Face-to-Face and CR Ask-the-Contractor Teleconference June 24, 2015

Transcription

1 Face-to-Face and CR 9119 Ask-the-Contractor Teleconference June 24, 2015

2 Home Health Coverage Resources CMS Medicare Benefit Policy Manual (CMS Pub ) Chapter 7; Home Health Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Medicare Benefit Policy Manual Chapter 7 - Home Health Services Table of Contents (Rev. 208, ) 2

3 Home Health Coverage Resources CGS Home Health Coverage Guidelines Web page rage_guidelines.html 3

4 Change Request (CR)

5 CR 9119 Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services Learning-Network- MLN/MLNMattersArticles/downloads/MM9119.pdf 5

6 CR 9119 CMS Manual System; Pub Medicare General Information, Eligibility, and Entitlement; Change Request Guidance/Guidance/Transmittals/Downloads/R92GI.pdf 6

7 CR 9119 CMS Manual System; Pub Medicare Benefit Policy; Change Request Guidance/Guidance/Transmittals/Downloads/R207BP.pdf 7

8 CR 9119 Three Changes to Face-to-Face Requirements 1. CMS eliminated the narrative requirements 2. If HHA claim is denied, the certifying/recertifying physician claim is noncovered. Because there would be no corresponding claim 3. Clarification that the face-to-face (FTF) encounter is required for certifications; rather the initial episodes New FTF for every completed start of care OASIS assessment 8

9 CR 9119: Supporting Documentation Per Ch. 7 section , for SOC effective January 1, 2015, documentation in certifying physician s medical record and/or acute/post-acute care facility s medical record: Will be used as basis for patient s home health eligibility Must contain information to justify the referral for home health services including: Need for skilled services; and Homebound status 9

10 CR 9119: Supporting Documentation Per Ch. 7 section , for SOC effective January 1, 2015, documentation in certifying physician s medical record and/or acute/post-acute care facility s medical record: Must be provided to home health agency when requested 10

11 CR 9119: Supporting Documentation Change Request 9112, Clarification of Ordering and Certifying Documentation Maintenance Requirements, Network-MLN/MLNMattersArticles/Downloads/MM9112.pdf 11

12 CR 9119: Supporting Documentation Per Ch. 7 section , certifying physician and/or acute/post-acute facility medical record (if the patient was directly admitted to home health) for the patient must contain the actual clinical note for the FTF encounter visit that demonstrates that the encounter: Occurred within required timeframe; Was related to primary reason patient requires home health services; and Was performed by an allowed provider type. 12

13 CR 9119: Supporting Documentation Information from home health associations (HHAs), such as initial and/or comprehensive assessment of the patient, can be incorporated into certifying physician s medical record for the patient and used to support patient s homebound status and need for skilled care HHA s documentation must be signed/dated by certifying physician to indicate acceptance of documentation into their medical records Physician s dated signature must be on/before the date of the physician s certification 13

14 Physician Certification The physician certification must include: 1. Patient is confined to home 2. Patient needs skilled services 3. Plan of care has been established and is periodically reviewed by physician 4. Patient is under care of a physician 14

15 Physician Certification 15

16 Physician Certification 16

17 Physician Certification I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I authorized services on this plan of care and will periodically review the plan. 17

18 Physician Certification The physician certification must be completed prior to billing. The physician should complete the certification when the plan of care is established, or as soon as possible thereafter. Guidance/Guidance/Manuals/downloads/bp102c07.pdf (Pub ; Chapter 7; Section ) 18

19 CR 9119: Supporting Documentation Information from the HHA incorporated into the physician s medical record must not conflict with other medical record entries in certifying physician s and/or the acute/post-acute care facility s medical record for the patient Information submitted & incorporated from HHAs must be received timely to ensure certifying physician has all relevant information when making decision to certify/recertify the patient The certifying physician (or allowed non-physician provider) must have a face-to-face encounter with the beneficiary before they certify the beneficiary's eligibility 19

