Archive for December, 2010

December 31, 2010

CMS answers face-to-face questions

These Q&As answer a lot of questions, including:

  • whether the plan of care and the certification need to be signed by the same physician (not necessarily in home health)
  • whether lead-in phrases are allowed (yes, if the doctor fills out other parts),
  • for patients admitted before January 2011, are face-to-face rules applicable (no!),
  • are electronic signatures acceptable (yes)
  • and more ….

Q: What effect does the face-to-face requirement have on agency practices for meeting Medicare requirements associated with the plan of care and certification?

A: Long-standing Medicare regulations have described the distinct content requirements for the plan of care and certification. The Affordable Care Act (ACA) requires the face-to-face encounter as an additional certification requirement. Many providers have implemented the requirements for the plan of care and certification by using one form which meets all the content requirements of both the plan of care and certification. This approach is perfectly acceptable and it will continue to be acceptable. Several years ago, CMS ceased to require that providers use a specific form for the plan of care and/or certification. Providers have the flexibility to implement the content requirements as best makes sense for them.

Q: Can you please clarify the hospitalist’s role?

A: The statute requires that the certifying physician must document that the face-to-face encounter occurred with himself or herself, or certain non-physician practitioners (NPPs) who inform the certifying physician. Where the patient is admitted to home health from acute or post-acute care, we believe that current practice associated with the home health certification would apply to the face‑to‑face encounter as well. In most cases, we would expect the same physician to refer the patient to home health, order the home health services, certify the beneficiary’s eligibility to receive Medicare home health services, and sign the plan of care. It would be this physician who would be responsible for documenting on the certification that he or she, or a NPP working in collaboration with the certifying physician, had a face–to–face encounter with the patient.

However, we recognize that, in some scenarios, one physician performing all of these functions may not always be feasible. An example of such a scenario would be a patient who is admitted to home health upon hospital discharge. While we would still expect that in most cases, a patient’s primary care physician would be the physician who refers and orders home health services, documents the face‑to‑face encounter, certifies eligibility, and signs the plan of care, there are valid circumstances where this is not feasible for the post-acute patient. For example, some post-acute home health patients have no primary care physician. In other cases, the hospital physician assumes primary responsibility for the patient’s care during the acute stay, and may (or may not) follow the patient for a period of time post-acute.

In circumstances such as these, it is not uncommon practice for the hospital physician to refer a patient to home health, initiate orders and a plan of care, and certify the patient’s eligibility for home health services. In the patient’s hospital discharge plan, we would expect the hospital physician to describe the community physician who would be assuming primary care responsibility for the patient upon discharge.

We also believe that with growing prevalence of NPPs in the acute and post-acute care settings, NPPs may increasingly collaborate with the community certifying physician regarding the NPP’s encounter with the patient in the acute and post-acute settings.

Q: Do both the plan of care and the certification have to be signed by the same physician?

A: Prior to Calendar Year 2011, CMS manual guidance required the same physician to sign the certification and the plan of care. Beginning in Calendar Year 2011, CMS will allow additional flexibility associated with the plan of care when a patient is admitted to home health from an acute or post-acute setting. For such patients, many asked that CMS allow the contact between the physician who attended to the patient during an acute or post-acute stay to satisfy the encounter requirement, even when the physician may not follow the patient in the community. These commenters asked CMS to allow such physicians to inform the community certifying physician as the law allows non-physician practitioners (NPPs) to do.

We are limited by the law that requires the certifying physician to document that the encounter occurred with himself or herself, or a permitted NPP. To adopt as much flexibility as the law allows, we will allow physicians who attend to the patient in acute and post-acute settings to certify the need for home health care based on their face-to-face contact with the patient (which includes documentation of the face-to-face encounter), initiate the orders (plan of care) 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. As we described above, we continue to expect that in most cases the same physician will certify, establish, and sign the plan of care. But the flexibility exists for home health post-acute patients if needed.

Q: Can the physician document the certification when the physician or hospitalist has the patient’s record in front of him?

A: Yes. As long as the face-to-face encounter occurs in the specified timeframe of 90 days prior to the start of care or 30 days after the start of care and the documentation is completed before billing, this scenario is acceptable.

Q: The final rule requires that the certifying physician documents how the clinical findings of the face-to-face encounter support home health eligibility. The rule references homebound status and skilled need. Is the documentation of the clinical findings sufficient?

