Home Health & Hospice Week

CMS defends its face-to-face documentation requirements for physicians.

Face-to-face documentation may be out of your hands, but you'll still be penalized for problems with it. That's the message representatives from the home care industry gave the Centers for Medicare & Medicaid Services at the National Association for Home Care & Hospice's March on Washington conference March 26.

After expending lots of effort and resources, the Visiting Nurse Association of Mercer County in Trenton, N.J. has reached almost 100 percent compliance with the F2F physician encounter occurring, the VNA's Joanne Ruden told CMS reps in an agency panel at the conference. But the compliance rate is much lower for sufficient documentation, she reported.

The VNA has seen an 11 percent decrease in referrals due to the problem, Ruden believes. "Phy-sicians are angry" about the extra documentation requirements, Ruden said.

"You guys really don't get it," Chicago-based regulatory consultant Rebecca Friedman Zuber told CMS at the session. "This is out of our control."

The referring physicians have to complete the documentation, and many just don't. "It doesn't affect them, it affects agencies," Zuber stressed. "We're stuck."

Nix The Narrative, Industry Urges

The actual Affordable Care Act language doesn't specify a physician narrative, Ruden told CMS, so the agency should just require an attestation that the encounter took place without the requirement for a written statement about eligibility.

But CMS doesn't agree that the ACA language is that flexible. The ACA does require physician documentation, maintained CMS's Randy Throndset. The documentation must show that home health is appropriate, he said.

What the statute says: The ACA section on the home health F2F says, "prior to making such certification the physician must document that the physician ... has had a face-to-face encounter ... with the individual during the 6-month period preceding such certification, or other reasonable timeframe as determined by the Secretary." Of course, in rulemaking CMS changed the timeframe to 90 days.

A disagreement over what "document" means in that language is what's causing the "different interpretation," Throndset allowed.

F2F documentation requires five elements, noted CMS's Kelly Horney in the session: (1) the patient's name, (2) the date of the encounter, (3) how the patient's clinical condition as seen during the encounter supports homebound status and the need for skilled services, (4) the physician's signature, and (5) the date of the signature.

One chief complaint from docs is that they end up "redocumenting" the same thing in the F2F documentation. CMS requires the F2F documentation -- whether on the certification form itself or as an addendum to it -- to be separate and distinct, Throndset noted. That's so contractors don't have to go hunting all through the record for it when reviewing claims and supporting records. "Contractors are really following what the regulation says," Thrond-set said.

The F2F documentation should paint a picture of the patient's condition, urged CMS's Latesha Walker in the session. "If we could write it, we would do that," Zuber responded. "We know what needs to be in there," but physicians don't -- and many aren't interested in learning.

If MACs, ZPICs, or other contractors start auditing for the content of the F2F physician narrative in a big way, many HHA claims will be sunk, experts predict. The entire episode gets denied when the F2F encounter is missing or isn't properly documented, pointed out NAHC's Mary St. Pierre in the session.

Medicare medical reviewers have been finding problems with the limited F2F reviews they've done so far, Walker related.

CMS did have a few suggestions for helping with the F2F burden. CMS has said it's OK to use forms to help physicians document the requirement, Walker pointed out. CMS isn't endorsing a particular form, but agencies can generate or adapt one on their own.

And CMS soon will be issuing an MLN Matters article about F2F requirements aimed at physicians, Horney revealed. CMS also will be revising some F2F questions-and-answers, which are at www.cms.gov/center/hha.asp -- scroll down to the "Home Health Face-to-Face" section.