CMS has delayed enforcement of the new face-to-face rules until April 1, but they keep answering questions to clarify policy.
Q. If the required information is contained in physician documentation, such as a discharge summary from an acute care episode, will this document suffice as the addendum to the POC [plan of care]?
A. No. The face-to-face encounter documentation must be included as part of the certification form itself or as a signed addendum to it, and it 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. If a facility physician completes the encounter documentation and the community physician completes the plan of care, which of the two may bill Medicare for physician certification?
A. The physician who certifies may bill Medicare for physician certification.
Q. May physicians use their own electronic medical records with drop-down menus to select from prepared descriptive language when completing the face-to-face encounter documentation for their patients? Can the narrative be typed?
A. Yes. The regulation requires that the certifying physician document how the encounter supports the patient’s homebound status and need for skilled services. We allow the documentation to be either on the certification or as a signed addendum to it. This allows the sort of flexibility where such documentation could be dictated by the physician to one of his support personnel, or to allow it to be generated by the physician’s electronic medical record software. Such is common practice for physicians to document their patient encounters.
Q. If a patient has a face-to-face encounter on day 33 after the start of care, will the HHA [home health agency] be denied payment for services provided from day 1 through day 30?
A. If the certification content requirements are not complete, the agency cannot bill.
Q. Can an HHA obtain and record verbal orders regarding the required encounter information, which are then sent to the physician for signature?
A. No. We believe that a verbal communication by the physician to the HHA regarding the encounter, where the HHA would then document the certification and get the physician to sign it, does not satisfy the statutory mandate that the certifying physician must document the encounter.
Q. What happens if the certification isn’t documented before a patient is discharged? In other words, should a discharge be “held”?
A. We are assuming the question relates to short-stay patients. The HHA should treat this scenario as it always has when the patient’s care plan goals have been met but the certification is not yet complete.
Q. Will subsequent episodes be covered if face-to-face requirements are not met timely during the first episode?
A. The face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes.
Q. Can a physician certify a patient’s eligibility and document the face-to-face encounter based on information received from another physician who recently saw the patient, such as the patient’s attending physician during an acute stay?
A. No. The law mandates that either the certifying physician, or certain non-physician practitioners (NPPs) who inform the certifying physician, can perform the face-to-face encounter. A patient’s encounter with an attending physician during an acute stay does not satisfy the requirement unless the attending physician is also the physician who certifies eligibility. However, certain NPPs in the acute care setting may collaborate with the certifying physician. In such cases, an NPP’s encounter with the patient during an acute or post-acute stay may satisfy the requirement.
Q. Can a resident conduct the face-to-face encounter?
A. Only the certifying physician or certain NPPs can perform the face-to-face encounter. Additionally, only Medicare-enrolled physicians can certify home health eligibility, per the Affordable Care Act.
Q. Will there be an exceptional circumstance whereby an encounter did not occur but the situation was out of the control of the agency (e.g. patient dies, changes physicians, moves, etc.)?
A. The face-to-face encounter is an additional content requirement associated with the certification. Agencies should deal with the above described situations as they always have when such occur prior to obtaining a completed, signed certification. Refer to Section 10.11, Chapter 7, Pub. 100-02.
Q. Since the HHABN Option Box 1 does not apply, do Option Box 2 (discontinue services for agency business reasons) or Option Box 3 (no physician orders) apply?
A. The HHABN, Form CMS-R-296, has been approved by the Office of Management and Budget to provide limitation of liability protections to Original Medicare beneficiaries receiving home health services under section 1862(a)(1)(A) of the [Social Security] Act for care that CMS or its contractors determines is not reasonable and necessary under Medicare; section 1862(a)(9) of the Act, for custodial care; section 1862(g)(1)(A) of the Act, for care when the beneficiary is not homebound; and section 1862(g)(1)(B) of the Act, for care provided to a beneficiary who is not in need of skilled nursing care. The HHABN must not be used to transfer liability to the beneficiary when technical requirements for payment, such as a face-to-face encounter, are not met. The HHABN is not approved for this use. A beneficiary is not financially liable if the certification is incomplete.