Palmetto GBA: Medical Review Requirements for HH Face-to-Face Documentation

Palmetto GBA has noticed an increase in overpayments for Home Health Prospective Payment System (HH PPS) claims. The top reason for this increase is attributed to the requirement for a face-to-face encounter with the beneficiary.

Palmetto GBA evaluated its criteria for review of these types of claims. Effective immediately, Palmetto will begin a more comprehensive review using the regulations governing these types of claims. Palmetto GBA encourages all providers to review their internal processes to ensure that all of the criteria for coverage have been met and documented in the medical record.

As a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’s eligibility for the home health benefit, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP), has had a face-to-face encounter with the patient.

According to the, CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1, the face to face documentation must contain a brief narrative which ‘describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.’

Documentation must include details showing how specific clinical findings support homebound status.

Examples of inadequate documentation include the following:

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
  • ‘Gait abnormality’ without specific clinical findings
  • ‘Weakness’ without specific clinical findings

The face-to-face documentation must also include clinical findings to support the need for skilled services, i.e. skilled nursing or therapy.

The Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22 states, ‘The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled and dated and the certification must be signed by the certifying physician.’

For more information, please refer to Medlearn Matters article SE1219 (PDF, 128 KB).

References:

  • CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1
  • Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22
  • Medlearn Matters article SE1219

Tags: , , , ,


%d bloggers like this: