CMS Proposes Welcomed Changes to the Medicare Home Health Face-to-Face Requirement

On July 1, 2014, CMS published the 2015 Home Health Prospective Payment System Rate Update proposed rule, which included proposed changes to the home health face-to-face encounter requirement. The face-to-face encounter, a requirement added by the Affordable Care Act, requires that prior to certifying a patient’s eligibility for Medicare’s home health benefit, the physician must document that the physician himself or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. The current face-to-face encounter requirements call for the certifying physician to document the date of the encounter and include a narrative explaining why the clinical findings of the encounter support that the patient is homebound and in need of intermittent skilled care. The face-to-face encounter must occur no more than 90 days prior to the start of care or within 30 days of the start of care and be related to the primary reason the patient requires home health services. The documentation was required to be clearly titled and dated, and signed by the certifying physician. The face-to-face documentation, even if included as an addendum to the home health certification, also had to be separately signed by the physician.

The proposed rule explains that a review of the Comprehensive Error Rate Testing (CERT) program’s reporting for FY 2013 revealed a 17.3 percent improper payment rate for home health services, representing approximately $3 billion in improper payments. The majority of the improper payments were due to findings of “insufficient documentation” – most of which occurred in the narrative portion of the face-to-face encounter documentation.

Home health industry stakeholders have voiced concerns over the challenges related to meeting the face-to-face documentation requirements, including the difficulty in relying on physicians to complete the required documentation with no incentives to encourage physician compliance. At present, only the Medicare payments for the home health services, not the related physician services, are dependent upon completion of the face-to-face encounter documentation.

In response, CMS has proposed the following changes to simplify the face-to-face encounter requirements:

  1. Eliminate the narrative requirement found in 42 CFR 242.22(a)(1)(v). The certifying physician would still be required to:
    • Certify the face-to-face encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care or within 30 days after the start of care;
    • Certify the encounter was performed by a physician or allowed NPP; and
    • Document the encounter as part of the certification of eligibility.
  1. Review the certifying physician’s medical records for the patient (or records of the acute/post-acute care facility supporting the home health certification) in determining whether the patient was eligible to receive services under the Medicare home health benefit at the start of care. If the patient’s medical record is not sufficient to demonstrate home health eligibility, payment would not be made.
  2. Physician claims for certification/recertification (G0180 and G0179) of home health eligibility would not be payable by Medicare if the underlying home health claim is determined to be non-covered due to insufficient documentation supporting that the patient was eligible for home health. This proposed change would be implemented through future sub-regulatory guidance.

The proposed changes seem to acknowledge some of the frustrations voiced by the home health industry. Removal of the requirement calling for the face-to-face documentation to be a separate and distinct document may allow for the face-to-face to be made part of the certification. Likewise, tying physician payments for certification or recertification activities to the face-to-face documentation requirements may encourage greater compliance on the part of certifying physicians. But the proposed changes also raise questions about how the documentation will function in practice. For instance, if the certifying physician’s medical record would serve as support for the patient’s home health eligibility, will this documentation regularly be provided to the home health at the time of the certification or will home health agencies find themselves stuck trying to obtain this supporting documentation in response to a claim denial or Medicare audit? While some questions remain, the changes aimed at reducing the concerns surrounding the face-to-face documentation are welcomed.

CMS is accepting comments regarding the proposed changes through September 2, 2014.

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