Home Health & Hospice Week

Enforcement of the physician face-to-face encounter requirement for home health agency and hospice patients is nearly a month along, but agencies continue to wrestle with the mandate.

The F2F rule continues to create a huge burden. "We are pulling staff from other tasks just to track the forms and to follow up with the physician offices," says JoAnne Ruden with the Visiting Nurse Association of Mercer County in Trenton, N.J. The VNA is seeing about 40 percent of F2F forms completed accurately, often after staff have followed up with physicians to secure valid forms, says Ruden, who spoke up about F2F problems to CMS at last month's March on Washington conference held by the National Association for Home Care & Hospice. About 20 percent of forms aren't coming back at all, Ruden adds.

Heavy toll: "Physicians remain angry at the documentation requirements and still consider them to be unreasonable, even after explanation and instruction," Ruden tells Eli. "The lost productivity is a big cost impact for us, and having to return incomplete forms to physicians is damaging good relationships."

The F2F requirement has "the potential to deny otherwise eligible Medicare beneficiaries -- most of whom will have had their F2F encounter -- their right to receive home care and hospice service on a massive scale over technicalities associated with the physician completion of a redundant form," Ruden fears.

Requiring physician encounters is a good idea, but the details of how the Centers for Medicare & Medicaid Services is implementing the mandate are sabotaging the effort. "There are compromises such as adding the F2F encounter date to the physician plan of treatment that would resolve the problems we are all having and meet the intent of the legislation," Ruden maintains. "We want to communicate with our physicians, not alienate them."

Despite such difficulties, CMS is expecting home health agencies and hospices to be complying with the requirement included in last year's Affordable Care Act.

"Now April 1 is past and so ... we would expect that face-to-face documentation to be present" in HHA claims pulled for medical review, CMS's Lori Anderson said in the April 13 Open Door Forum for home care providers. "Similarly for hospices that have patients in their third or later benefit period, where that benefit period began April 1, 2011 and later, we would expect to see the full documentation for those face-to-face encounters."

Home care providers did get help with some of their outstanding F2F questions that haven't been addressed in CMS's written questions and answers on its website. Anderson addressed these F2F issues in the forum:

• Signatures. Providers are confused about exactly where the physician signature is required. When all of the certification requirements (including the physician narrative supporting terminal illness for hospice) and the F2F documentation are on one document, one signature below the items is acceptable, Anderson explained.

But if the F2F documentation is included in an addendum, that addendum must have a separate physician signature, Anderson continued. "We adopted the addendum to make it more flexible, not to try to increase burden," she pointed out.

Also, electronic signatures are fine, but physicians can't use date stamps for their signatures, Anderson clarified.

• Physicians. Another physician in the certifying physician's clinic or practice can't sign the F2F documentation for the certifying physician, Anderson said in response to a question from NAHC's Mary St. Pierre. "That doesn't make a lot of sense to us either, but it is the statutory language and we are bound by that, at least at this point," Anderson said in the forum.

Heads up: The requirement that the certifying physician must perform and sign the F2F documentation also means that residents can't perform the F2F encounter, Anderson said.

• OASIS. HHAs won't be able to bill for an episode unless the F2F encounter is performed timely (up to 90 days before or 30 days after the start of care). If a F2F encounter is finally performed after that 30-day mark, the agency can move the start of care date forward so that the encounter is within the timeframe. In other words, only the beginning of the episode will be cut off for reimbursement purposes.

But agencies will need to have an OASIS assessment for the new start of care date, Anderson said in response to another question from St. Pierre.