Home Health & Hospice Week

You can expect a few tweaks to the face-toface rule to make your life easier come Jan. 1 -- but not much easier.

In the 2012 home health prospective payment system final rule, the Centers for Medicare & Medicaid Services makes a change to who may conduct the face-to-face physician encounter requiredby law.

Now: Currently, if the attending physician in the hospital conducts the F2F encounter, she also must perform the documentation of the encounterand certify the patient for home care.

In January: In the new year, any hospital doc (not just the attending) who performs the F2F can inform another certifying physician of his findings instead. Then the certifying physician can complete the F2F documentation. That mirrors what non-physician practitioners already can do under F2F regs.

Catch: The provision applies only to patients discharged to home care from a hospital or post-acute facility, CMS notes in the rule published in the Nov. 4 Federal Register. That's about half of home care patients, CMS estimates.

What won't change is the hospital doc's ability to hand off the plan of care to the community physician. Even if the hospital physician completes the F2F encounter and documentation, she can still pass the POC on to the patient's community doctor.

CMS also clarifies that it will allow an HHA to "facilitate" communication between the facility and community physician. "The rule reiterates that the HHA can forward the facility's discharge plan to assist, but cannot prepare documentation to assist the physician," notes financial consultant Ken Hooper with HC Healthcare Consulting in Boise, Idaho.

"The HHA can send a copy of the discharge plan to the certifying physician to expedite the information exchange," CMS explains in the rule. "However, it would be unacceptable for the HHA to fill in missing clinical information concerning the patient, based on the HHA's assessment of the patient.

The documentation must reflect the physician's (or NPP's) experience with the patient, not the HHA's."

This change is "some help, but far short of a solution for agencies struggling with physician communication and documentation problems," Hooper maintains. "These changes do not help providers with communication issues between the home health agency and the certifying physician, or between the certifying physician and the facility."

There's no reimbursement ramifications for the physician if he fails to complete F2F paperwork, laments attorney Robert Markette Jr. with Friedlander Coplan & Aronoff in Indianapolis. That's contributing to physicians' widespread balking at the F2F requirement, Markette believes.

Under the final rule, "the physicians' desire not to be bothered and to have the HHA do it all won't happen," Markette says of the F2F changes.

Many of the headaches HHAs have in securing physician F2F documentation would go away if CMS would loosen up on the standards, commenters on the 2012 PPS proposed rule told the agency. They suggested numerous documentation changes such as:

• requiring a simple attestation of homebound status and skilled service need;
• letting the plan of care narrative stand in for the F2F documentation;
• allowing docs to use a checkbox form;
• allowing NPPs to complete the F2F documentation; and more.

"These comments are outside the scope of this rule," CMS maintains in the final rule. But the agency points out that the Affordable Care Act that enacted the F2F rule allows little to no wiggle room on the requirements. Many of the suggested changes would require congressional action, CMS says.  

Physicians can use the hospital dischargeplan as their F2F documentation if it hits all the requirements, CMS reminds HHAs in the rule. "If ... a discharge summary from a physician who cared for the patient in an acute or post-acute facility contains all of the needed documentation content, the certifying physician would simply need to sign and date the discharge summary and ensure it is attached as an addendum to the certification," the agency says.

But often the discharge summaries don't contain everything that's required, Markette says. Discharge plans tend to "not hit all the points, so they're hard to use as an addendum."

Tip: Remind reluctant referring physicians that their own staff can craft the F2F documentation from the patient's record, and the doc just has to sign and date it, Markette suggests.

If you've had a tough time complying with the F2F requirement, you can expect to start paying the price. The National Association for Home Care & Hospice reports "numerous" claims denials over F2F requirements.

Be alert: However, you can save yourself some hard-earned reimbursement if you pay attention to the denials and appeal incorrect ones, NAHC insists. For example, some of the denials are for episodes starting before April 1 -- before the F2F rule was in effect. Other erroneous F2F denial reasons include for missing certifications when one is present; for having two different physicians (hospital and community) sign the certification and POC, even though that is allowed; and for homebound status based only on the F2F encounter.

"The determination of homebound status should be based on all components of clinical documentation including the patient's comprehensive assessment and plan of care, not the F2F encounter alone," maintains NAHC, which is conducting appeals on members' behalf in these cases.