A: The documentation must include the certifying physician’s synthesis of how the patient’s clinical condition, as seen during the encounter, supports that the patient is homebound and needs skilled services.

Q: Can the home care agency title a document with a lead-in phrase such as: I had a face-to-face encounter on _______ (date). The clinical findings support home health eligibility because:

A: The lead-in phrase is acceptable as long as the physician completes the description of how the clinical findings support homebound status and the need for skilled services, in his or her own words.

Q: Is the face-to-face required for patients in Medicare Advantage plans?

A: No, the face-to-face provision applies only to Medicare fee for service.

Q: Is the face-to-face encounter requirement effective only for patients admitted to home health (i.e. have a new start of care) January 1, 2011 and later?

A: Yes, that is correct. We have interpreted the language in the statute to apply only to certifications and not recertifications.

Q: Will documentation of an encounter submitted via an electronic portal and electronic signatures on face-to-face encounter documentation be acceptable?

A: Yes, that is fine. However, it is important to reiterate that the documentation must be part of the certification itself, or an addendum to it.

Additional information about face-to-face encounter requirements can be found on the NAHC website under the heading “HH PPS 2011 Final Regulation” at

December 23, 2010

Peace and blessings

Peace and blessings to all of you at this holiday time. Thank you for your interest in Selman-Holman Associates, and your continued support and questions.

If you are traveling, I hope it is safely. If you are working, I hope the time goes quickly.


December 23, 2010

Fee-for-service claims for Q4 2009 are due Dec. 31

All Medicare fee-for-service claims with service dates Oct. 1, 2009, through Dec. 31, 2009, must be received by Dec. 31, 2010, or Medicare will deny them. Claims with services dates from Jan. 1, 2009, to Oct. 1, 2009, keep their original Dec. 31, 2010, deadline for filing.

Looking for more information like reporting a line item date of service and the accompanying change request?

CMS has some resources: For additional information about the new maximum period for claims submission filing dates, contact your Medicare contractor or review the MLN Matters articles listed below:

  • MM6960 – Systems Changes Necessary to Implement the Patient Protection and Affordable Care Act (PPACA) Section 6404 – Maximum Period for Submission of Medicare Claims Reduced to Not More Than 12 Months; and
  • MM7080 – Timely Claims Filing: Additional Instructions.

A podcast on this subject is available at

December 20, 2010

CMS call Tuesday deals with medicare Advantage disenrollment

As part of CMS’s education series, the National Medicare Training Program (NMTP)  is having an audioconference on the Medicare Advantage Plan Disenrollment Period.

The simple facts:


Tuesday, December 21, 2010


2:30-3:30 p.m. EST


  • Conversation with CMS’ Jim Canavan on the new Medicare Advantage Plan Disenrollment Period
  • Stacey Platte Providing an Update on CMS Plan Finder Enhancements

How to attend:

Dial toll-free: 877-251-0301

Conference ID: 32067690

December 17, 2010

Redo your SOC when patient returns from facility

Question: I remember that you said if you were doing a SOC on a patient and they were ill enough to go to the hospital that day the SOC was started that you didn’t want to claim the hospitalization for your agency. However, I don’t remember what you said to do and I can’t find it in my notes. Can you help?

Lisa says: The answer depends on whether the patient is admitted.
If admitted, you want to keep the assessment in a medical record and document the circumstances. No transfer is required. When the patient returns from the facility, re-do the SOC.

December 15, 2010

Yes, the Symposium has contact hours, admin hours, and CEUs!

I’ve gotten a number of questions on whether the First Annual Coding and Regulatory Symposium, my two-day conference in January in Las Vegas, is approved for education credits.

Yes! It is approved for:

12 nursing contact hours
12 administrator hours

Learn all about the Jan. 27-28 conference and why it is useful for administrators, coders, and OASIS experts!

2011lasvegas … see the attached brochure!

December 14, 2010

Check box does not meet F2F requirements, but labels might

These questions are the Q&As from NAHC from questions that the organization has received on the face-to-face encounter issue.

