Home Health Face-to-Face Encounter Adapted from Presentations of National Association for Home Care & Hospice and Home Care Association of Washington by Home Care Association of New Hampshire

Home Health Face-to-Face Encounter: What Is the New Requirement? Effective for starts of care on and after Jan. 1, 2011, a physician must perform and document a face to face encounter with their patient up to 90 days before or 30 days after the SOC. Encounter must be related to need for home health. Requirement is for certification period only, not re-certs. Can be performed via telehealth if provisions are met per 1834(m) – unlikely. Applies to Medicare fee-for-service; not applied to Medicare Advantage patients.

CMS Encounter Rule: Why the New Requirement? Mandated by Affordable Care Act Section 6407 Final rule: HH PPS Update 2011 Link at CMS web site: Regulatory citation: 42CFR § CMS Manual revision underway RAP payment process not affected Intended to strengthen link of physicians to the plan of care, and ensure that skilled need and homebound status requirements are confirmed by physician.

Face to Face Encounters: Who Can Perform the Encounter? Certifying physician, or NPP: NP, CNS, Nurse Midwife working in collaboration with certifying physician, or PA under supervision of certifying physician Hospitalist can perform and document the encounter, even if community physician will be signing the plan of care and assuming responsibility after hospital discharge.* * Note: CMS announced that it will amend the longstanding policy in Pub Chapter 4, Section 30 that “since the certification is closely associated with the plan of care (POC), the same physician who establishes the plan of care must also certify to the necessity for home health services.” The amendment will allow the hospitalist to certify and the primary care physician to sign the plan of care.

Encounters: Related Reason Related Reason Encounter must be related to primary reason for home health Not necessarily primary reason for encounter CMS Intention Enable physicians to: Understand current clinical needs Establish effective plan of care Ensure homebound status Ensure skilled need

Encounters: When? No earlier than 90 days prior to the start of care (SOC) or within 30 days after the SOC If the encounter occurred within 90 days of the SOC but is not related to the primary reason for home health, the NPP or certifying physician must have a face to face encounter within 30 days after the SOC.

Encounters: Documentation Non-physician practitioner performing face-to-face encounter must: Document encounter in the medical record Communicate findings of encounter to certifying physician, who must document the encounter for the HHA Documentation must include: Date the encounter occurred Clinical findings that support the need for intermittent skilled nursing or therapy Homebound status

Encounters: Documentation Documentation of encounter must be: Separate and distinct section of certification, or addendum to certification Based on findings of the encounter Standardized language prohibited BUT, agency can provide a list of topics to be addressed, such as Date of Encounter, Medical Condition for Encounter, Services Needed, Clinical Findings, Homebound Status, Physician Signature, and Date NOTE: CMS removed physician medical record documentation requirements from final PPS rule.

Encounters: Enforcement Literal interpretation of “primary reason for home health” not intended No intent to edit for relationship Physician claim diagnosis compared against home health claim diagnosis CMS Plan Expand manual guidance on enforcement Issue instructions to medical review contractors Review via other program integrity efforts Monitoring of compliance by surveyors NAHC and HCANH are advocating for a delay in enforcement for at least 6 months.

Encounters: Certification Requirements Timing of Certification – Unchanged from Current Policy At the time the plan of care is established, or As soon thereafter as possible Signature Requirements Certification of plan of care signed and dated by physician who establishes plan of care* * CMS has recently clarified that physicians MUST date their signatures on the plan of care; agencies are not allowed to date stamp when receive signed POC if physician fails to date his/her signature.

Encounters by HHA Employees/Contractors Certification by physician or NPP with financial relationship prohibited unless: Stark exceptions and anti-kickback safe harbors, e.g. Paid for and perform administrative functions Paid fair market value Proof of work done Physicians and NPPs May NOT be paid by HHA to conduct face-to-face encounters

Beneficiary Notification CMS has not provided guidance for notifying beneficiary. HHABN deemed not appropriate by CMS CMS has reaffirmed that patients cannot be billed for services if they fail to have the encounter within the specified time period. HHAs may not provide free transportation to patients for physician visits.

Resources 1. NAHC Website, Regulatory Webpage Sample letters to Patients, Referral Sources, Physicians Guide to Documentation 2. One-Page FAQ by CAHABA (RHHI) uick_homehealth_face.pdf uick_homehealth_face.pdf

To Do List for Home Health Agencies Identify any questions and seek answers Develop policies and procedures Finalize letters and notices Develop encounter tracking protocols Educate Agency staff and contractors Patients Physicians Referral sources