Home Health & Hospice Week

If your patients fail to see the doc in the mandated timeframe, it means no money for you.

The feds have given home health agencies a bit more leeway on the physician face-to-face encounter requirement, but it’s still going to give you serious operational headaches.

Based on a provision in the Patient Protec-tion and Affordable Care Act (PPACA), the Centers for Medicare & Medicaid Services is requiring physicians to have a face-to-face encounter with patients before certifying them for home care, or Medicare won’t pay for the patient’s claims.

Proposed: Back in July, CMS proposed that the face-to-face encounter must occur 30 days before or two weeks after the start of care.

Final: Now CMS has relaxed that timeline to 90 days before or 30 days after, as long as the visit is for the same reason the patient needs home care, according to the 2011 home health prospective payment system final rule CMS issued Nov. 2.

The expanded timeframe "should ease some of the burden of the face-to-face requirement," expects attorney Robert Markette Jr. with Gil-liland & Markette in Indianapolis. But it’s still less than the six months originally suggested in PPACA.

Another good change: CMS also makes clear that in cases where a patient is discharged from the hospital, the "hospitalist" physician may perform the face-to-face encounter, while the primary care physician certifies the patient’s care plan.

CMS "clearly ‘got’ our issues in situations where in-patient care is provided by hospitalists," cheers Chicago-based regulatory consultant Rebec-ca Friedman Zuber.

And CMS confirms that the face-to-face encounter requirement applies only to initial certifications, notes the National Association for Home Care & Hospice.

Can You Trust Reviews On Visit Reason?

While there are some improved aspects of the face-to-face requirement, there are still lots of problems with this new requirement that will take effect in January.

For example: CMS’s interpretation of the regulations related to telehealth "make this a virtually unusable option for both home health agencies and hospices who are dealing with highly incapacitated individuals," Zuber maintains.

NAHC believes the restrictive telehealth option "is essentially useless."

And the doctor visit still must be for the same reason the person is receiving home care, CMS stresses in the rule.

However, reviewers shouldn’t get too picky on the matter. "It is not our intent that those who enforce the provision would take such a literal interpretation to look for a cause and effect relationship between a diagnosis on the physician’s claim and the diagnosis on the HH claim," CMS says in the rule. "Instead, it is our intent that should a patient’s clinical condition change significantly between the time of the encounter and the start of home health care such that the physician’s or NPP’s ability to accurately assess eligibility and care plan would be at risk, a more current encounter would be necessary in order to meet the goals of the statutory requirement."

Stay tuned: CMS will issue further clarification on this topic in manual guidance, it pledges.

Take-away: "The improvements in the en-counter requirements are valuable, but do not allay concerns that physicians/non-physician practitioners as well as their patients will not be ready for these new requirements in January," NAHC cautions in its member newsletter. "There are several hundred thousand physicians/non-physician practitioners and many more patients that will be affected, with limited time to understand this complex rule on home health services encounters."

The rule also still puts agencies on the financial hook for behavior of physicians or patients whom they can’t control, NAHC worries. "Congres-sional intervention in this matter appears necessary," the trade group says.