Question:  Clarify the regulatory requirement of no standardized language. To be used in documentation of F2F are we able to create a form that contains check box options for the physicians in regards to diagnosis, etc.?
Answer: A check box would not meet CMS’ intent since the agency would be providing prescribed verbiage that a physician must choose from. This “standardized” language may not fit with the clinical condition of the patient. The full text from CMS in the Federal Register reads: “The law requires this as a condition for HH payment. We proposed that the documentation of the encounter be a separate and distinct section of, or an addendum to, the certification, and that the documentation include why the clinical findings of the encounter support HH eligibility. We believe that our proposed documentation requirements meet the Congress’ intent for more physician involvement in determining the patient’s eligibility and managing the care plan. We believe that were we to allow the HHA to craft standard language which the physician would then simply sign, we would not achieve the sort of physician involvement in the eligibility determination and care plan which was the Congress’ intent. As such, we believe that if a HHA were to develop standardized encounter language to be signed by the physician, they would not be adhering to the statutory payment requirements that the “physician document” the encounter.”

Question:  May a home health agency put labels on a form for the physician to complete?
Answer: When asked if it would, however, be acceptable for the agency to at least label the section of the 485 or addendum where the physician’s documentation should be placed, titling it for example “Physician Verification of Face-to-Face Encounter,” and then to include subheadings which include: Date of Encounter, Medical Condition for Encounter, Services Needed, Clinical Findings, Homebound Status, Physician Signature, Date. CMS responded Yes, this is fine.  As long as the info/clinical findings and how the findings support eligibility are documented by the physician, in his/her own words.

Question:   If a hospitalist documents the F2F and certifies the patient, is the primary physician (who will sign the 485 and oversee the episode of care) required to complete a face to face as well?  Or does the hospitalists F2F meet the requirement?
Answer: No, a second face-to-face by the physician ordering services and signing the plan of care is not required.

Question:   If a F2F encounter occurred within the past 90 days prior to referral for homecare and the reason for the F2F was not related to the homecare referral we must then get an additional F2F encounter documented?
Answer: Yes a second encounter will be required.

Question:   I thought the face to face for homecare was effective for admissions as of 1/1/11?
Answer: The face-to-face encounter is required for any patient with a Start of Care Medicare fee-for-service episode 1/1/11 and after. It is not required for recertification episodes.

December 13, 2010

Maternity patients are exempt from OASIS

Question: If a patient has a disrupted wound post c-section, do we do an OASIS assessment? 

Lisa says: No, maternity patients are exempted from OASIS. The ONLY time you’d want to complete OASIS on a maternity patient is if Medicare is the payor. In that case, you’d want an HHRG.

December 9, 2010

HHAs must convert to OASIS individual user IDs

To comply with CMS security regulations, CMS is changing the way agencies login to the OASIS Submission System and CASPER Reporting. The change will require agency users to register for a named individual user account ID.

When the security changes are deployed to your state, you will no longer be able to
access the OASIS State Submission System using your state-assigned shared login ID.
You will be required to register for a named individual user ID.

The HHA Individual User Registration link will be added to the OASIS State Welcome
page. The link will be displayed directly above the OASIS Submission link.


December 8, 2010

2011 OIG Work Plan focuses on payments

If you haven’t seen it yet, or you don’t know about it, the Office of the Inspector General is implementing its FY2011 Work Plan. The great thing about OIG is that the agency spells out exactly what  it will be focusing on in each care continuum.

Here’s a look at the HHA (Medicare Part B) focus:

Payments for HH Beneficiaries: The OIG will review Part B payments for services and medical supplies provided. The agency specifically mentions identifying payments to outside supplies to examine controls.

HHA Claims for Medicare HHRG: Coverage requirements (homebound, intermittent care, under care of MD, etc.) are a focus. OIG will also assess the accuracy of HHRGs submitted in 2008.

Oversight of OASIS: OIG will review CMS’s oversight of OASIS data. The focus is to review CMS’s process that should ensure that HHAs submit accurate, complete data.

HHPPS Controls: This includes reviews for billings at the appropriate service location. This focus will analyze HHA activities on items such as the number of claims submitted, number of visits provided, ownership information, and arrangements with other facilities.

HHA Profitability: This analysis items seeks to determine whether the payment methodology should be adjusted.

Medicare HHA Enrollment: This item really focuses on cross relationships with suppliers and ownership. OIG specifically mentions that previous work found that DME suppliers omitted or provided inaccurate information … and that these suppliers were often associated with HHAs through shared owners or managers.

See OIG’s focus across the health care spectrum.

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