Additional Documentation Requests (ADR’s) Home Care Association of Washington 2015 1686_0215

Today’s Presenters Shelly Bernardini RN, CPHM HH Clinical Consultant Jurisdiction K & Jurisdiction 6

Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at http://www.cms.gov.

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Acronyms Acronyms used in this presentation can be viewed on the NGSMedicare.com website. On the Welcome page, click on Provider Resources > Acronyms.

Agenda Morning Afternoon Additional Documentation Requests (ADR’s) Receiving Mock Charts Collection of the Medical Record Review of Materials Prior to Submission Collaboration of Documentation Face to Face Encounters (F2F) Plan of Care (POC) Homebound Status Need for Skilled Services Certification Documentation Process References & Resources

Medicare Home Health Eligibility To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and, per §1814(a)(2)(C) and §1835(a)(2)(A) of the Act: Be confined to the home; Need skilled services; Be under the care of a physician; Receive services under a plan of care established and reviewed by a physician; and Have had a face-to-face encounter with a physician or allowed non-physician practitioner (NPP). It is required to support all of these eligibility requirements in your documentation when it is requested from NGS or the CERT or the RAC, or any other entity that may pay or deny your claim upon review of the medical records.

Additional Development Request Request for documentation to support the claim previously submitted Upon receipt, it is imperative to have a process or policy in place to ensure that the documentation is collected efficiently and appropriately Mock Charts Staff Member(s) Assigned to Collect Documentation in Order of the Mock Chart Staff Members Assigned to Review Documentation Prior to Submission When an ADR is received it is a request for documentation to support that the claim is legitimate and the services were medically necessary for a homebound patient. Upon receipt of an ADR it is imperative that a process is followed to ensure that the documentation in collected efficiently AND appropriately to avoid errors that result in denial or adjudication of payment. Ways to improve your ADR process are to create a Mock Chart to follow when collecting information for the ADR, assign that task to one or multiple people to ensure that all pieces are obtained and then assign 3 or more people to review the chart for all of the eligibility and documentation requirements prior to final submission.

Additional Development Request Utilize the instruction on the ADR as your guide to collect the information requested. THIS CLAIM REQUIRES ADDITIONAL INFORMATION IN ORDER TO MAKE APPROPRIATE PAYMENT DETERMINATION AND PROCESSING. PROVIDED BELOW ARE RECOMMENDED SUPPORTING DOCUMENTS, BUT NOT AN ALL INCLUSIVE LIST. THE DOCUMENTATION SHOULD SUPPORT THE VERIFICATION OF THE ISSUE THAT GENERATED THIS REQUEST. FOR FURTHER INFORMATION, ENTER THE REASON CODE(S) LISTED BELOW IN THE APPROPRIATE FIELDS IN THE ON-LINE SYSTEM. WE ACCEPT DOCUMENTS VIA PAPER, FAX, CD/DVD AND ESMD OMB #0938-0969 PLEASE NOTE: **MEDICAL** RECORDS ARE DUE TO THE MAC WITHIN 45 CALENDAR DAYS. *NON-MEDICAL* RECORDS ARE DUE TO THE MAC WITHIN 14 CALENDAR DAYS. 45 Days

Additional Development Request MEDICARE REQUIRES A LEGIBLE IDENTIFIER FOR SERVICES PROVIDED AND ORDERED. MEDICARE WILL ACCEPT CLEARLY LEGIBLE HANDWRITTEN SIGNATURES, HANDWRITTEN INITIALS OR ELECTRONIC SIGNATURES. STAMPED SIGNATURES ARE NOT ACCEPTABLE ON ANY MEDICAL RECORD.

