Archive for the ‘Face to Face Encounters’ Category

Summary of the CMS Released 2013 Final Rule

Tuesday, November 27th, 2012

Market Basket and Payment Rate Update

On November 2, 2012, CMS released the Medicare Home Health Final Rule for the Home Health Prospective Payment System 2013. The proposal includes the 2013 Market Basket Index (MBI) update of 2.3%, the required 1 point reduction under the Obama Affordable Care Act, and the reduction in rates of 1.32%, which is approximately a $10M decrease to payments for the home health 60 day episodes for 2013. The main change, per NAHC, from the July 5th proposed rule adjustment is an adjustment of the MBI from 2.5 to 2.3% occurring as a result of more current data. Proposed payment base episode rates are set at $2137.73 from a current $2138.52.

Though a small increase, the gain is that it is not the decrease CMS had proposed if  a full creep adjustment had been incorporated. The base rates are adjusted up by 3% for service to patients in rural areas.



For agencies submitting the required quality data, the LUPA rates are :

HH Aide $  51.79

MSS       $ 183.31

OT          $ 125.88

PT           $ 125.03

SLP        $  135.86

SN          $  114.35


For those agencies that have not submitted quality data, their rates will be reduced by 2 percentage points.


The outlier eligibility standards are changed from 2012. The Fixed Dollar Loss Ratio is lowered from 0.67 to 0.45. This will increase the number of episodes that will qualify for outlier payment.



Home Health agencies should expect payments subjected to a 2% sequestration, as part of the deficit reduction law. Though this is not a rate change, in and of itself, it will be a withhold of 2% from the claims payment. This is another  home health  reduction. Be prepared for expected significant changes for 2014 when CMS rebases the HHPPS rates as required under the Affordable Care Act.



CMS finalized three revisions regarding qualified therapists completing a functional reassessment of the patient at the 14th and 20th visit and every 30 days.


First: CMS states that if a qualified therapist misses a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, NOT the visit after the qualified therapist completed the late reassessment.


Second: CMS states that in cases where there is multiple therapy disciplines involved, if the required reassessment by the qualified therapist was missed for any of the therapy disciplines, therapy coverage would cease for only the therapy discipline involved.


Third: CMS states that in cases where the patient is receiving more than one type of therapy, qualified therapist must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and they must complete the 19th visit reassessment during the 17th, 18th, or 19th visit. CMS also states that in instances where the beneficiary receives more than one therapy type, if the frequency of a particular discipline does not make it feasible for the reassessment to occur during the specified times without providing an extra unnecessary visit or would delay a needed visit, then it is acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the beneficiary during the visit associated with the discipline that is scheduled to occur closest to the 14th Medicare covered therapy visit, but no later than the 13th Medicare covered visit. Likewise for the 20th Medicare covered therapy visit but no later than the 19th covered therapy visit.


Thus, the revised rule states that if, in multiple therapy visit cases, the required reassessment was missed for any of the therapy disciplines, therapy coverage would cease only for that particular therapy. Therefore, as long as the required therapy assessments are completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines, unlike presently.


Face to Face

CMS finalized adjustments allowing non-physician practitioners in an inpatient setting to perform the encounter and inform the inpatient physician who can then become the certifying physician.



M1024, effective January 1, 2013, is to only be used for acute fracture codes for case mix points. Patient resolved conditions are not to be coded in home health. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. These, then will be the only resolved codes allowed in M1024. Neoplasms, diabetes codes, neuro codes, and skin will no longer garner case mix points if placed in M1024, although CMS has stated an agency may continue to place resolved conditions in M1024 to present a more complete picture of the patient.


The final rule can be found at

Compliance Q&A: Survey protocols, CoPs, HIPAA, ACOs, and Transitions of Care

Saturday, November 19th, 2011

Questions regarding 2011 Survey protocols

Q. We have several questions re the new survey protocols. What are some of the key differences? What does the pre-survey preparation include?

A. The new survey protocols focus on specific standards within identified conditions that are related to quality care. To identify the care delivered and its relationship to the assessment and plan of care designed, besides reviewing the clinical record, the surveyor will also rely on personnel interviews as well as home visits. The survey is data-driven, patient-focused, and outcome-oriented.

The surveyor is expected to collect data and review State file data, prior survey results, OASIS reports, and agency specific characteristics. (S)he will review outcomes, potentially avoidable events of both active and discharged patients, and make visits for higher risk patents. The new protocols provide specific guidance on citing standard and condition-level deficiencies.

