CMS Provides Clarification Regarding HHA Face-to-Face Documentation

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In January 2014, CMS released a Special Edition Article of MLN Matters [PDF] to clarify the documentation requirements for Home Health Prospective Payment System (HH PPS) Face-to-Face Encounters. CMS found that insufficient documentation of the face-to-face encounters has led to the majority of HH PPS improper payments. This Special Edition Article is meant to educate home health agencies, non-physician practitioners (NPPs), and physicians who refer patients to home health, order home health services, and/or certify patients' eligibility for the Medicare home health (HH) benefit, about the necessary elements of face-to-face encounter documentation. CMS also included helpful examples of correct and incorrect documentation.

In accordance with the mandates of the Affordable Care Act, physicians who certify a Medicare beneficiary's eligibility for the HH benefit must document that they, or certain NPPs, had face-to-face encounters with beneficiaries prior to the required certification of the patient being homebound and being in need of skilled services. In the corresponding documentation, physicians must note why the clinical findings support the patients' homebound status, and must evidence the need for either intermittent skilled nursing services or therapy services. The MLN Matters article addressed both the proper form and substance of the required documentation.

CMS emphasized that the substance of the face-to-face encounter documentation should mirror the necessary elements to qualify for the HH benefit. To qualify for the HH benefit, a beneficiary must be homebound and must require intermittent skilled nursing services. The documentation should explain using clinical and expressive terms why the patient is homebound, and what the skilled nursing care providers will do in the beneficiaries' homes. Encounter documentation must address those necessities as the two key substantive elements of the certifying physician's narrative.

Physicians must draft the encounter documentation in narrative form. The narratives should explain why the findings from the face-to-face encounters support the homebound status and the medical necessity of the services ordered. One common documentation error arises when, instead of writing a complete narrative, physicians simply list beneficiaries' diagnoses, recent injuries, or procedures. Providing only a list of diagnoses, injuries, or procedures will be deemed absolutely insufficient documentation in the eyes of CMS. In the article, CMS reminds physicians, home health agencies, and NPPs that documentation of the face-to-face encounter must be dated, signed by the physician, titled "Home Health Face to Face Encounter," and be written in narrative form to illustrate the connection between clinical findings from the encounter and the homebound status and services ordered.

Ober|Kaler's Comments

The examples provided in this MLN Matters article should provide helpful guidance to HHAs as they continue to educate physicians on the requirements for face-to-face documentation. At least one Medicare contractor, Palmetto GBA, has reported that failure to meet the face-to-face requirements was the number one reason for home health and hospice denials during the last quarter of 2013. Providers should anticipate Medicare audits examining this issue.