20 CR 9119: Physician Recertification New requirement: The physician must include an estimate of how much longer skilled services will be required. This estimate may be longer than the benefit period The ordered frequency (on the 485) CANNOT be used as the physician s estimate Note: A recertification that does not include this information may result in a claim denial 20

21 CR 9119 Scenario #1 Patient discharged from acute/post-acute facility directly to home health services The hospitalist is seeing patient while in the hospital 21

22 CR 9119 Scenario #2 Patient admitted to home health, not resulting from acute/post-acute discharge Community physician is seeing patient in physician s office with no hospitalization 22

23 CR 9119 Scenario #1: Patient discharged from acute/post-acute facility directly to home health services Hospitalist sees patient & performs FTF encounter Community physician will follow patient after discharge and certifies HH services HH criteria requires patient to be under care of physician Certifying physician must document the date of the FTF encounter NOTE: If hospitalist performs FTF encounter and also certifies patient for home health, the hospitalist must identify the community physician who will follow the patient 23

24 CR 9119 Scenario #2: Patient admitted to home health, not resulting from acute/post-acute discharge Community physician has in-person visit (FTF) with patient 90 days before or 30 days after 1 st HHA visit (and the in-person visit is related to the reason for home health services) Documents FTF encounter in medical record, and certifies patient s eligibility for home health by the physician certification 24

25 MLN Matters SE1436 Certifying Patients for the Medicare Home Health Benefit SE1436. Important information plus document examples Network-MLN/MLNMattersArticles/downloads/SE1436.pdf 25

26 MLN Matters SE

27 MLN Matters SE

28 MLN Matters SE

29 MLN Matters SE

30 Face-to-Face Documents To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and: 1. Be confined to the home; 2. Need skilled services; 3. Be under the care of a physician; 4. Receive services under a plan of care established and reviewed by a physician; and 5. Have a face-to-face encounter performed by: Certifying physician (must be Medicare enrolled) Non-physician practitioner (NPP) in collaboration with the certifying physician Physician who cared for the patient in an acute/post-acute facility during a recent stay and has privileges in that facility 30

31 Face-to-Face Documents Information from the HHA can be incorporated into the certifying physician s and/or the acute/post-acute care facility s medical record for the patient. Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered. The certifying physician must review and sign off on anything incorporated into the patient s medical record that is used to support the certification of patient eligibility. 31

32 When? Certifying physician must document FTF took place within 90 days prior to start of care (SOC), or 30 days after SOC Reminder: FTF must be related to primary reason for home health admission Exceptional circumstance: Patient death before FTF can be performed 32

33 Face-to-Face The physician who cared for the patient in an acute or post-acute facility may choose to use documentation from the patient s medical record, (such as a discharge summary) to inform the certifying physician of the clinical findings from the face-to-face encounter. IF The compiled documentation is reflective of the clinical findings of the face-to-face encounter AND Serves as that physician s communication to the certifying physician 33

34 Face-to-Face Signatures The document from the acute or post-acute facility record Must be signed and dated by the certifying physician, Must indicate the certifying physician received the information from the physician who performed the face-to-face encounter, and Must show the certifying physician is using that documentation as his/her documentation of the face-to-face encounter 34

35 Documentation Does the documentation clearly answer why home health and why now? Reminder: Good documentation should address: Objective clinical evidence of patient s individual need for care Progress or lack of progress Medical condition Functional losses 35

36 Examples of FTF Documentation Don ts Insufficient documentation Miscellaneous The following may cause a claim to NOT BE PAID: Diagnoses/clinical findings on FTF not related to home care ordered Altered documentation without acceptable notations for changes FTF signed by Non Physician Practitioner (NPP) only No date of FTF encounter Not clearly titled as face-to-face encounter 36

37 FTF Documentation: Important Reminders FTF is requirement for Medicare payment Missing/incomplete documentation results in entire claim being denied As the billing entity, the home health agency s (HHA s) responsibilities include: Facilitating and coordinating between patient and physician to ensure FTF occurs timely Ensuring all FTF requirements are met Ensuring physician s documentation is complete Delaying submission of claim until documentation complete 37