Q. Can you explain the survey levels? How is a standard survey extended?

A. A Standard Survey focuses on Level 1 standards (9 of 15 CoPs) which focus on the delivery of high quality patient care using not only clinical records but inclusive of interviews. If the home health agency is in compliance with all Level 1 standards and there are no identified concerns requiring investigation, the survey will be concluded and form CMS 2567 is issued.

Partial Extended Survey begins/expands when expected outcomes are not met for one or more Level 1 Standards. It requires a review of Level 2 standards. It should be expected that related information would be sought for areas of concern such as agency policies and procedures, personnel competency evaluations, and inservice training

Condition-Level Deficiencies can occur with serious findings related to or not related to Level 1 and 2 standards. Immediate patient jeopardy is always cited at the condition level. All conditions are reviewed.  Refer to the State Operations Manual, Appendix B Guidelines.

Questions re CoPs

Q. What are the required leadership positions stated in the CoPs?

A. The Conditions of Participation cite three administrative positions:  a governing body, an administrator, and a supervising physician or RN.  You may title these three positions whatever  your agency prefers, however the positions must exist and the individuals appointed must perform the duties identified in the CoPs. Be certain job descriptions, policies and procedures, and other necessary documentation clearly define that the positions perform all required designated responsibilities.

Do not forget the delegates required. Be certain that agency policy identifies who will function as the administrative delegate. The agency must also be in compliance with state requirements, which frequently are more stringent. Compare both State and Federal requirements so the agency is in compliance.

Q. Is it true that we must have a realistic end point for intermittent services for a patient who has a chronic diagnosis, such as Alzheimer’s disease?
A.The CMS Publication 100-2, Chapter 7, § 40.1.1,  states  services can be provided “without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time.”

According to the publication, if the patient with a chronic disease is homebound and needs skilled, reasonable, and necessary services that meet the part-time or intermittent requirements, then the agency can provide care.  That documentation must carefully be documented, The agency must be certain there exists an intensive assessment of the patient and their support services with interventions and goals clearly stated.  Carefully delineate the SKILLED need for each visit made. If the patient with Alzheimer’s disease qualifies for Medicare coverage through a need for monthly catheter changes and receives home health aide services 1x per mon, be certain each visit shows progress and document pt/cg response to care.

Up to a maximum of 28 hours per week of skilled nursing care and home health aide services combined completed in less than 8 hours per day or up to 35 hours per week of skilled nursing and home health aide services and subject to review by the fiscal intermediary. Medicare requires supporting evidence of the continued skilled care need. The agency must reflect the need for compliant skilled care through clear documentation.

Questions about ACOs and New Payment Methods

Q. I am hearing about bundled services. Should I be concerned?

A. Home Health Agencies should be aware of potential ACO formation in their respective markets.  Does your agency have a specialty you should be marketing to local hospitals? Some hospitals are looking at the bundled payment options as well as ACOs. Read more at the CMS website but know that the proposed pilot gives participants the opportunities to make choices regarding patients to include, length of episodes of care, whether acute inpatient care should be included, and the target payment to be established. There are a variety of proposed models. Go to to learn more.

Q. I have heard there will be new payment methods. What are they?

A. Select Data will be providing ezine articles in late November and December regarding some of the proposed payment and treatment methods being considered and presently being evaluated. Those may include:

Accountable Care Organizations (ACOs) with Bundled Payments or Shared Savings Programs where the ACO shares risk. There will be various types of risk sharing programs. There may be Value- based Payment plans. Expect to see ACOs lead by hospitals or physician groups. Home Health Agencies will need to show value to become a part of such collaborative formalized groups.  Expect CMS to utilize comparative-effectiveness techniques of evidenced-based practices. Become familiar with the following terms:

ACOs: Integration of providers to assume responsibility for the quality, costs, and outcomes of care.

Total Costs of Care: A reimbursable methodology that is being designed to reduce cost by person by episode.

Predictive Modeling: A methodology to estimate how clients may use services and the related costs based upon variables, prior behavior, and attributes assigned.

Transition of Care: The movement of patients from one health care practitioner or setting to another as the condition and care needs change. Under this model, there will be NO discharge summary. Instead expect a “Transition Summary”. See the next Select Data article: CMS and Transitions of Care.

