Home Health & Hospice Week

If you furnish management and evaluation to patients as their only skilled service, you'll have a lot more work securing your Medicare payment for them starting Jan. 1.

That's because the Centers for Medicare & Medicaid Services has finalized a requirement to have ordering physicians write "a written narrative of clinical justification" for the services, according to the home health prospective payment system 2010 update in the Nov. 10 Federal Register (see Eli's HCW, Vol. XVIII, No. 39, p. 298).

CMS will require the narrative for both certs and recerts, the final rule says. The narrative must prove that "the patient's overall condition supported a finding that recovery and safety could be  ensured only if the care was planned, managed, and evaluated by a registered nurse."

Securing this narrative from docs will be "very burdensome," warns clinical consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "Physicians do not really understand the home health benefit and are also reluctant to write any additional information."

What's ahead: "Agencies will have a difficult time getting this narrative," predicts consultant Sharon Litwin with 5 Star Consultants in Ballwin, Mo. "Physicians will most likely not want to do these, as it is more paperwork."

Regulatory consultant Rebecca Friedman Zuber expects the narrative to "eat up around an hour of combined agency and physician time if it is implemented appropriately." That means not using a "canned attestation" for the requirement.

"The narrative must be composed by the physician performing the certification or recertification and not by other home health personnel," CMS explains in the rule.

CMS did let up on one point, however. The agency will allow the narrative as an addendum attached to the plan of care, it says. But the doc must sign the addendum. When the narrative is part of the cert or recert form, it must immediately precede the physician's signature.

CMS finalized the narrative requirement over vociferous opposition submitted in response to the proposed rule. Commenters protested that the requirement diminishes the role of the nurse in home care, adds too much burden to ordering physicians, and complicates billing for dually eligible Medicare-Medicaid patients, among other problems.

No dice: The requirement is necessary because it "addresses a specific program vulnerability which has been identified by our Medicare contractors," CMS responds.

And it may not be the last new requirement for this service. The narrative "is a first step in addressing vulnerabilities identified by the Office of Inspector General (OIG)," CMS adds.

"The brief narrative should be a simple task for the physician because of the physician's responsibility for the clinical determination of the patient's skilled need as part of the certification or recertification requirement," CMS insists.

The requirement also addresses another problem -- the physician's lack of involvement. "The physician may rely too heavily on the home health staff for the determination of skilled need for Medicare's home health benefit," CMS believes.

The new narrative requirement is tough, but it's supposed to be, points out Friedman Zuber. "CMS is hoping that if a physician has to actually write out why this patient needs skilled nursing oversight of non-skilled care, that he will be discouraged from just signing these plans of care."

Note: For tips on M&E billing success, see the next issue of Eli's Home Care Week.