Home Health & Hospice Week

Will new F2F clinical template help you?

Scrutiny of your claims is heavier than ever, and physician certification - including the face-to-face encounter - is a hot target for reviewers.

Inadequacy of physician documentation is a longstanding issue in home health, notes consultant Joe Osentoski with QIRT in Troy, Michigan. "There is no 'magic bullet' to address this problem," Osentoski acknowledges. But HHAs can take productive steps to protect their claims against denials based on physician documentation.

Check out the experts' top advice to combat the widespread, reimbursement-threatening problem:

1. Know the basics. Medicare and HHH Medicare Administrative Contractors have laid out the elements they expect to find in the physician certification documentation, including to support the F2F encounter. Those elements range from the physician dating the F2F encounter to explaining why the patient is homebound (see Eli's HCW, Vol. XXVII, No. 10). Go to the source to see what Medicare and its contractors expect of you (see box, p. 85, for resources).

2. Educate referral sources. If physicians can't support their patients' need for home care services in their documentation, agencies can't accept the patients and they won't be able to access home care services.

Use tools provided by CMS and the MACs to educate physicians and their office staff, advises clinical consultant Anna Doyle with McBee Associates in Hilton Head, South Carolina.

"Providing your referring physicians with the educational materials is a necessary first step," Palmetto GBA Medical Director Harry Feliciano said in response to an HHA commenter on one of the MAC's educational posts about the requirements.

"A thorough understanding of how your top referral sources create their F2F documentation, however, is the next step. By studying the actual steps taken by your major physician referral sources to identify, document, and communicate the functional status information necessary to meet the F2F requirement, your organization will gain insight as to the processes that need to be revised in order to prevent future denials," the physician suggested.

Consider: HHAs may want to use CMS's new version of the draft clinical templates or suggested clinical data elements (CDEs) for F2F encounters, which the agency issued last month, Osentoski points out. CMS also issued a draft template and CDEs for the Plan of Care/Certification last September.

This is CMS's second attempt to develop a clinical template that would support the eligibility criteria for home health patients, notes the National Association for Home Care & Hospice. CMS issued a draft template in 2015 that was roundly criticized and never finalized.

Drawback: Industry experts have complained that the F2F template is much too long for physicians to utilize as a stand-alone form and requires many more details than a doc usually records (see Eli's HCW, Vol. XXV, No. 3). Attendees of a March 1 Special Open Door Forum on the template and CDEs raised this issue again with CMS and offered numerous suggestions for improvement, NAHC reports.

3. Provide the requirements and the examples. While providing the outlines of what's required for the certification - the five points the Centers for Medicare & Medicaid Services outlines in MLN Matters article SE 1436 - is important, you'll likely see better results if you also provide multiple examples of what good certifications and supporting documentation look like, experts say. That's where educational articles from the MACs come in handy (see box, p. 85).

4. Double-check the F2F date. "The certifying physician must also document the date of the face-to-face encounter," CMS notes in MLN Matters article SE 1436. But MAC CGS "has observed many physician certifications do not contain a statement for documenting the date of the face to face encounter," it says on its website. Be sure to check this technical detail before you bill.

"If the certifying statement on the plan of care does not contain the F2F encounter date, provide a separate form to the MD to sign identifying the date of the encounter," counsels consultant Pam Warmack with Clinic Connections in Ruston, Louisiana.

5. Get the physician documentation - every time. "If the [physician or facility] documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided," CMS warns in the MLN Matters article.

Key: "The certifying physician's and/or the ... facility's medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates" the requirements, CMS stresses.

Don't just operate on blind faith that the physician documentation will be up to snuff if you need it. "We must secure the face-to-face encounter documentation from the physician or facility ourselves for our own charts," Warmack stresses.

Tip: "In addition to the actual clinical note for the face-to-face encounter visit, any documentation from the physician's or ... facility's medical records can be used to help justify/substantiate the need for home health services and homebound status," offers HHH Medicare Administrative Contractor National Government Services in a tips sheet generated from Probe & Educate denials. "Include in your submitted documentation any recent ... facility therapy notes, social work or discharge planning records, history & physicals, and other clinical progress notes."

6. Make sure your documentation is signed in - every time. Don't count on the physician record alone to defend your claim against certification and F2F scrutiny. "Provide to physicians and referring facilities the documentation from agency assessments and plans of care," advises Beth Noyce with Noyce Consulting in Salt Lake City.

"Information from the HHA, such as the patient's comprehensive assessment, can be incorporated into the certifying physician's and/or ... facility's medical record for the patient," CMS explains in the MLN Matters article. However, keep in mind that "information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered," CMS says.

Also, "the certifying physician must review and sign off on anything incorporated into the patient's medical record that is used to support the certification of patient eligibility (that is, agree with the material by signing and dating the entry)."

Warning: "A blanket form signed by the certifying physician will not suffice to meet the regulations in lieu of signing off on the particular pages being incorporated," CGS says on its website.

And "the home health documentation being incorporated would be expected to corroborate or match and should not contradict the certifying physician's documentation," CGS says.

"Always submit to the physician documentation from your assessments or findings and request that the certifying physician sign it and incorporate it into his/her clinical records," Warmack recommends. "My clients have been doing so since January 2015 and have had good success with this practice."

7. Educate your own clinicians. While it's good news that you can get your documentation signed into the physician record to defend against cert/F2F denials, it underscores the importance of your own clinical documentation.

"The majority of providers ... continue to be confused about where and how to document eligibility for home health," Doyle laments. "Home health compliance and subsequent payment for reasonable and necessary services cannot rely on physician documentation in their own records" - your documentation needs to boost your docs'.

"Re-educate clinicians how and where to document eligibility," Doyle instructs. This may include working with the electronic medical record if possible "for clinicians to document eligibility for home health services in a specific and standardized area (i.e., a field for specific homebound status narrative and a field for attestation of F2F encounter date and/or collaboration as applicable on the 485)," she adds.

HHAs should go "to the basics of clearly understanding what is required, ensuring agency staff and quality assurance/review staff have this knowledge," Osentoski recommends.

8. Audit yourself. Before medical reviewers take a whack at your claims, make sure you've given them your own third-degree.

Your documentation process should begin with "checking content of the record at time of admission" and then "pursuing acquisition of sufficient content from the physician to meet the requirement," Osentoski says. But that's not the end of it.

"Checking compliance before final billing is done will yield the most chance of improvement," Osentoski tells Eli. "Best practice is to at least check the record at start of care and before billing that first episode to reduce chances of problems."

Tool: Use CGS's prebilling documentation checklist to help make sure your record is complete: www.cgsmedicare.com/hhh/education/materials/pdf/hh_documentation_checklist_tool.pdf.