Questions re Face to Face

Q. Is anyone working to get some help for home health agencies regarding the face-to-face rule?

A. Yes, several state associations as well as NAHC are working to obtain some legislative relief. NAHC has called for 1) exemptions in specific hardship circumstances, 2) a reduction in documentation required, 3) expanded use of telehealth to meet the face to face requirement, 4) protection of home health agencies from denials without fault, 4) allow one physician/NPP to complete the Face to Face and another to certify (CMS has proposed this but is limiting it only to an inpatient physician).

Q. Could you give a summary of key points of the proposed 2012 Home Health PPS Rate Rule?

A. Agencies will need to be efficient as there is a proposed 2.5% inflation update, a 5.06% case mix creep adjustment, and a 3.56% rate reduction for 2012. In addition there is a recalculation of case mix weights proposed that includes elimination of two hypertension codes (401.1 Benign essential hypertension and 401.9 Unspecific essential hypertension). Also, there would be lower therapy episode coding weights. This would include a deceleration of a higher number of visits with a removal of the therapy visit step indicators. There will also be a recalculation of points to clinical and functional scores. Additionally, if an agency failed to complete a successful dry run  in Q3 of 2010 for HHCAHPs, they risk a 2% reduction in payment. (See October, 2011 Select Data ezine for more regarding HHCAHPs).

A few questions regarding HIPAA

Q. Could you give a brief summary of HIPAA HITECH? Can you discuss breach? Can you discuss best practices needed?

A. The American Recovery and Reinvestment Act (ARRA) of 2009 brought changes to HIPAA regulations in three broad areas: breach notifications, business associations, and penalties. It increases enforcement of HIPAA and allocates billions of dollars to invest in the implementation and exchange of health information technology such as the EMR.

Under HITECH, if a breach compromises the privacy and security of the patient’s information and poses a significant risk of financial, reputational, or other harm, patient notification is required.

Five new definitions have been added:

  • Breach Electronic
  • Health Record (HER)
  • National Coordinator
  • Personal Health Record (PHR)
  • Vendor Of PHI

HITECH strengthens the specifics of privacy, significantly increasing penalties, establishing a heightened enforcement scheme and giving state attorney general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

If a breach involves 500 or more individuals, the department of HHS should be immediately notified. DHHS began posting names on March 1, 2010. Breaches below 500 must be logged and annually sent to DHHS.

For Business Associates, the Covered Entity must ensure that BAs have implemented the administrative, physical, and technical safeguards of HIPAA security. The CE must also specify that the BA must comply with use and disclosure rules in the HIPPA Privacy Rule. The BA should demonstrate how they will negotiate security/data breach coordination. There should also be an agreement on reporting and dispute resolution.

If the health care organization suspects or knows that a BA has committed a material breach or violation of the agreement, “the health care organization is in violation of the business associate rules unless it takes reasonable steps to cure the breach or end the violation {45CFR 164.504 (e)(1)(ii)” (Decision Health, HIPAA, 2010).

Penalties include a Tiered System for assessing both the level and penalty for each violation. There is a cap of $50,000 per violation and 1.5 million for the calendar year for the same type of violation.

Health care organizations should have in place policies that address various levels of violation, such as failing to sign off a computer terminal when not attended, sharing passwords, assessing a patient record without legitimate reason, releasing data for personal gain, and intentionally destroying or altering data.

Use Best Practices for:

Authentication: pre-boot and intricate passwords

Access: Need to know basis on approved devices

Retention: Destroy if not needed

Encryption: Laptops, notebooks, desktops, email, and social networks

For some peace of mind, have a written information security program, an active HIPAA privacy program, and a living Corporate Compliance Program.

Hospice Face-to-Face Encounter Requirement

Thursday, August 25th, 2011

This hospice encounter, like the home health face-to-face encounter, is causing concern among the industry. Agencies view it as yet another burden. Below we break down the regulation and look at “Who” may perform the face-to-face encounter, “What” all is required, and “When” must it take place.

“Who” may certify the face-to-face encounter?

Effective January 1, 2011, in response to the Patient Protection and Affordability Act, CMS added a “face-to-face encounter” requirement to the hospice certification requirements. The rule requires that hospice patients have a face-to-face encounter with a hospice physician or hospice nurse practitioner. The rule requires the same physician who has the encounter to certify the patient’s terminal illness.