Additional Development Request PATIENT IDENTIFICATION, DATE OF SERVICE, AND PROVIDER OF THE SERVICE SHOULD BE CLEARLY IDENTIFIED ON THE SUBMITTED DOCUMENTATION. IF THE RENDERING PROVIDER SIGNATURE IS NOT CLEARLY LEGIBLE, ATTACH A SIGNATURE LOG/KEY THAT INCLUDES THE TYPED NAME OF THE PROVIDER WITH CREDENTIALS, THE SIGNATURE, AND THE INITIALS FOR EACH PROVIDER FOR WHICH THE RECORDS ARE REQUESTED. IF YOU QUESTION THE LEGIBILITY OF YOUR SIGNATURE, YOU SHOULD SUBMIT AN ATTESTATION STATEMENT IN YOUR DOCUMENTATION RESPONSE. IF THE SIGNATURE REQUIREMENTS ARE NOT MET, THE REVIEWER WILL CONDUCT THE REVIEW WITHOUT CONSIDERING THE DOCUMENTATION WITH THE MISSING OR ILLEGIBLE SIGNATURE. THIS COULD LEAD THE REVIEWER TO DETERMINE THAT THE MEDICAL NECESSITY FOR THE SERVICE BILLED HAS NOT BEEN SUBSTANTIATED. PLEASE SUBMIT THE SUPPORTING DOCUMENTATION WITHIN 45 DAYS FROM THE DATE OF THIS NOTICE. THIS DOCUMENTATION MUST BE CLEAR AND LEGIBLE.

Additional Development Request CONSIDER THE FOLLOWING LIST AS A DOCUMENTATION GUIDE WHILE PREPARING RECORDS IN RESPONSE TO THIS REQUEST: PLEASE INCLUDE THE FOLLOWING ITEMS: - ALL APPLICABLE PHYSICIAN SIGNED PLANS OF CARE (485) FOR THE CLAIM PERIOD; - ALL SIGNED PHYSICIAN ORDERS PERTAINING TO THE PLAN(S) OF CARE; - CLARIFY HOMEBOUND STATUS, INCLUDING FUNCTIONAL AND ACTIVITY LIMITATIONS; - ALL DISCIPLINE NOTES AND FLOWSHEETS, INCLUDING INITIAL EVALUATIONS AND SUMMARY REPORTS. - FOR ANY DME BILLED, PLEASE INCLUDE THE MEDICAL EXPLANATION OF NECESSITY, AND ANY SUPPORTING DOCUMENTATION. -IMPORTANT, PLEASE INCLUDE ALL OASIS FORMS, INCLUDING ANY SCIC OASIS FOR THE CLAIM PERIOD LISTED. -IF THERE IS AN ABN ON FILE, PLEASE SUBMIT THE ABN WITH THE REQUESTED DOCUMENTATION. -PLEASE INCLUDE DOCUMENTATION TO SUPPORT THE FACE TO FACE ENCOUNTER

Additional Development Request Other sources of documentation that often assist in defining the patients need for skilled services and homebound status may include: Discharge Summary Inpatient History & Physical Inpatient Plan of Care Case Management and Discharge Planner Documentation from Inpatient Facility The list on the ADR that is sent is not all-inclusive…some other sources of documentation that often assist in defining the patients need for skilled services and homebound status include: D/C Summary H&P Inpt POC Case Management and D/C Planner documentation Lets see if we can name a few more that arent listed… It would be beneficial to have these written down and kept in the Mock Chart to ensure that ALL records are forwarded when an ADR is received. BRAINSTORM….

Additional Development Request Prior to submission of documentation, it is imperative that all paperwork is completely reviewed to ensure: All pages are for the appropriate patient The patients name is on each page The correct dates of service for all materials Dates and signatures are clear and appropriate Legibility Accuracy Documentation supports the patients need for skilled services Homebound status is identified and comprehensible (as per CMS guidelines) Again…it is imperative to have the chart reviewed by many eyes prior to submission. They should have a check list for all of the required criteria and eligibility requirements. They should ensure All pages are for the appropriate patient The patients name is on each page The correct dates of service for all materials Dates and signatures are clear and appropriate Legibility Accuracy Documentation supports the patients need for skilled services Homebound status is identified and comprehensible (as per CMS guidelines)

