Face-To-Face Encounter Instructional guide to Medicare Compliance Biana Krayevsky, RN, Administrator/DPCS ProHealth Home Health Services, Inc Disclaimer This article was prepared as a service to the Transitions of Care Community Coalition. This article contains references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written laws or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Face-to-Face Overview Mandated by the Affordable Care Act (ACA) in 2011-The Patient Protection and Affordable Care Act (ACA) provides new tools to enhance CMS’s efforts to prevent and detect fraud in its programs. F2F is a Condition for payment according to the regulations at 42 CFR 424.22(a)(1) Prior to certifying a patient’s eligibility for the home health benefit, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient Documentation regarding these encounters must be present on certifications for patients with starts of care on and after January 1, 2011

Background A physician must order Medicare home health services and must certify a patient’s eligibility for the benefit. The face to - face 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. In addition to the certifying physician, NPPs who may perform the face –to - face are: A nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Social Security Act), who is working in collaboration with the physician in accordance with State Law A certified nurse-midwife (as defined in section 1861 (gg) of the Social Security Act, as authorized by State Law) A physician assistant (as defined in section 1861(aa)(5) of the Social Security Act), under the supervision of the physician)

Home Health Prospective Payment System (HH PPS) Final Rule Implementation Provisions CMS implemented the ACA mandate via the HH PPS Calendar Year (CY) 2011 rulemaking and finalized the following provisions: Documentation regarding these face-to-face encounters must be present on certifications for patients with starts of care on and after January 1, 2011 As part of the certification form itself, or as an addendum to it, the physician must document when the physician or allowed NPP saw the patient, and document how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or NPP must see the patient within 30 days after admission.

Implementation Provisions –Physician Flexibility ACA and the final rule include several features to accommodate physician practice: In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allows a physician who attended to the patient in an acute or post-acute setting, but does not follow patient in the community (such as hospitalist) to certify the need for home health care based on their contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then “hand off” the patient’s care to his or her community-based physician. Medicare will also allow physicians who attended to the patient in an acute or post-acute setting to certify the need for home health care based on their contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. An allowed NP who attends to a patient in an acute setting can collaborate with and inform the community certifying physician regarding his/her contact with the patient. The community physician could document the encounter and certify based on this information. The law allows the face-to-face encounter to occur via telehealth, in rural areas, in an approved originating site.

Certification Requirements: Supporting Documentation Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. If documentation is not sufficient, payment will not be rendered. According to the regulations at 42 CFR 424.22(c), Certifying physicians and acute/post-acute care facilities must provide required documentation upon request. Certifying physicians who are not in compliance will be subjected to provider-specific probe reviews. The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: Need for the skilled services: and Homebound status

Certification Requirements: Supporting Documentation (Continued) The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter: Occurred within the required timeframe; Was related to the primary reason the patient requires home health services; and Was performed by an allowed provider type. This information can be found most often in, but is not limited to, clinical and progress notes and discharge summaries.

Recertification Requirements At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient for a subsequent 60-day episode. According to the regulations at 424.22(b)(1) recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode: Recertification: 1. Must be signed and dated by the physician who reviews the plan of care; 2. Indicate the continuing need for skilled services; and 3. Estimate how much longer the skilled services will be required.

Samples of Estimated Time Estimated continued time patient to remain on services is 60 days until caregiver is found to assume responsibilities for ……IV infusions…subcutaneous injections….etc. Estimated continued time patient to remain on services is 3 weeks for the wound healing process to complete. Estimated continued time patient to remain on services is 60 days until all goals met; medical condition is stable and patient is no longer in need of skilled services. No foreseeable day of discharge due to continuous TPN infusions indefinitely and no available CG to assume responsibility for PICC care and blood draw. “ESTIMATED TIME” MUST BE WRITTEN BY MD! IT CAN NOT BE WRITTEN IN PLAN OF TREATMENT BY AN AGENCY AND SENT TO MD FOR SIGNATURE. Disclaimer: these examples were collected from samples of charts from different agencies and do not guarantee payment or medical necessity for Recert patients.