Some flexibility has been added in the new final wage index published July 29, taking effect October 1, 2011. The face-to- face encounter will indeed become more flexible and will “allow any hospice physician to perform the face-to-face encounter regardless of whether that same physician recertifies the physician’s terminal illness and composes the recertification narrative.” (

A hospice physician is one who is employed by the hospice or contracts to perform work for the hospice. The hospice nurse practitioner must be employed by the hospice.

In the final rule of July 29, 2011, effective October 1, 2011, CMS rejected the request by the National Hospice and Palliative Care Organizations (NHPCO) to include physician assistants and clinical nurse specialists to perform the Face-to-Face encounter. The approved list continues to only include hospice physicians and nurse practitioners.

CMS did clarify that “hospice employee” does include employees of an organization which owns a hospice. There had been much confusion regarding whether health systems that employed nurse practitioners and owned a hospice  could have those practitioners perform the face-to-face encounters.

“What” additionally may be necessary?

Once the physician or nurse practitioner conducts the face-to-face encounter, they attest to the date of the encounter, and sign the attestation clause.

Since 2009, the physician must also document a narrative of clinical findings supporting life expectancy of six months or less.

With the new face-to-face encounter requirement, physicians must now include a narrative for the third beneficiary period and each subsequent benefit period. The narrative must delineate clinical findings with the face-to-face encounter that supports the life expectancy of six months or less.

The physician signature is required immediately below the narrative if it is a part of the certification form. If the narrative is a part of the addendum to the certification form, the addendum must also be signed by the physician.

“When” must the face-to-face encounter take place?

The face-to-face encounter must take place no more than 30 days prior to the patient’s third benefit period AND every subsequent benefit period thereafter. In the Open Door Forum on March 2, 2011, CMS was very clear that they expect a face-to-face encounter to be completed prior to the start of the third benefit period. However, CMS recently issued CR7337 to include exceptional circumstances for this requirement. In cases where a hospice newly admits a patient who is in the third or later benefit period exceptional circumstances may prevent a face-to-face encounter from being conducted prior to the start of thebenefit period. In this circumstance, a face-to-face which occurs within 2 days after admission will be considered timely. If the patient would die within 2 days of admission without a face-to-face encounter, the encounter requirement would be considered complete.

In the March 2, 2011 Open Door Forum, CMS was most direct in stating that the exception is meant for the last minute admission, weekend admissions, and other exceptional circumstances.

The new Rule effective October 1, 2011

CMS is seeking public reporting of quality data from hospice agencies. Public Reporting will begin with two indicators: 1) the percentage of patients whose pain was brought to a comfortable threshold within 48 hours of hospice admission and 2) a structural measure indicating the hospice has a quality assessment and performance improvement (QAPI) program.

Data collection will become mandatory CY2012 with data submission required by January 2013 for the structural measure and April 2013 for the quality measure. Hospices that do not submit quality data should expect the market-based update for 2014 reduced by two percentage points.

Data reporting is expected to increase with additional quality indicators. Most hospice leaders will not find this surprising.

Note that after the release of the CY2011 and the face-to-face encounter, CMS stated, “we will issue instructions to the contractors who perform medical reviews to ensure compliance with this regulation.” The Z-PICs, PSCs, and RACs are expected to be more active within the Hospice industry. Compliance plans not yet mandated have become expected and essential. Tracking the signed face-to-face encounter is a requirement for payment; another essential element for the billing review.

Educational Videos: Face-To-Face Encounter

Monday, July 25th, 2011

Face To Face Encounters CY2011 Clinical Compliance

CMS was mandated by the Affordable Care Act to provide this encounter. You will be able to look on page 296 on the Final Rule to read the depth of it. But, essentially what CMS is stating is that the physician must see the patient within 90 days prior to the admission in a home health agency.  And that means that also, in seeing that patient for that face-to-face encounter, that diagnosis or that reason for seeing that patient must be directly related to the home health referral.  Now, if they don’t see them within 90 days prior to they must see them within 30 days after admission.

As of December 10, 2010 CMS is sending out a notice to the physician regarding this face-to-face encounter information.  So the home health agencies are going to have to do a lot of education with physicians.  It also requires then, that the physician provide this attestation that they have completed this face-to-face encounter, and it has to be attached to/or a part of the POC.