Collaboration of Documentation It is the responsibility of the referring, certifying &/or community physicians to record all pertinent HH information in the medical record and collaborate all documentation with the HHA HHA documentation is also reciprocal; as it compliments & supports documentation in the referring, certifying &/or community physicians records. All of the documentation that is collected includes the documentation in the HHA, as well as that documentation from the referring physician and the community physician. This collaborative effort is imperative in the effort to support the claim submitted. It is the responsibility of the referring, certifying &/or community physicians to record all pertinent HH information in the medical record and collaborate all documentation with the HHA HHA documentation is also reciprocal; as it compliments & supports documentation in the referring, certifying &/or community physicians records. We will talk more about this collaborative effort later in the day.

Q&A Discussion Period

Face to Face Encounter, Plan of Care and Certification Documentation Collaboration

Collaboration of Documentation Home Health Agency Referring Physician Therapist DME Pharmacy Community Physician In in order to ensure the patient receives the Medicare services for which they are entitled, as we discussed earlier, collaboration of all documentation should be supported & maintained by all parties providing services for the patient. Going forward in 2015 it is important for all entities to have collaborating documentation supporting the HH services provided.

Collaboration of Documentation Referring Physician Referral Orders F2F/POC Certification DME, Therapy, Pharmacy Progress Notes Community Physician Updates to POC Recertification Home Health Agency Collaborates ALL documentation with ALL other entities As you can see on the screen, the collaboration of documentation works from both sides.…if the referring physician sends the referral, plan of care, F2F, & certification documentation to the HH agency and documents that in the medical record on January 2, the HH agency should have January 2nd documented in the patients record that they received the information for a SOC on the patient. The HH agency would follow up with the provider in the community to ensure they have also received the documentation from the referring physician to ensure collaboration and continuity of care. They would begin to further develop the POC with the community physician.

Collaboration of Documentation The HHA and physician who will be following patient’s care in community should receive the following documentation from referring physician/facility in a timely fashion, in an effort to provide an efficient and effective initial start of care visit: Referral/Order for HH Services FTF Encounter Documentation Basic Initial POC Documentation Supporting the *Homebound Status Documentation Supporting the *Need for Skilled Service Certification &/or Recertification Statement Refer to Medicare Eligibility slide #7 In an effort to ensure that all of the eligibility criteria are met (as discussed on the previous slides) proper documentation must be maintained and shared. This would include A referral or an order for any/all HH services Basic Initial POC FTF Encounter Documentation Documentation anywhere in the Medical record that supports the patients homebound status and need for skilled services Certification and/or recertification of the services being ordered, the POC & that a F2F was completed prior to the initial SOC

FTF Encounter Timing Requirement Timing requirements for “in-person” encounter: Up to 90 days prior to the SOC If the visit was for the same diagnosis/condition that now requires HH services Within 30 days after the SOC For the diagnosis/condition that requires the HH services Exception to timing requirements If the patient dies shortly after admission to HH There must be a documented good faith effort to facilitate/coordinate the F2F encounter, and All other certification requirements must have been met Like many other healthcare forms required by CMS, the FTF encounter has a timing requirement. The beneficiary/patient must have had a visit with their physician within 90 days before the start of HH. The visit must have been for the diagnosis/condition that now requires HH care services. If there was no such visit prior, there must be a F2F encounter within 30 days after the start of care. The appointment should be documented in the HHA medical record. An exception to the requirement for the FTF is if a patient is admitted to HH and the patient has made an appointment with their physician to have a FTF visit, but dies before the visit occurs. This would be an exception to the requirement assuming that the other certification requirements are met and there is a documented good faith effort on behalf of the HH agency demonstrating that an appointment had been made.

