Archive for the ‘Face to Face Encounters’ Category

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.” (www.ofr.gov/OFRUpload/OFRData/2011-19488_PI.pdf).

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

Summary

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.

CMS Q&A:
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 30.5.1.1 Face to Face Encounters 3/10/2011.

CMS Q&A:
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&As:
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&A:
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 http://www.cms.gov/MLNGenInfo

Educational Video: Face To Face Encounters

Thursday, March 17th, 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.  Read more

The Face to Face Encounter Required for the Home Health Industry: More Updates

Wednesday, March 2nd, 2011

The face to face requirement is a mandated condition for payment of the Affordable Care Act (ACA) has caused much confusion and concern. CMS has responded with the transmittal cited below. Home health agencies may need to craft letters to physicians with the key components that can assist to educate physicians as to requirements. Agencies continue to report that physicians claim they are not familiar with the new face to face requirements.

Be certain the face to face encounter information, for the physician, is in a short concise format.

-Let the physician know the face to face encounter visit is billable.

-Educate physician office personnel.

-Have a card with key websites that can provide information for the physician and his/her office personnel.

CMS identifies the reason for this encounter: “The face to face encounter requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition.”  www.cms.gov/center/hha.asp.

CMS issued an update to the Medicare Benefit Policy Manual, Chapter 7, Pub 100-02 on February 16, 2011. It may be reviewed at:

www.cms.gov/transmittals/downloads/R139BP.pdf

General comments that answer some of the most frequently asked questions include:

Who may perform the face to face encounter?

-Only Medicare enrolled physicians may certify Medicare beneficiaries for Medicare certified home health services.

-The certifying physician must certify through documentation that (s)he authorized a  “non-physician practitioner (NPP) to have a face to face encounter  with the beneficiary.”

- A NPP is inclusive of a nurse practitioner, clinical nurse specialist, a certified nurse midwife, or a physician’s assistant.

-The physician or NPP may not be an employee or have a financial relationship with the home health agency as defined in 411.354 through 411.357.

-The certifying physician must document the encounter and sign the certification.

CMS FAQS stated: there have been questions as to whether residents may complete face to face encounters.

CMS FAQs reply: “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.”

Please note: There had been questions as to whether one physician could certify patient’s eligibility and document the face to face encounter based on information from another physician who recently saw the patient, such as the patient’s attending during an acute stay.

CMS FAQs state: “NO, The law mandates that either the certifying physician or certain non-physician practitioners (NPPs) who inform the certifying physician, can perform the face to face encounter. A patient’s encounter with an attending physician during an acute stay does not satisfy the requirement unless the attending physician is also who certifies eligibility. However, certain NPPs in the acute care setting may collaborate with the certifying physician. In such cases, an NPP’s encounter with the patient during an acute or post acute stay may satisfy the requirement.”

However, the new transmittal states that a hospitalist or an attending physician who cares for the patient in an acute care setting but does not follow the patient to the community MAY CERTIFY the need for home health care and transfer care to the designated community based physician who has assumed care for the patient.

When must the face to face encounter be completed?

-The face to face encounter must occur no earlier than 90 days prior to the Start of Care (SOC) or within 30 days after the Start of Care.

-If the face to face encounter meets the timeframe guidelines (within 90 days of the SOC),  but the encounter does not relate to the primary reason for the home health admission, then a new encounter is needed to be completed within 30 days from the SOC.

Where can the face to face encounter be performed?

-There is no mandate as to location.

-Telehealth may meet criteria for face to face encounters but go to www.cms.gov/telehealth for the particulars.

What are the documentation requirements?

-The certifying physician must document the face to face encounter even if the approved NPP completed the actual encounter.

-If a NPP completed the encounter, they must document the clinical findings and give them to the certifying physician for review.

-If the face to face encounter is a part of the certification, it must have a separate section or be an addendum.

-The documentation MUST include the date of the encounter, a narrative describing the patient’s condition and its relationship to the primary reason for  skilled home health services, and homebound status justification.

-The documentation must be dated and signed by the certifying physician.

-Agencies are NOT permitted to formulate drop down choices or provide written standard language on the forms for the physician.

-It is acceptable for the certifying physician to dictate his/her findings.

-It is Not acceptable for the physician to verbally dictate the encounter to the home health agency as part of the certification.

The face to face encounter is now a requirement. It will be fully enforced by April 1, 2011 so use this first quarter to work out the best processes for your agency. Use this time to educate the physicians and their personnel as well as educating hospital discharge planners. Also, be certain your clinicians are fully capable of explaining the face to face encounter as some agencies are reporting that physicians are asking questions when contacted by the home health nurse.

Remember, nothing has changed re home bound status rules or the “need for skilled services.” CMS reminds readers of their new powerpoint presentation re the face to face encounter, “to be eligible for the benefit, a patient must need skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy.”

Additional Sources: Home Health Prospective Payment System Rate Update for Calendar Year 2011, final rule, p.57-63: http://edocket.access.gpo.gov/2010/pdf/2010-27778.pdf