concrete examples. When training physicians and your own employees, "give them written examples [in] a teaching tool about the kind of documentation necessary to support why the patient will need home care and what specific indicators are present that renders the patient homebound," Laff advises.

Don’ts: Tell them, for example, that "the supporting homebound documentation cannot be ‘patient cannot drive’ or ‘patient in hospital for 5 days,’ etc.," Laff says. (See box, p. 170, for more examples of commonly used phrases that MACs say won’t pass muster.)

Dos: Documentation "must be more specific as to the patient’s functional status," Laff ex-plains. "The supporting documentation for why the patient requires home care should include the reasons such as ‘requires skilled nursing for monitoring heart failure symptoms due to changes in medication during hospitalization’ or ‘physical therapy is necessary to improve patient’s ability to safely climb 5 stairs and to teach the patient to walk with a walker’ or ‘currently patient is not safe with bed to chair transfers,’ etc."

"Acceptable FTF documentation does not have to be lengthy or overly detailed," maintains HHH Medicare Administrative Contractor CGS in an educational article for providers. "However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound."

5. Give docs a form to fill out. CMS prohibits you from providing F2F documentation for the physician to sign, but you can give him a form to fill out that prompts him to furnish the necessary documentation. The National Association for Home Care & Hospice furnishes a free sample form at www.nahc.org/advocacy-policy/home-care-regulatory-issues — scroll down to "Face to Face Encounter templates."

Checkbox debate: CMS has given the green light to HHAs to use checkboxes on F2F forms they furnish to physicians, although just how far the checkboxes will go in fulfilling the requirements is still in controversy (see Eli’s HCW, Vol. XXII, No. 19).

Be sure your form covers all the elements CMS requires, particularly the narrative justifying homebound status and skilled services, Gordon advises. (See requirements in box, p. x).

"Make sure your F2F form is easy to follow," Laff adds.

And while it’s smart to give physicians examples of good documentation to follow, don’t include those examples right on the form, Laff cautions. Medicare says you aren’t allowed to fill out the form for the doc.

6. Review the F2F documentation. War-mack’s clients have "become far more careful in reading the documentation when it returns from the physician," she says. And when staffers find the forms are insufficient in documentation or when portions of the form are incomplete, they are returning them for completion. "Everyone is being educated to read the forms as they pass through their hands" from marketers to clerical staff to clinicians, she says.

This is where things can get touchy. Some docs get mad when they feel they are corrected by a home health agency, Gordon notes. And some physicians feel there’s no justification for the extra work, especially when the information is duplicated in the certification or plan of care.

This is leading some docs to quit referring to home care altogether, Warmack observes.

But you can’t let up on the requirement, the MACs insist. "Palmetto GBA encourages all pro-viders to review their internal processes to ensure that all of the criteria for coverage have been met and documented in the medical record," the MAC says on its website.

7. Appeal. If you do receive a F2F-based denial, don’t take it lying down. HHAs have an excellent chance of winning an appeal, Gordon believes.

Tip: "If the denial notes that the narrative was not descriptive enough to support homebound status or skilled service, submit the dated physician’s progress note from the visit used for the face-to-face" for the appeal, MAC NHIC suggests in an article about the F2F denials. "These notes often have the clinical findings supporting the homebound status and the need for home health services." Just be sure the date of the visit is the same as the face-to-face certification form.