Palmetto GBA October 15, 2013 J11 Home Health and Hospice “Ask the Contractor” Questions and Answers Posted

Palmetto GBA has posted the questions and answers from their Oct. 15, 2013 Ask The Contractor segment. They provide this helpful session to help answer some of the critical questions many providers have for the MAC. This installment focuses on many questions related to face2face documentation.

Question
Can the physician dictate the information for the face-to-face documentation?

Answer
The physician is able to dictate the documentation of the face-to-face encounter, but it has to be dictated to his/her staff and the physician will have to be the one who signs and dates it.

Question
I need the phone number for Palmetto GBA’s consolidated customer service center please?

Answer
The number is 855-696-0705.

Question
In the Palmetto 2013 home health workshop series, there were examples of the face-to-face documentation that the physician could provide. One of them is what my client is using with the small tweak of not specifying the leaving home as a considerable taxing effort like the example shows. My client also lists the diagnoses the patient has but doesn’t identify which of the diagnoses requires the home health service. He doesn’t actually detail anything out about why the patient is homebound or how those diagnoses require skilled nursing per se. He’ll mark it skilled nursing or he’ll mark the patient needs lab work or education but he doesn’t give any detail. Is that something that would not qualify for a face-to-face?

Answer
We would have to look at the individual documentation in order to tell you if we think it meets the face-to-face documentation requirements. If you’re saying that you are looking at their documentation and feel it’s not meeting the Centers for Medicare & Medicaid Services (CMS) face-to-face requirements, then you would be correct to advise them not to leave it in that format and to be more detailed.

Question
If the documentation does not meet medical necessity for the face-to-face, does that make the entire home health episode null and void?

Answer
Yes, because the face-to-face encounter documentation is a requirement for the initial certification for home health.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 44 (PDF, 171 KB)

Question
This question is on the home health visit recertification of care. I am a consultant and I have a provider who missed the five-day window by doing the recertification two days too early. They did not go back and redo the assessment during the five-day window as instructed by Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS), if you do the recertification too early. They billed the visit as if it had been done during the five-day window, which obviously is incorrect. What are they going to do to the second episode of care that does not have a valid certification exam to support its’ medical services? Because this is a retroactive audit, they cannot go back and redo that recertification assessment during the five-day window. Is the provider allowed to change the service from a recertification to a teaching service, if that was documented? If so, that visit then becomes a non-chargeable visit and I don’t believe you can just downgrade to a different type of visit?

Answer
If the recertification was not valid, then the episode cannot be billed. If it was already billed, the claim should be cancelled and the money repaid to Medicare. For questions on OASIS assessments and reassessments, please contact your State OASIS Coordinator for assistance.

Reference: A listing of State OASIS Coordinators (PDF, 82 KB) may be found on the CMS website.

Question
Does the primary care physician or the person who is signing the 485 home health plan of care also need to co-sign the face-to-face, if that was done by the hospitalist?

Answer
The hospitalist is able to certify the need for home health, do the face-to-face and initiate the plan of care. The hospitalist can then hand off the patient to the community physician.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013 Question 20 (PDF, 171 KB)

Question
We have home health referrals where the physician gives us the referral based on the office visit completed that day.  We admit the patient, send the 485 and the face-to-face to the physician to complete. The physician signs and dates the 485 and on some occasions signs and dates the face-to-face on a different date, so that they have two separate dates. I think we’ve gotten denials because the dates on the 485 and the face-to-face don’t match. Does that matter?

Answer
There’s nothing in the Medicare regulations that say they have to be the exact same date.

Question
Some of our physicians who are failing to date the face-to-face at the time they’re doing it. So what we’re doing is sending it back to their offices and of course, saying that we must have a date on there. We have a face-to-face where the encounter date was February 13, 2013 and then the physician later dated the face-to-face document on March 13, 2013. We’re being told that the date he entered on the face-to-face is outside the compliance timeline.

Answer
The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care. As per the CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013 Question 17, “HHAs are allowed to title and date the face-to-face encounter documentation. The content requirements must be that of the certifying physician, the documentation must be signed by the certifying physician, and the documentation cannot be otherwise altered/changed by the HHA in any way. In most cases, the expectation is that the certifying physician signs, titles, and dates the face-to-face encounter documentation. Prior to billing, a home health agency should ensure that the certification is complete. The certification is not complete without a face-to-face documentation that has been clearly titled and dated and signed by the certifying physician.”

References: Medicare Learning Network (MLN) Article SE1038 (PDF, 73 KB) and CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 17 (PDF, 171 KB)

Question
A physician who attended the patient in acute or post-acute setting may certify the need for home health. Previously, the several questions about the co-signing was very helpful. My question is about the certification. If the hospitalist signs a face-to-face that has everything on it, the skilled need, the homebound, and there is a certification statement that says, “I certify the patient as confined to their home and needs intermitted skilled nursing care, physical therapy, and/or speech therapy.” That certification statement is on the face-to-face, in addition to the narrative for clinical necessity and homebound. Does that then – would the possibly list signature on that face-to-face, with all the pieces and the certification statement. Then he hands it over to the community physician who signs the 485. In that situation, you have two different physicians signing, no co-signature, no anything else is necessary. Is that correct?