At Select Data we’ve created a documentation of the face-to-face encounter tool click here to download a copy of this form: DocumentationFacetoFaceEncounter.pdf


The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition

The Face to Face Encounter – UPDATES

Wednesday, April 13th, 2011

On and after April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices to have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and recertification for Medicare hospice services.

There has been much discussion re the Face to Face Encounter required by the Affordable Care Act and a part of the CY 2011 Final Rule. (See page 296 of the Final Rule) What exactly is required? The Face to Face encounter document needs to be part of the physician certification. CMS has added the term “travels together” to describe the relationship between the two activities.
The new regulation requires a patient to have been seen by the certifying physician within 90 days prior to the Start of Care (SOC). If that is not achieved, the patient must be seen within 30 days of admission to the home health agency. The regulation went into effect January 1, 2011 for patients admitted to home health on that date or later. Enforcement began April 1, 2011.

Q: Is the face to face provision applicable to Medicare Advantage Plans?
A. No. The Face to Face provision applies only to Medicare fee for service.

Keep in mind that many private carriers have even more stringent rules on Face to Face visits than CMS. It is becoming very common with many carriers to require physician visits every month while being under the care of a home health agency.

Per CMS, Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.
The physician is required to document on the certification how the clinical findings of the encounter support eligibility requirements as well as primary focus of home care. (See pages 498-500 of the rule). The certifying physician must document that they or a specified Nurse Practitioner had the required face to face encounter (including use of telehealth which is subject to requirements in 1834 (m) of the Act). Also see Publication b100-02 Medicare Benefit Policy 30.5.1 content of physician certification and Face to Face Encounters 3/10/2011.

Q. Can a resident conduct the face-to-face encounter?
A. Only the certifying physician or certain NPPs can perform the face-to-face encounter. Additionally, only Medicare-enrolled physicians can certify home health eligibility, per the Affordable Care Act.

“Since the F2F encounter is part of the certification for home health care, the resident would have to be eligible to certify. Therefore, he/she would need to be authorized by the State to practice medicine and enrolled in Medicare. If the resident met the criteria, it is possible that a resident could conduct this encounter” per NAHC.

The physician must document either on the certification form itself or as an addendum to it that the patient has a condition warranting home health involvement and that the patient is homebound, and has needs for skilled services.
Per the letter sent to physicians from CMS dated 12/10/2011,
• ”The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition.”
• The new regulation effects Starts of Care initiated on or after January 1, 2011.

Q: Can the ER physician caring for a patient during an ER visit and who determines that a patient is in need of home health services and is homebound, and who establishes a plan for home care document the face to face encounter/certification?
A: Per NAHC, yes, with the same caveats as above (regarding a resident).

The physician who conducts and documents the F2F encounter must be the physician that certifies the patient. The referring physician from the hospital may not conduct the encounter and have another physician sign the certification. The F2F encounter and the certification go hand in hand. Another (different) physician may sign the POC.
The final Rule states that agencies may not use “standardized encounter language” on the face to face encounter form that the physician must sign. A “template” may be used that allows physicians to describe the patient’s condition and primary reason for the encounter and referral to home health.

Q. Given the most recent CMS Q&A which seem to indicate that physicians could use drop down menus built into their electronic medical records to document the F2F, does that mean a home health agency can create a form with several checkboxes re diagnoses/reasons for homecare?
A. Many home health agencies are asking CMS what the difference is between electronic drop down choices and checking a box next to the appropriate written selection. CMS has specifically stated that checkboxes can not replace the physician’s narrative.

As a service to our clients and other agency leaders, Select Data has prepared a sample Face to Face Encounter Form for your use. You will note that it meets the requirements of:
• Specifying the individual completing the face to face encounter
• Specifying the date of the encounter
• Specifying the primary medical reason/diagnosis/condition for the encounter
• Specifying additional clinical findings that support home health medical necessity
• Specifying the patient meets the CMS requirements of Chapter 7 Medicare Benefits Manual for homebound status
• Specifying findings of the encounter support the skilled services for home health; SN, PT, S/LP
• Physician signature and Date

CMS has required that the “certifying physician document show the clinical findings of the Face to Face Encounter that supports home health eligibility. The Rule references homebound status and skilled need. It also causes the physician to be certain the clinical findings identified are sufficient to support home health care. CMS Manual System: Pub 100-2 Medicare Benefit Policy Transmittal 139.

Please note the MLN website will have a special edition article which may be found at