The Face to Face Encounter – UPDATES
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
How can I get a copy of your sample face to face encounter form?
It appears that many physicians are signing the forms, but will not fill in the data needed to complete them. Some have stated that if the patient can visit them in their office, they are not homebound. One agency I know of has had to discharge 3 patients in April alone because the physician refused to complete or failed to fill out the form completely. All of these patients had already received more than one visit, and the agency had to “eat” the cost. While I’m sure that CMS is aware of these problems, is there any movement toward an attempt to resolve them, or is this just another way to close agencies?
Maribeth, Just email me at susanc@selectdata.com and I will send you it as an attachment. Susan
Hi Charles, Face to Face has proved challenging to home health agencies nationwide. The National Association of Home Health/Hospice Care (NAHC) is requesting agency experiences as they are compiling data to present to CMS/Congress. Many Senators, after education by NAHC and Agency leaders are becoming aware of the hardship to both the patients and the agency that this legislation is causing (per many agencies). NAHC is lobbying for congressional awareness. Patients who have need for homecare may not be able to get out to see their physician without a taxing and expensive effort. It is believed, by many, that this legislation places barriers before the fundamental purpose of home health care:care for the patient at home; many of whom cannot get out easily to their physician. Write your Senators and Congress persons. Susan
Is general muscle weakness or deconditioning considered a homebound reason for the face to face?
Do you have an updated homebound reasons list?
A patient was admitted to Home Health on April 13 2012, then 2 days later decided that he wanted hospice instead. He was discharged from Home Health and admitted to Hospice. We had not received the face-to-face for the Home Health admission and still do not have a face to face. Do we need to continue to obtain the face to face? We have not received the signed certification yet. Thank you
Can a PA or FNP sign a F2F?