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 www.nahc.org/regulatory/home.html.