38 Medical Necessity All services (even skilled) must be reasonable and medically necessary related to the patient s condition. Does the documentation clearly answer why home health and why now? Reminder: Good documentation should address: Objective clinical evidence of patient s individual need for care Progress or lack of progress Medical condition Functional losses Treatment goals Discharge planning 38

39 Medical Necessity Covers all disciplines Nursing Physical therapy Occupational therapy Speech language pathology 39

40 Additional information Medical Necessity elines/1e.html 40

41 Medical Necessity - Do s Identify skilled service, and reason skilled service is necessary for beneficiary in objective terms Examples of good documentation: Wound care completed per POC to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Range of motion (ROM) is tolerated to lower extremities. Unsafe to teach caregiver ROM due to displaced fracture. 41

42 Medical Necessity Do s Demonstrate medical necessity of skilled observation and assessment by documenting complexity of beneficiary s condition and co-morbidities affecting outcomes. Examples of good documentation: Lungs sound coarse throughout. Patient finished antibiotic therapy today for pneumonia, and seeing pulmonologist tomorrow for follow up to due to COPD and emphysema. Stasis wound on LLE continues to show 50% granulation and moderate serous drainage. Instructed patient on need to elevate legs and exercises related to peripheral vascular disease. 42

43 Medical Necessity Don ts Medicare Benefit Policy Manual (CMS Pub ) Ch. 7, 40.1 and 40.2 lists requirements in order for a service to be covered by Medicare as skilled. The service must: Require the skills of a nurse or qualified therapist Service is NOT skilled because it is performed by a nurse or qualified therapist Service does NOT become unskilled because it is taught Be reasonable and necessary to treat patient s illness or injury Patient s condition warrants the skilled care MUST BE evident in documentation 43

44 Homebound Criteria idelines/1c.html 44

45 Homebound Criteria Learning-Network- MLN/MLNMattersArticles/Downloads/MM8444.pdf 45

46 Homebound Criteria MLN Matters Home Health Clarification to Benefit Policy Manual Language on Confined to the Home Definition Clarifies definition of patient being confined to home Reflects definition in Social Security Act (Section 1835(a)) Removes vague terms to ensure clear and specific definition Not a change in homebound definition 46

47 Homebound Criteria Two criteria are used to determine homebound status Criteria-One: The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence. OR Have a condition such that leaving his or her home is medically contraindicated. 47

48 Homebound Criteria Two criteria are used to determine homebound status (continued) Criteria-Two: There must exist a normal inability to leave home AND Leaving home must require a considerable and taxing effort 48

49 Homebound Criteria The patient may be considered homebound (confined to the home) if absences from the home are: infrequent; for periods of relatively short duration; for the need to receive health care treatment; for religious services; to attend adult daycare programs; or for other unique or infrequent events the patient may have more than one home vacation home, home of caregiver, seasonal home 49

50 Homebound Criteria Documentation must support homebound status throughout Beware of vague descriptions: taxing effort, unable to leave home Utilize objective, measurable language Examples of good documentation: After ambulating 20 feet, patient has increased dyspnea and complains of back pain. Patient has unsteady gait, and must sit to rest after 20 feet of ambulation due to uncontrolled dyspnea. 50

51 CGS Home Health Denial Fact Sheets T.html 51

52 CGS Home Health Denial Fact Sheets 5HHBD Homebound Status _5hhbd_factsheet.pdf 52

53 CGS Home Health Denial Fact Sheets 5HMED Medical Necessity _5HMED_FactSheet.pdf 53

54 2015 MAC Satisfaction Indicator (MSI) Survey MSI tool used by CMS to measure provider satisfaction with Medicare Administrative Contractors (MACs) Your opinions matter Share your experiences 10 minute survey Confidential Access survey at, MAC_BRNC=16 CFI Group conducting survey on behalf of CMS For any technical difficulties contact, 54 June 16, 2015

55 Questions? CGS Provider Contact Center (Option 1) 55