Answer
Yes, you are correct. The hospitalist would be signing and dating their own face-to-face and then the community physician would be signing and dating their own plan of care.

Reference: CMS Home Health Face-to-Face Encounter Question& Answers Revised February 28, 2013, Question 22 (PDF 171 KB)

Question
If the certification statement just says, “I certify the patient as confined to his or her home,” and it doesn’t also specifically say, “and needs intermittent skilled nursing, physical therapy, and /or speech,” would that be considered an incomplete certification statement? Do both components have to be present in a certification statement?

Answer
You need to make sure the certification statement is complete and meets all the requirements for a valid home health certification.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 27(PDF, 171 KB)

Question
My question is about once you get a denial from an Additional Development Request (ADR) or Recovery Audit Contractor (RAC). What recourse do you have if they determine the documentation was not adequate to meet the face-to-face requirement? Can we get documentation from the doctor? What can we do?

Answer
If you’re asking whether or not you can submit a redetermination request for face-to-face documentation denials, the answer is yes. Anything additional that you can provide from the physician as further documentation of the physician’s findings concerning the patient’s condition during that face-to-face encounter would be beneficial.

Reference:
CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 5 (PDF, 171 KB)

Question
Are the physicians allowed to use checkboxes?

Answer
As far as the checkboxes are concerned, there is not a requirement that says that you cannot use the checkboxes or incorporate them in some way.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 24 (PDF, 171 KB)

Question
Sometimes the physician does not complete the section on our form. Our form says, “I certify that my clinical findings support that this patient is homebound.” The doctor doesn’t write anything specific on there. Is that good? What if we have a statement that says you’re certifying your clinical findings support that the patient is homebound?

Answer
I don’t think that would be sufficient. I think that you would really want to make sure that you’re explaining what about the patient makes them homebound. They’re looking for that extra piece of information that speaks specifically to this patient’s condition and not simply a restating of the Medicare requirements home homebound status.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 28 (PDF, 171 KB)

Question
We received quite a few face-to-face documents that have as the reason for the visit the listing of the diagnosis number only. Is that sufficient as long as the rest of the clinical documentation is there as the necessity for home health?

Answer
There isn’t a problem with the diagnosis code being on the face-to-face document. However, if that’s the only information that’s given, that wouldn’t be enough information to meet the requirements. If in your example you’re saying they gave that diagnosis code but then they also gave other clinical documentation such as information about why the patient is considered homebound and why they need these skill services, then that should be sufficient.

Question
CMS says that they don’t specify a form or format for the communication documentation. So would it be acceptable if the physician sends us two different documents that together address all the required elements? Would that satisfy a face-to-face or does it all have to be contained in a single document?

Answer
The face-to-face can be multiple documents. However, the documentation must be clearly titled and dated and signed by the certifying physician that it is to serve as documentation of the face-to-face encounter.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 6 (PDF, 171 KB)

Question
We get a lot of orthopedic patients where they’re only homebound during the time directly after their surgery. We get a lot of the homebound statuses from the doctors that are just “status post-surgical procedure, can’t drive” and obviously those aren’t acceptable. For patients that are seen for orthopedic procedures, like a total hip or a total knee, what exactly are you looking for, for the homebound status?

Answer
Providers may consider details such as the date of surgery; type of surgery and if there were any complications; presence or absence of staple sutures; condition of the surgical site and whether or not wound care is needed. Please note that Medicare guidelines do not provide for a pre-authorization or pre-approval process. The decision as to whether or not certain pieces of information would be accepted should the claim be reviewed, has to be done in conjunction with the review should the claim be selected. It is the provider’s responsibility to determine whether or not the documentation they submit contains all the required elements to ensure that the regulations are met.

Question
As long as the hospitalist is certifying the home health services completely, and the information that they’re putting on the face-to-face documentation is what we’re turning around to see the patient for, then it’s ok that they sign the face-to-face and the patient’s primary care physician signs the plan of care?

Answer
That’s correct.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 26 (PDF, 171 KB)

Question
We have a physician in our area that does send back the face-to-face with “See progress notes” written all the way across. He does sign and date it and sends in his progress notes from the visit that he documents with the face-to-face visit.  Is that acceptable or not? The whole entire visit is from the physician himself.

Answer
Yes, that’s fine. Just assure the progress notes are signed, dated and clearly titled as the face-to-face documentation.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 4 (PDF, 171 KB)

Source: Palmetto GBA

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