FTF Encounter Documentation Requirements F2F encounter is a condition of payment HHA should maintain written documentation that the F2F encounter occurred F2F should contain: Title (as the F2F encounter) Patient’s full name Date of the actual F2F encounter Home bound status & need for skilled service information (*Narrative requirements changing for 2015*) Dated signature of physician (completing encounter) As stated there is currently no mandatory form for the FTF encounter document. All HH agencies should obtain a copy of the F2F encounter form prior to submitting a claim, as it is a condition of payment. The f2f encounter may occur in a progress note or anywhere in the referring physicians medical record…the documents should be titled, contain the patients name and date of the encounter, narrative information regarding any orders for SN oversight and the dated signature of the physician completing the encounter. The Certification statement may be on this F2F document, it may be on the POC, or it may be a separate document.

FTF Encounter Reminders When the Physician signs the certification statement, he/she certifies that the patient was seen and had a F2F encounter for the current diagnosis There currently is not mandatory CMS form for the F2F encounter F2F encounter is part of the certification, along with the POC. Certification statement may be on F2F encounter form, POC or separate form of its own Electronic signatures are acceptable Some reminders regarding the FTF encounter include the facts that The physician must certify that the patient was seen and had a F2F encounter for their current diagnosis. The certification statement may be on the F2F encounter, the POC or a separate form of its own The SN narrative must be above the certification statement Electronic signatures are acceptable and the F2F encoutner is a component of the certifcation

Plan of Care When a beneficiary/patient is referred to HH services, it is beneficial to have an initial basic POC prior to their SOC. HHA will further develop the POC with the assistance of the community physician following the patient’s care Per §1814(a)(2)(C) and §1835(a)(2)(A) of the Act, the patient must receive HH services under POC established and periodically reviewed by a physician. There are no mandatory CMS forms for the POC. Form 485 is not a current or CMS endorsed document. The certification statement on Form 485 does not encompass the F2F encounter, nor does it include all of the information required in the current certification statement. When a beneficiary/patient is referred to HH services, it is beneficial to have an initial basic POC prior to their SOC. HHA will further develop the POC with the assistance of the community physician following the patient’s care Per §1814(a)(2)(C) and §1835(a)(2)(A) of the Act, the patient must receive HH services under POC established and periodically reviewed by a physician. There are no mandatory CMS forms for the POC. Form 485 is not a current or CMS endorsed document. The certification statement on Form 485 does not encompass the F2F encounter, nor does it include all of the information required in the current certification statement.

Homebound Status Per §1814(a) and §1835(a) of the Act, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met: A patient/beneficiary must be confined to their home to be eligible for the Medicare HH benefit The home bound status definition was revised and became effective in Nov 2013. It states that if a patient meets one of the criteria on the left (for example, uses a walker to leave the home) they MUST ALSO meet both of the two criteria on the right which imply that the patient has a normal inability to leave home and that leaving home requires a considerable & taxing effort. Remember: It may be a taxing effort for any individual to leave home on any given day, but the documentation is required to understand exactly WHY this specific patient is homebound at the present time related to their current diagnosis.

Homebound Status The patient may be considered “confined to the home” (homebound) if absences from the home are: Infrequent and relatively short in duration For medical appointments/treatments For religious services To attend adult daycare programs For other unique or infrequent events funeral, graduation, hair care A beneficiary/patient does not have to be “confined to the home” 24 hours per day to be considered homebound. As defined by the Centers for Medicare and Medicaid Services, the patient may leave the home infrequently, for short durations of time for such things as: Medical appointments/treatments Religious services Adult Daycare programs Other unique or infrequent events such as funerals, graduation ceremonies and/or hair care services.

Homebound Status Documenting the need for homebound status Include information about the injury/illness & the type of support and/or supportive device/assistance required for illness/injury to assist the patient in leaving home Explain in detail how the patient’s current condition makes leaving home medically contraindicated Clarify exactly what about the illness qualifies the patient as homebound Reminder: Declaring any portion of this regulation as a blanket statement copied from the CMS manual is vague. An explanation is required that describes the patients normal inability to leave home and exactly what effects are causing the considerable and taxing effort to leave home. Documentation to support homebound status in the medical record should Include information about the injury/illness & the type of support and/or supportive device/assistance required for illness/injury to assist the patient in leaving home – which for example may state: The patient is s/p MVA with multiple injuries and THR, requires one assist with ADL’s and a walker for ambulation. There are 4 steps to navigate to go in and out of the patients house and the patient will require 1:1 assistance with the steps. Explain in detail what about the patients current condition makes leaving home medically contraindicated. - which for example may state: Patient did not require assistance with ADL’s/Ambulation prior to MVA. Detail exactly what about the illness qualifies the patient as homebound. Which for example may state: The patient is homebound & unable to ambulate or drive without assistance d/t multiple traumas, THR, and routine narcotic pain medication.

