Home Health & Hospice Week

Latest clarification from CMS offers little comfort.

A little-noticed provision in the 2015 PPS rule may be about to wreak havoc on your reimbursement.

Reminder: In the home health prospective payment system final rule published in the Nov. 6, 2014 Federal Register, the Centers for Medicare & Medicaid Services stated that “In recertifying the patient’s eligibility for the home health benefit, the recertification must indicate the continuing need for skilled services and estimate how much longer the skilled services will be required.” CR 9119, the transmittal issued April 22 that put this requirement into regulation, similarly stated that “The physician must include an estimate of how much longer the skilled services will be required.”

Newest instruction: CR 9189, issued July 10, reinforces the requirement. “The contractor shall review for the certifying physician statement which must indicate the continuing need for services and estimate how much longer the services will be required,” CMS says in the transmittal that updates the Medicare Program Integrity Manual.

Many home health agencies had never heard of this requirement, or thought that the usual frequency and duration of services listed on the recert would fulfill the mandate, experts note — until HHH Medicare Administrative Contractors said otherwise in recent teleconferences.

For example: In a June 24 Ask-The-Contractor teleconference, MAC CGS noted that “the physician must include an estimate of how much longer skilled services will be required,” according to slides from the call. “The ordered frequency (on the 485) CANNOT be used as the physician’s estimate,” the MAC emphasized.

“A recertification that does not include this information may result in a claim denial,” CGS warned.

CGS went into more details in a question-and-answer document for the conference. “The agency cannot estimate the length of services — this must be done by the physician,” the MAC stressed.

Frequency and duration on the recert do not cut it, CGS reiterated. “That is merely the ordered frequency,” CGS says. “It does not indicate how long skilled services are estimated to be needed. There should be something that more clearly indicates how much longer skilled services are needed; even if it estimates services for the entire 60- days or longer.”

Yet Another Regulatory Burden

The new requirement “will present one more difficulty for home health agencies,” laments Judy Adams with Adams Home Care Consulting in Asheville, N.C. 

Referral threat: The mandate will be “one additional aggravation to physicians who are ordering home health services,” Adams predicts. “Physicians who are already unhappy with the face-to-face requirements will be even more reluctant to continue to order home health services with the increasing documentation requirements.” The end result will be “more pushback by physicians,” she says.

Instruction from CGS indicates that the physician should sign off on the POC, and also fill in and sign a separate statement estimating the length of service. Docs are bound to be confused when “we seem to be asking them to sign two separate statements,” says clinical consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. The documentation is “confusing even to those who think we understand it,” Laff exclaims.

“Agencies will have difficulty understanding and actually following this regulatory requirement,” Laff expects. “I see it as another avenue for edit and audit.”

Waiting For The Denial Shoe To Drop

Providers have yet to report receiving denials based on this topic. But don’t expect that to last long.

“This is going to be an easy denial, folks,” says Julianne Haydel of Haydel Consulting Services on her blog. “Like dated signatures, the prior face-to-face grammatical errors, etc., this is considered a statutory denial. It does not matter what kind of care you give and how much the patient benefitted,” she cautions.

Watch out: “The CGS call is like a big foghorn saying [denials] are coming,” Haydel tells Eli. “Wait for them.”

Timeline: “This is going to be a real problem in 90 days,” Haydel believes. “Until the denials come, people still don’t think it applies to them.”

This requirement took effect Jan. 1, but CMS and the MACs haven’t been enforcing it. That delayed enforcement is going to lead to denials piling up, Haydel fears. “We went a really long time with no F2F denials,” she offers as a comparison. “The longer we go before we catch on, the more denials we will have.”

Bottom line: “Your claim can and likely will be denied if this date is not included on recertifications,” she emphasizes on the blog.

Could A Reprieve Be In Sight?

Exactly how burdensome this reg will be will depend on how CMS and the MACs interpret it, says Chicago-based regulatory consultant Rebecca Friedman Zuber. “If the MACs and CMS want a separate indication in the record of the physician’s estimate of how much additional service will be needed, then the burden will be much greater,” Friedman Zuber expects.

That’s an example CGS gives in the Q&As. “The agency can provide a written statement with a blank left for the estimated time as a reminder to the physician to complete and sign,” the MAC says. That statement would require the doc’s signature, experts say.

But if CMS and the MACs accept the estimate as part of the verbal order for the recert episode, the burden could be a bit less heavy, Friedman Zuber says. 

The Manual “now specifies that there has to be a verbal order in place prior to the end of the previous cert period when a recent is being prepared,” Friedman Zuber explains. “That means to me that there has to be a record of a conversation with the physician before the end of the cert period, but after the followup comprehensive assessment is completed — just like there should be at admission between the comprehensive assessment and the initiation of care. That way when the physician signs the plan of care he or she is, in effect, signing a verbal order.”

A good sign: In the July 8 Open Door Forum for HHAs, CMS’s Randy Throndset seemed to agree that an agency should be able to take a verbal order for the estimate, then include that verbal order in the body of the recert statement. However, Throndset qualified his answer by saying it would need to be reviewed.

If CMS sticks to this interpretation — if the end point “is in the body of the 485 (goals or summary or wherever the agency wants to put it) and the physician signs and dates — it should be OK,” Haydel says. “It can be a verbal order and does not have to be handwritten by the physician.” HHAs still must be sure to include it in every single recert, however.

But don’t be surprised to see CMS come back and say “the actual length of care projection must be completed by the MD himself — it cannot be written in or entered by the agency,” Laff says. “It is still very problematic.” 

Note: CR 9119 is online at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R92GI.pdf and CR 9189 is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R602PI.pdf. Links to the slides and Q&As are on Haydel’s blog at http://haydelconsultingservices.com/2015/06/24/end-in-sight-for-home-health-services.