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.