Exceptional Circumstances If a home health patient dies shortly after admission before the face-to-face encounter occurs, if the contractor determines a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.

Home Health Prove and Educate Process On 12/7/2015 for episodes with start of care dates on or after August 1, 2015, 5 claims will be selected for each HHA. The Probe & Education edit codes are: J6: 5WPE1 and 5CPE1. A Medical Review Additional Development Request (ADR) will be generated for claims that meet the Probe & Education criteria. Claims will be reviewed for valid Face-to-Face encounter documentation, medical necessity, compliance with the CMS coverage guidelines, correct billing and coding associated with updates in the CMS-1611-F, Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule.

REFERENCES: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/se1436.pdf https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/downloads/face-to-face-requirement-powerpoint.pdf https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/downloads/qandasfull-revised-062712.pdf http://oig.hhs.gov/oei/reports/oei-01-12-00390.pdf

5 Main Reasons for Claim Denials The actual clinical note for the face-to-face encounter visit (physician's progress note or the facility’s discharge summary) is not being submitted by the home health agency when responding to the ADR. The face-to-face attestation form that was commonly used prior to 2015. As of 2015, this attestation with a brief clinical narrative is no longer required and is not sufficient. Rather, the actual visit that comprised the face-to-face encounter must be supplied. CMS Publication 100-2 Chapter 7, Section 30.5.1.2 indicates that documentation from the certifying physician's medical records and/or the acute/post-acute care facility’s medical records are to be used to determine eligibility for the Medicare home health benefit. It further states that this medical record must contain the actual clinical note for the face-to-face visit. Tip: Make sure to submit the actual medical record of the face-to-face encounter with your records for NGS to review. This information can be found most often in clinical and progress notes and discharge summaries.  

REASON #2 The eligibility requirements to substantiate that the patient has the need for skilled home health services and is homebound is not justified by the documentation in the certifying physician's and/or the acute/post-acute care facility records. These parameters are often not being addressed in the actual medical records when they are submitted. According to CMS Publication 100-2, Chapter 7, Section 30.5.1.2 “The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s need for the skilled services and homebound status.”

REASON #3 The physician from the acute/post-acute care setting is certifying the patient's eligibility for the home health benefit and completing the face-to-face encounter, but will not be following the patient after discharge, and there is no documentation of the community physician who will be following the patient after discharge. In this situation, the certifying physician must identify the community physician who will be following the patient after discharge. Per CMS Publication 100-2, Chapter 7, Section 30.5.1, “One of the criteria that must be met for a patient to be considered eligible for the home health benefit is that the patient must be under the care of a physician. Otherwise, the certification is not valid.

REASON #4 The home health agency is not providing the certification and face-to-face encounter documentation from the start of care (SOC) episode when the claim under review is a recertification claim. The Medical Review department is responsible for determining whether the patient was eligible to receive services under the Medicare home health benefit at the start of care, so it is critical this documentation is supplied, regardless of what certification/recertification claim it is.

REASON #5 The recertification does not include an estimate by the physician of how much longer the skilled services will be required. This estimate must be specifically stated and will not be inferred by the Medical Review staff from the certification dates on the plan of care, or the frequency/duration of the orders. TIP: The home health agency should review all recertification forms for the estimate of how much longer the skilled services will be required; if missing, obtain documented clarification from the physician before the services are billed to Medicare.

References: 1. CR 9189 Medical Review of Home Health Services Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services Link to MLN Connects National Provider Call: Certifying Patients for the Medicare Home Health Benefit https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-12-16-HHBenefit-HL.pdf Link to MLN Connects National Provider Call Transcript December 16, 2014 https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-12-16-HH-Benefit-Transcript.pdf Link to Home Health Face-to-Face Encounter Question & Answers https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/downloads/qandasfull-revised-062712.pdf