Need for Skilled Services Documentation in the patient’s HH medical records should include details about the patient’s need for any/all skilled services requested (including NSG, PT/OT/SLP, SW) and should corroborate with the referring and/or certifying physician documentation Distinguish exactly what services are going to be provided by the skilled professional in the patients home Explain why a skilled professional is required to provide the HH care services requested Disclose clinical information (beyond a list of recent diagnoses, injury, or procedure) that is individual and specific to the patient Clarify why the findings from the FTF encounter with the patient support the medical necessity of the services being requested The patient/beneficiary must have a need for “SKILLED” services in their home in order to qualify for the Medicare HH benefit The documentation about the patients need for skilled services should corroborate in the medical records of all entities involved, including but not limited to the referring physician, the HHA and the community physician that is following the patients homecare services. The records should detail the patients need for skilled homecare services and should : Distinguish exactly what services are going to be provided by the skilled professional in the patients home. For example: SN to assess sacral wound & change sterile dressing as ordered on this paraplegic w/c bound patient. Explain why a skilled professional is required to provide the HH care services requested. For example: SN required for Sterile dressing changes with silvadine cream and packing with kerlix at sacrum. Patient lives alone or patients wife unable to learn dressing changes r/t cognitive disability, etc. Disclose clinical information (beyond a list of recent diagnoses, injury, or procedure) that is individual and specific to the patient. AS ABOVE Clarify why the findings from this individual patient FTF encounter support the medical necessity of the services being requested. AS ABOVE

Certification As a condition of payment, the physician certification must state (Per 42 CFR 424.22(a)(1)(i-v): Patient needs intermittent SN care, PT, and/or SLP services Patient is homebound POC has been established (for the current diagnosis) and will be periodically reviewed by a physician Services will be furnished while the individual was or is under the care of a physician Patient had a dated FTF encounter that Occurred meeting the timing requirements Was related to the primary reason the patient requires HH services Was performed & signed by a physician or allowed NPP The physician certification must state: The patient needs intermittent SN care, PT, and/or SLP services The patient is homebound A plan of care has been established (for the current diagnosis) and will be periodically reviewed by a physician Services will be furnished while the individual was or is under the care of a physician The patient had a dated FTF encounter that occurred meeting the timing requirements was related to the primary reason the patient requires HH services was performed & signed by a physician or allowed non-physician practitioner The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as these certification requirements, outlined in 42 CFR §424.22(a)(1), are documented & met.

Certification Certification should be completed when the POC is established & prior to submission of Medicare claim for reimbursement Reminder: The certification statement also certifies the face- to-face encounter It is not acceptable for HHAs to wait until the end of a 60-day episode of care to obtain a completed certification When the initial POC is established, the certification should be completed. Remember, the POC is further developed as the patient is cared for in their home…it is an ever evolving document. It is not acceptable for HHA’s to wait until the end of a 60 d period to obtain a completed certification.

Certification Supporting Documentation Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered. Information from the HHA can be incorporated into the physician and acute/post-acute care facility’s medical record The physician following the patients POC in the community must review and sign any documentation incorporated into the patient’s medical record that is used to support the certification All documentation shared between corroborating entities while providing HH services to a patient must be signed & dated by the certifying physician and incorporated into the patient’s medical record to support the certification.

