Medicare Compliance & Reimbursement

Physicians must see patient 30 days before or two weeks after start of care -- and sometimes more.

Based on a provision in the Patient Protection and Affordable Care Act (PPACA), CMS has proposed requirements for physicians to have a face-to-face encounter with patients before certifying them for home care.

Under the regulation in the July 23 Federal Register proposed rule for the 2011 home health prospective payment system, physicians or qualifying non-physician practitioners would have to see the patient 30 days before start of care or within two weeks after SOC.

Qualifying NPPs include nurse practitioners, physician assistants, clinical nurse specialists, and certified nursemidwives, CMS says. However, the NPPs (as well as the physicians) can't be employed by the home health facility.

Thirty days is a stricter timeframe than the six months suggested in PPACA. "We believe that the face-to-face encounter statutory provision was enacted to strengthen physician accountability in certifying that home health patients meet home health eligibility requirements," CMS explains in the proposed rule. "We also believe that in order to achieve this goal, the encounter must occur close enough to the home health start of care to ensure that the clinical conditions exhibited by the patient during the encounter are related to the primary reason for the patient's need for home health care."

Another burden: Not only do physicians have to see the patient before certifying her, they have to document the visit and show why the patient qualifies for home care, CMS says in the rule. Under the proposal, the physician's documentation must "describe how the clinical findings of that encounter supported the patient's eligibility for the Medicare home health benefit," CMS says.

"Specifically, the physician would document how the clinical findings of the encounter supported findings that the patient was homebound and in need of intermittent skilled nursing and/or therapy services." And the physician must document it, even if her NPP is the one who made the visit to "inform" her of the patient's condition, the rule proposes. This documentation must be in a "separate and distinct" area of the certification that is "clearly titled," or even in a separate addendum, to make it easy to identify, CMS says. The doctor must also sign and date it and include the date of the encounter.

The encounter timeframe gets even stricter if the patient's condition changes. The 30-day window would apply only if the encounter was for the primary reason for home care. If the physician visit was for a different reason and/or the patient's condition changes significantly, another visit within two weeks of SOC would be required.

When a patient's condition changes significantly, "we believe that a more contemporaneous visit is needed to ensure the certifying physician can accurately certify the patient's eligibility for services, and effectively plan the patient's care," CMS justifies in the rule.

This provision should help ensure program integrity, CMS says. "Patient care and access are ultimately what CMS is looking to protect, while working aggressively to prevent fraud," CMS Deputy Administrator Jonathan Blum says in a release.

Consequences: If episodes don't meet the face-to-face encounter requirements, they won't be eligible for Medicare payment, CMS warns.

Editor's note: The rule is at http://www.edocket.access.gpo.gov/2010/pdf/2010-17753.pdf.