Medicare Compliance & Reimbursement

Missing or insufficient documentation among top flaws.

Ever since F2F became mandatory it has been a difficult issue for home health agencies as well as referring providers. A study conducted by the HHS Office of Inspector General (OIG) shows just how complicated it is to meet this documentation requirement.

In the 2011-to-2012 timeframe that the OIG studied for its new report, the Centers for Medicare & Medicaid Services and its contractors did very little review of F2F, the watchdog agency notes. But now the bad habits that physicians developed in the first few years of F2F are taking a toll on agencies.

For the report, the OIG took a 680-claim sample from the 7.8 million claims in 2011 and 2012 and examined their F2F documentation. The OIG didn’t receive documentation at all for about 10 percent of claims, it notes. Of the claims for which it did receive documentation, the OIG found 25 percent were missing at least one of the six requirements for F2F compliance.

“Some face-to-face documentation failed to specify why the patient was homebound or to include the reason the skilled service was necessary” in the physician narrative, the OIG notes. The OIG found that for homebound, docs sometimes included vague phrases in the narrative that did not specify how they applied to the patient, using these words:

• Taxing effort to leave home, 17 percent
• Weakness/fatigue, 16 percent
• Unable to leave home unassisted, 14 percent
• Unsteady gait/risk of falls, 13 percent
• Decreased mobility, 10 percent
• Shortness of breath/dyspnea, 9 percent
• Poor endurance, 7 percent.

In about half the documents where physicians used “taxing effort to leave home” to explain their patients’ homebound status, the physicians did not list any other reasons, the OIG says. “The phrase ‘taxing effort to leave home’ is included in CMS’s definition of homebound, and, therefore, offers no specific statement about the patient’s condition.”

HHH Medicare Administrative Contractor CGS identified these phrases that were insufficient to document homebound for F2F, the OIG says:

• Weak,
• Unable to drive,
• Unable to leave home,
• Dementia or confusion,
• Functional decline.

For skilled need, docs included these phrases that did not meet standards, CGS says:

• Family is asking for help,
• Continues to have problems,
• List of tasks for nurse to do,
• Patient unable to do wound care,
• Diabetes.

“The brief narrative section of the face-to-face encounter documentation is the most subjective component to the documentation requirement,” observes law firm Wachler & Associates in its analysis of the report. “Many contractors deny payment for entire episodes of care based on the fact that the brief narratives are insufficient.”

The OIG notes in the report that the doc should be able to provide an adequate narrative in a minimum of three sentences.

Checkboxes Come With Pros And Cons

While CMS has given guarded approval to F2F documentation that uses checkboxes, it comes with a significant risk: physicians failing to supply a narrative in their own words to go along with the checkboxes. “The option next to each checkbox must contain the physician’s assessment specific to that patient,” the OIG stresses.

One MAC indicated it gives more leeway to forms with checkboxes that are generated by the physician rather than the HHA. Six percent of F2F documents the OIG reviewed used checkboxes.

Another risk area: While the physician narrative is an ongoing problem, physician signatures also presented a pitfall for agencies. Seventeen percent of the claims that didn’t pass F2F muster contained errors related to the certifying physician’s signature, the OIG relates.

The OIG lauded F2F documents that include unrequired but helpful information, such as the physician’s National Provider Identifier number, physician’s printed name, and the name of the non-physician practitioner who conducted the encounter.

This report may “help our cause by finding that virtually all of the noncompliance is documentation related (particularly the narratives), that a model form would be helpful, and that CMS needs to do direct education of physicians,” says William Dombi with the National Association for Home Care & Hospice in a message to members.

Lawsuit update: As CMS continues to signal an unwillingness to work out F2F problems jointly with the industry, NAHC expects to file its lawsuit over the matter shortly, Dombi tells Eli. 

Note: The report is at http://oig.hhs.gov/oei/reports/OEI-01-12-00390.pdf.