Certification Supporting Documentation The physician and/or the acute/post-acute care facility’s medical record for the patient must contain Actual clinical note for the FTF encounter visit that demonstrates that the encounter: Occurred within the required timeframe Was related to the primary reason the patient requires HH services Was performed by an allowed provider type. Information that justifies the referral for Medicare HH services. This includes documentation that substantiates the patient’s: Need for the skilled services Homebound status This information may be found in clinical progress notes and/or discharge summaries CMS has provided Certification Supporting Documentation Examples (Please refer to the CMS Link Provided for examples **See References**) The certifying physician medical records must contain information to justify the patient referral to HH and also contain the actual clinical note for the F2F encounter …. The patients need for skilled services, homebound status, timing requirements, primary reason for the order for homecare and the Medicare enrolled physician signatures may be found in the clinical progress notes or discharge summaries. CMS has provided handouts to assist providers in the comprehension of these regulations. Please refer to them for future assistance after this educational session.

Certification Statement Example I certify/recertify that the above stated patient is homebound and that upon completion of the/this FTF encounter, has a need/continued need for intermittent skilled nursing, physical therapy and/or speech or occupational therapy services in their home for their current diagnosis as outlined in their initial plan of care. These services will continue to be monitored by myself or another physician who will periodically review and update the plan of care as required. John Smith, MD 1/1/2015 I have provided a sample certification statement the encompasses all aspects of the certification, initial POC and FTF encounter

Recertification Recertification is required at least every 60 days when there is a need for continuous HH care after an initial 60-day episode unless there is a: Patient-elected transfer Discharge with goals met with no expectation of a return to HH care for the current diagnosis These situations would trigger a new certification, rather than a recertification Medicare does not limit the number of continuous episode re-certifications for patients who continue to be eligible for the HH benefit. As you may already know, recertification is required at least every 60 days if there is a need for continuous hh services unless the patient elects a transfer or the d/c goals are met with no expectation of a return to HH for the current dx. These two bulleted situations would require a new certification rather than a recertification and would require a new F2F encountner. Another important reminder here is that Medicare does not limit the # of continuous episode recertifications when the patient meets eligibility criteria.

Recertification Recertification must : Be signed and dated by the physician who reviews the plan of care Indicate the continuing need for skilled services. (Need for OT may be the basis for continuing services that were initiated because the individual needed SN, PT or SLP services) Estimate how much longer the skilled services will be required All re-certifications must be signed and dated by the physician monitoring the POC, they must indicate the continuing need for skilled services, and estimate in writing how much longer the skilled services may be required.

Documentation Process from Physician Office (Example) PCP or Specialist sees the patient in their office Completes an order/referral and certifies an initial basic POC & F2F Forwards order/referral, initial POC & F2F documentation immediately to the HHA HH Agency carries out SOC & assists in further development of the POC Monitors the patient’s care, updates & recertifies the POC in collaboration with the HHA as required HHA and the physicians office maintain up-to-date home care documentation in the patients medical records F encounter This is an example of the process as it should occur if the primary care or specialist physician orders HH services from their office and he/she will be the one to continue to develop the POC and monitor the HH care provided in the community.

Documentation Process from Acute or Post Acute Facility (Example) Physician or NPP discharges the patient from their acute or post acute facility (Hospital/SNF/Inpatient Rehabilitation Center/Surgery Center) Completes an order/referral and certifies an initial basic POC & F2F encounter Forwards order/referral, initial POC & F2F documentation immediately to HHA & office of physician in the community that will be following the home care services – ensuring both entities are aware of services ordered & documenting follow-through HHA carries out SOC & assists in further development of the POC Community physician monitors patient’s care and updates & recertifies the POC in collaboration with the HHA as required Community physician & HHA maintain up-to-date home care documentation in the patient’s medical records The referring physician in the acute or post acute facility is having a F2F encounter with the patient at the time of discharge. The intent of the directive from CMS maintains that the referring physician is responsible for documenting that discharge encounter as the F2F and getting that documentation and basic initial POC documentation with certifying statement to the physician in the community and the HHA so that an appropriate SOC may be completed.

