We’ve been responding to a lot of ADRs and other such medical review requests here at Selman-Holman & Associates and when the documentation in the chart is decent we are usually successful. One item we’re especially concerned with is the lack of, or inadequacy of, Face to Face documentation. No matter how much you’ve improved your clinical documentation, and no matter how much your patient needs your services, if the Face to Face documentation is lacking, they’ll deny. In fact, if they can deny based on 3 simple things, they will not even look at the clinical documentation. What are those three things? 1} Face to Face; 2) Physician signature and date on the POC; and 3) SOC or Recertification OASIS has been transmitted to the state depository and the HIPPS code matches that on the bill. If any of those are not adequate, they can deny the entire episode without looking further. There is a 4th of course—homebound, but for that one they do have to look at the clinical documentation a little bit.
This from Palmetto this morning:
Medical Review Requirements for Home Health Face-to-Face Documentation
Palmetto GBA has noticed an increase in overpayments for Home Health Prospective Payment System (HH PPS) claims. The top reason for this increase is attributed to the requirement for a face-to-face encounter with the beneficiary.
Palmetto GBA evaluated its criteria for review of these types of claims. Effective immediately, we will begin a more comprehensive review using the regulations governing these types of claims. Palmetto GBA encourages all providers to review their internal processes to ensure that all of the criteria for coverage have been met and documented in the medical record.
As a condition for payment, the Affordable Care Act mandates that 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.
According to the, CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 184.108.40.206, the face to face documentation must contain a brief narrative which ‘describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.’
Documentation must include details showing how specific clinical findings support homebound status.
Examples of inadequate documentation include the following:
• Diagnosis alone, such as osteoarthritis
• Recent procedures alone, such as total knee replacement
• Recent injuries alone, such as hip fracture
• Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
• ‘Gait abnormality’ without specific clinical findings
• ‘Weakness’ without specific clinical findings
The face-to-face documentation must also include clinical findings to support the need for skilled services, i.e. skilled nursing or therapy.
The Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22 states, ‘The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled and dated and the certification must be signed by the certifying physician.’
For more information, please refer to Medlearn Matters article SE1219 (PDF, 128 KB).
• CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 220.127.116.11
• Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22
• Medlearn Matters article SE1219
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