Posts tagged ‘face-to-face encounter’

June 17, 2011

NAHC begins face-to-face survey … let’s help!

NAHC is conducting a nationwide physician survey regarding  face-to-face home health requirements. NAHC will be meeting with Medicare soon regarding face-to-face and wants to have as much data as possible.

The survey is attached here and the survey deadline is June 24.

Here is the survey:


March 31, 2011

CMS says face-to-face does start April 1 (tomorrow!)

The Centers for Medicare & Medicaid Services (CMS) has just issued the following statement on the enforcement of the face to face requirement:

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services.

Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner  working with the physician, has seen the patient.  The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care.  Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient’s 180th-day recertification, and each subsequent recertification.  The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period.  The provision applies to recertification’s on and after January 1, 2011.

On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.

Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements.  CMS has posted guidance materials including a MLN Matters article, questions and answers documents,  training slides, and  manual instructions which are available via  CMS’ Home Health  Agency Center and Hospice webpages.  CMS’ Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials.

CMS will continue to address industry questions concerning the new requirements, and will update information on our Web site at


Look at some of my previous blog posts on face-to-face encounters:

NAHC receives many responses to face-to-face

Medicare updates face-to-face questions



March 10, 2011

NAHC receives many responses on face-to-face requirements

This is a brief from NAHC regarding the April 1 enforcement date on face-to-face encounters. I’ll keep you informed on more as I know it …

The implementation of the Medicare face-to-face encounter rules in home health services and hospice continues within the provider, physician, and beneficiary communities as the “dry run” opportunity before the April 1 enforcement date approaches its end (NAHC Report, 1/5/11). The National Association for Home Care & Hospice (NAHC) and a large contingent of supportive stakeholders are continuing their advocacy with the Centers for Medicare & Medicaid Services (CMS) in an attempt to get the rules applied in a sensible and understandable manner. On Monday, NAHC and the other stakeholders engaged CMS via teleconference to review progress on the face-to-face encounters to date, outline unresolved issues, propose further adjustments, and establish remaining action steps for both CMS and stakeholders this month before enforcement is set to begin.

The discussions with CMS involve a deep and dynamic coalition of provider and beneficiary representatives including AARP, the American Medical Association, and the American Hospital Association. Numerous other physician, hospital, case manager, and beneficiary groups are also part of the effort.

The teleconference earlier this week addressed both hospice and home health matters related to the face-to-face encounter requirements. CMS has now released guidance on two crucial hospice issues: (1) the timing requirement for the hospice physician encounter for patients admitted at the start of the third benefit period, and (2) whether the encounter physician must be the same as the terminal illness certifying physician (NAHC Report, 3/2/11).

A number of unresolved home health issues remain, including the nature of the physician documentation required. CMS was presented with a long list of pending questions that need answers or clarification.

A significant focus of the meeting was the results of the ongoing survey that NAHC has conducted since late last week. Home health agencies have responded in unprecedented numbers — to date, NAHC has received over 3,300 survey responses. The information provided is crucial to the efforts to address concerns about the rule, and NAHC thanks all who have provided their input.

A detailed survey report is being developed. However, a preliminary review of the data shows that:

  • Virtually all home health agencies are engaged in serious efforts to educate their staff as well as physicians and patient referral sources both with written materials and in person;
  • There is still an incomplete understanding of the requirements and significant confusion in the physician community, with over two-thirds of agencies reporting that physicians remain confused;
  • Despite the intensive educational efforts of home health agencies and CMS, 66 percent of respondents indicate that physician understanding has not improved and nearly 20 percent report that it has gotten worse;
  • Among the most alarming survey results, 47 percent of agencies report that they deal with physicians who intend to refer patients to other care settings instead of home care because of the face-to-face encounter requirements. Over 35 percent of agencies report that some physicians have indicated that they will refuse to provide the required documentation;
  • The most prevalent concern with physicians is the documentation requirements. Respondents recommend allowing the use of checkboxes (83 percent); eliminating the narrative on homebound status and medical necessity (77 percent); and allowing physicians to use other documents that include the needed information (72 percent); and
  • The survey also indicates that one-third of agencies expect to refuse admission to patients who have not had a qualifying encounter prior to admission, while 80 percent plan to terminate care to those who do not have the qualifying encounter within the 30-day window.

In response to these survey findings, CMS officials asked what more they could do to bring about compliance by April 1. The various responses offered by stakeholders included providing more time before enforcement begins and being more flexible on the documentation requirements.

An additional discussion with CMS is in the process of scheduling for mid-March. NAHC continues to recommend that home health agencies and hospices take advantage of this transition period to test what is working and what is not with respect to the requirements. At this point, the likelihood of sufficient compliance capability by April 1 is in serious doubt. Providers experiencing problems with the face-to-face encounters should continue to report these issues to NAHC. In addition, providers should encourage any physicians with concerns to convey them to CMS directly or through their associations/medical societies.

NAHC is continuing to compile results from the survey received through yesterday and will publish a full report in an upcoming issue of NAHC Report.


Note from Lisa: The links to the NAHC newsletter won’t work here because they are password protected, but I will get the hospice and other information posted soon.

January 22, 2011

Medicare updates face-to-face questions

CMS has delayed enforcement of the new face-to-face rules until April 1, but they keep answering questions to clarify policy.

The questions and answers can be found on the general Questions area of the CMS website, but we’re lucky: NAHC has compiled a list of the most recent Q&As. They are below.

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.

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.