F2F, POC, & Certification Reminders: F2F encounter and POC can be certified in one certification statement Must be a documented F2F encounter in the patient’s medical records which collaborates with all of the other medical entities referring to and providing home care services Certifying physician must be enrolled in the Medicare Program and be a Doctor of Medicine, a Doctor of Osteopathy; or a Doctor of Podiatric Medicine Certifying physician cannot have financial relationship with HHA unless it meets one of exceptions in 42CFR411.355-42CFR411.357 If a NPP provides the F2F encounter, a certifying physician must review & countersign the document. Allowed NPPs include: PA, CNS, NP, and CNM Because residents do not have privileges, if a resident is performing the FTF encounter, he/she must inform the certifying physician of the encounter through the supervising teaching physician who must review & countersign F2F encounter and POC can be certified in one certification statement Must be a documented F2F encounter in the patient’s medical records which collaborates with all of the other medical entities referring to and providing home care services Certifying physician must be enrolled in the Medicare Program and be a Doctor of Medicine, a Doctor of Osteopathy; or a Doctor of Podiatric Medicine Certifying physician cannot have financial relationship with HHA unless it meets one of exceptions in 42CFR411.355-42CFR411.357 If a NPP provides the F2F encounter, a certifying physician must review & countersign the document. Allowed NPPs include: PA, CNS, NP, and CNM Because residents do not have privileges, if a resident is performing the FTF encounter, he/she must inform the certifying physician of the encounter through the supervising teaching physician who must review & countersign

CERT A/B MAC Outreach & Education Task Force

CERT A/B MAC Outreach & Education Task Force A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program Shared goal of reducing the national improper payment rate as measured by the CERT program Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions Disclaimer The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate.

Participating Contractors Cahaba Government Benefit Administrators, LLC/J10 CGS Administrators, LLC/J15 First Coast Service Options, Inc./JN National Government Services, Inc./J6 and JK Noridian Healthcare Solutions, LLC/JE and JF Novitas Solutions, Inc./JH and JL Palmetto GBA/J11 Wisconsin Physicians Service Insurance Corporation/J5 and J8

CERT A/B MAC Outreach & Education Task Force The CERT Task Force educates on common billing errors and contributes educational Fast Facts to the CMS website CMS MLN Provider Compliance Fast Facts web page http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/ ProviderCompliance.html In addition, the CERT Task Force section on the NGSMedicare.com website provides a link to the CMS MLN Provider Compliance Fast Facts

CERT A/B MAC Outreach & Education Task Force CERT Task Force Web Page Go to our website, http://www.NGSMedicare.com; in the About Me drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page. Task Force Scenarios Complying with medical record documentation requirements Documenting therapy and rehabilitation services Look for new articles added to this page and provided in your Email Updates

CERT A/B MAC Outreach & Education Task Force CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT A/B MAC Outreach & Education Task Force http://www.cms.gov/Medicare/Medicare- Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task- Force.html

REFERENCES & RESOURCES

2015 Federal Register Reference Federal Register Vol. 79, No. 215 Released: Thursday, November 6, 2014 Page 66117 http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014- 26057.pdf

CMS MLN Matters Article SE1436 “Certifying Patients for the Medicare HH Benefit” http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/Downloads/SE1436.pdf

CMS References & Resources CMS IOM Publication 100-08 Medicare Program Integrity Manual Chapter 6 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c06.pdf CMS IOM Publication 100-02 Medicare Benefit Policy Manual Chapter 7 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf CMS Publication 100-04 Medicare Claims Processing Manual Chapter 10 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf HH PPS Web Page http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html Medicare HH Agency Web Site http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html Medicare Learning Network® Publication titled “HH Prospective Payment System” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/HomeHlthProsPaymt.pdf On your screen you will note all of the references and resources utilized to bring this material to you. That includes chapters 6 of the Medicare program integrity manual, chapter 7 of the Medicare benefit policy manual and chapter 10 of the Medicare claims processing manual. All of these manuals can be found in the Internet only manuals on the CSM website. On the CMS website you will also find the HH & PPS web pages and the Medicare learning network.

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