The home health face-to-face documentation requirement remains a compliance risk area as evidenced by recent government activity. The Patient Protection and Affordable Care Act changed the home health payment requirements as of Jan. 1, 2011, to require a physician or certain nonphysician practitioners to have and document a face-to-face encounter prior to certifying the patient’s eligibility for home health services. 42 C.F.R. § 424.22(a)(1)(v). This requirement, which is a condition for payment, mandates that the face-to-face encounter occur within a certain timeframe and include an explanation of why the clinical findings support that the patient is homebound and needs intermittent skilled nursing services or therapy services.
In April 2014, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) studied compliance with the face-to-face documentation requirement for home health, concluding there was limited compliance with this requirement. OIG, “Limited Compliance with Medicare’s Home Health Face-to-Face Documentation Requirements,” April 2014. The OIG found that 32 percent of home health claims that required face-to-face encounters did not meet Medicare documentation requirements, resulting in $2 billion in payments that should not have been made. The deficient claims had no face-to-face documentation or had face-to-face documentation that lacked at least one of the required elements. The OIG also found that physicians were inconsistent in completing the narrative content on the face-to-face documentation, even though the Centers for Medicare and Medicaid Services (CMS) provided an example of how this can be accomplished in as little as three sentences.
On July 7, 2014, CMS issued a proposed rule modifying the face-to-face documentation requirement. 79 Fed. Reg. 38366 (July 7, 2014). CMS proposed three changes to the face-to-face encounter requirements.
1) CMS proposes to eliminate the physician narrative requirement. The physician would still certify that a face-to-face encounter occurred with a physician or allowed nonphysician practitioner.
2) CMS proposes that to determine whether the patient is or was eligible to receive Medicare home health services, CMS will review “only the medical record for the patient or the acute/post-acute care facility … used to support the physician’s certification of patient eligibility.” If the patient’s medical record used by the physician to certify eligibility was not “sufficient” to demonstrate the patient was eligible to receive home health services, CMS will not pay for the services.
3) CMS proposes that physician claims for certification/re-certification of eligibility for home health services would not be covered if the home health agency’s claim was not covered because the patient was not eligible for home health services due to an incomplete certification/recertification or insufficient documentation. This change will be implemented through subregulatory guidance.
Although CMS claims that the changes will simplify the face-to-face documentation requirement by eliminating the physician narrative, it also expects that there should be sufficient evidence in the patient’s medical record to demonstrate that the patient is eligible for the home health benefit. However, to date, CMS has not provided guidance on what constitutes “sufficient” documentation. The deadline to file comments to the proposed rule is 5 p.m. on Sept. 2, 2014.
Until a final rule is in effect, home health agencies must comply with the current regulatory requirements for face-to-face encounter documentation. CMS has issued various documents that can assist in completing the face-to-face documentation, including a Medicare Learning Network (MLN) newsletter discussing the documentation requirements, as well as answers to 49 questions about the face-to-face encounter documentation requirements. Home health agencies should review this guidance in conjunction with their policies and procedures to ensure compliance with the face-to-face documentation requirement.