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There are many new requirements for the new face-to-face regulation for home health. Below are the answers to the questions LeadingAge has received from members about the regulation.
Q1. Who is qualified to perform the face-to-face encounter?
A1. The face-to-face encounter must be performed by the physician or certain non-physician practitioners (with physician certification) who develop the plan of care and who certify that the Medicare beneficiary is in need skilled nursing care or therapy and is confined to his/her home.
Q2. Does the physician who conducts the face-to face encounter need to care for the patient throughout the home health care episode?
A2. No. The certifying physician may transfer the patient to another doctor at any time.
Q3. I am a hospitalist and do not provide care to patients who are in their own homes. Can I perform the face-to-face encounter and certify the needs of the patient?
A3. Yes. Your encounter will qualify if:
Q4. The patient just was seen by a nurse practitioner. Would that encounter qualify?
A4. Very likely. To qualify, the encounter must be related to the need for home care. Also, the nurse practitioner must convey clinical findings to a physician who certifies the patient’s need for care and documents why the patient qualifies for coverage.
Q5. Does the encounter requirement apply to every time the physician orders care or changes orders?
A5. No. The face-to-face encounter requirement only applies for the initial start of care. However, if a patient is discharged from home care and is later admitted again, the requirement will apply.
Q6. I am already overburdened with paperwork for Medicare and insurance company claims. Isn’t this another unnecessary burden on physicians?
A6. This new requirement helps ensure that Medicare beneficiaries get the care and benefit coverage that they are entitled to. While it may add some new paperwork, the documentation only needs to be brief.
Q7. Can the term "physician support staff"-- the staff who can assist the physician in drafting the narrative be further defined?
A7. Yes. Physician support staff are those staff who work with or for the physician on a regular basis, and, as part of their job duties regularly perform documentation, take dictation from the physician and/or extract from the physician's medical records to support the physician in a variety of ways.
We note that HHA staff cannot assist the physician in drafting the narrative. The statute requires that the physician must document the face-to-face encounter. As we describe in our final rule, the HHA staff cannot draft the narrative documentation for the physician to sign as this would violate the statutory requirement.
Q8. Can documentation requirements for the face-to-face encounter be satisfied if the certifying physician’s staff complete the document as part, or addendum to the certification using the patient’s medical record & physician reviews and signs?
A8. The statute requires that the certifying physician document the encounter as part of the certification. A physician's own support staff can help the physician draft the face-to-face encounter documentation narrative in a number of ways which include but are not limited to:
These are examples of common practice for physicians to document their patient encounters, and all would meet the statutory requirement that the certifying physician must document the encounter as part of the certification.
CMS expects that because this same information is often present on the discharge summary and/or physician orders for home health services, the face-to-face encounter documentation narrative may satisfy multiple purposes. A physician's orders for home health services or an acute/post-acute discharge summary can be used to satisfy the face-to-face documentation narrative, if they reflect the clinical condition of the patient as seen during the encounter, they are drafted by the physician or the physician's support personnel, and they meet these requirements:
Q9. Can existing medical records (such as discharge summary plans) be attached to the certification and meet the face-to-face documentation requirements?
A9. Whether the face-to-face documentation is on the certification form itself or is an addendum to it, it must be separate and distinct. It must also include the following: 1) the patient's name; 2) date of the encounter; 3) how the patient's clinical condition as seen during the encounter supports homebound status and the need for skilled services; 4) the physician's signature (original signature, a faxed copy, copy of original document with signature or electronic signature - but not stamped signature); and 5) date of the physician's signature.
Q10. What is an example of the physician's narrative on the face-to-face documentation?
A10. The certifying physician's face-to-face description should be a brief narrative describing the patient's clinical condition and how the patient's condition supports homebound status and the need for skilled services. The following is an example:
"The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen."
You can visit CMS for more information about hospice and home health. The agency will continue to address industry questions concerning the new requirements.