Part B Insider (Multispecialty) Coding Alert

You may have some hard choices ahead.

Under Medicare’s new “Probe & Educate” medical review initiative for the face-to-face physician encounter, you could find yourself stuck on prepay medical review indefinitely.

Smart certifying physicians and home health agencies will take these steps to increase their chances of defending against the P&E review and obtaining their reimbursement:

1. Know which elements the physician note requires. For a claim to pass medical review, a physician’s note containing three elements must be present: Proof that the visit occurred within the required timeframe, was related to the primary reason the patient requires home health services and was performed by an allowed provider.

2. Educate physicians. Ultimately, the physician’s documentation will make or break the claim, says Chicago-based regulatory consultant Rebecca Friedman Zuber. Help them understand what needs to be in the record to ensure their patients can receive home care services.

Pointer: Remember, the certifying physician can sign and date information from the HHA into the record, CMS offers in MLN Matters No. SE1524.

And agencies might want to have their referring docs use the voluntary F2F form CMS has proposed. However, agencies and their representatives have taken issue with the form, saying it repeats many of the flaws of the now-eliminated narrative requirement.

3. Set up F2F review processes. “Ensure appropriate controls are in place to monitor documentation compliance,” Little advises. You don’t want to realize the physician’s record doesn’t support the claim only when it comes up for review.

4. Watch for P&E ADRs. Don’t face F2F claims denials because you weren’t aware of the Additional Development Requests for the claims. “Instruct billing personnel to watch closely for the ADRs to come,” Little urges.

 

 

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