Home Health Face-to-Face - End Those Denials! Ask the Contractor Teleconference (ACT) December 13, 2018
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- What education can we provide to doctors so they are aware of the compliance issue and what their documentation should contain?
What information is available to present to doctors concerning why face-to-face documentation is required, who can perform a face-to-face encounter and how often it is required.
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Medicare Learning Network (MLN) Matters Number SE1436 from CMS is a good resource to provide to doctors. The document can either be printed and presented to them or they can go directly to Medicare Learning Network (MLN) Matters Number SE1436. This article will explain to the doctors and their staff what documentation is required and examples for their reference.
Published: 01.15.19
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- Please advise how to handle face-to-face encounter notes and/or face-to-face signatures that are not dated or are not legible.
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All signatures must be legible and dated. If the signature isn’t legible, the signature can either be identified by printing the name under the signature or a signature log may be used. If the signature is not dated, it must be returned and an attestation must be included to signify the correct date of the signature. Don’t forget to make sure the attestation also has a dated signature (legible or identified). A good resource for signature information is CMS Medicare Learning Network – Complying with Medicare Signature Requirements.
Published: 01.15.19
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- Can a Family Nurse Practitioner (FNP)/Advanced Practice Registered Nurse (APRN)/Physician Assistant (PA) sign the home health referral/order or does the collaborating physician have to sign the referral along with the POC?
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A nurse practitioner or a physician assistant cannot sign an order.
Published: 01.15.19
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- If the physician who performs the face-to-face encounter is the patient's primary care physician (PCP), does the PCP then have to be listed in the face-to-face information?
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No, that is not necessary.
Published: 01.15.19
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- Should we accept cases if at start of care (SOC) the face-to-face encounter has not been completed, since we have no way of insuring patient will go to PCP?
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This is a decision each provider will need to make for themselves. It is the responsibility of the home health agency to ensure the face-to-face encounter takes place in a timely manner and the documentation is complete.
Published: 01.15.19
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- What type of documentation from the certifying or face-to-face physician can be used to appeal a denial based upon face-to-face?
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Any documentation which further supports the need for skilled care, homebound status, etc. can be used as supporting documentation in an appeal.
Published: 01.15.19
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- Does the physician who signed the order for home health have to be the same physician who performed the face to face document? Is it ok for the clinical note that is used for the face-to-face encounter be completed and signed by a nurse practitioner or physician assistant?
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The physician who signs the referral order does not have to also perform the face-to-face encounter. The face-to-face encounter must be performed by 1) the certifying physician, 2) a physician who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health, or 3) an allowed non-physician practitioner.
Published: 01.15.19
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- Is it required for the home health primary diagnosis to exactly match the face-to-face diagnosis as the face-to-face encounter can be 90 days before the start of care (SOC)?
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It is not required that the actual diagnosis code be matching, but the face-to-face documentation must be related to the primary reason the patient requires home health services. It’s fine to have other conditions mentioned, as long as the documentation reflects the primary diagnosis was considered.
Published: 01.15.19
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- If the face-to-face encounter occurs after the timeframe it can print on the 485 - can a supplemental order be sent? It is understood the 485 cannot be signed until the encounter takes place.
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It is required for the certifying physician to document the date of the face-to-face encounter. If you are unable to include the date of the face-to-face encounter on the 485, the certifying physician should cosign the clinical note for the face-to-face encounter.
Published: 01.15.19
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- If the face-to-face encounter is performed by the same doctor as the doctor signing the 485-can they be signed on same date?
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Yes, the face-to-face encounter must happen before the 485 (certification) can be signed, but it is allowable for both events to happen on the same day.
Published: 01.15.19
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- If a patient had an acute care stay, followed by a post-acute stay, then discharged with home health services ordered, can a face-to-face encounter from the hospital be used even though the patient was admitted directly from the rehab facility and not the hospital?
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As long as the face-to-face documentation from the hospital meets all of the required criteria, the face-to-face from the hospital is allowed.
Published: 01.15.19
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- Is a coordination note that identifies the supervising physician included in an agency's electronic medical record (EMR) sufficient to show who that nurse practitioner (NP) works with or is more proof needed?
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That should be enough information to identify the physician who is working with the nurse practitioner.
Published: 01.15.19
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- If the patient is transferred to the hospital and at resumption of care (ROC) there is a new primary diagnosis for home health - do you need a new face to face encounter?
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The primary diagnosis at the start of care is what needs to be a focus of the face-to-face encounter documentation.
Published: 01.15.19
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- Can the referral order be communicated by the nurse practitioner to the home health agency as a representative of the physician and the order be sent to the physician for signature and/or incorporated in section 25 of the 485 verbal order start of care section?
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If the order originates with the physician and the physician will sign the verbal order, this is allowable.
Published: 01.15.19
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- Does the face to face clinical note need to be on chart for billing, or is the addendum sufficient?
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The face-to-face clinical note is required to be in the documentation submitted.
Published: 01.15.19
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- In the state of Pennsylvania does the physician need to cosign the discharge summary performed by the nurse practitioner (NP) that is being used as the face-to-face?
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Please check with your state home health association for individual state requirements or regulations.
Published: 01.15.19
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- If the initial face-to-face encounter visit note does not clearly address the primary reason for home care, can an addendum be made?
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An addendum can be made to include information inadvertently left off of the original face-to-face clinical note. It cannot be used to add information that was not part of the original face-to-face encounter. The addendum must be complete and correct prior to original submission of the documentation for review.
Published: 01.15.19
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- We recently had an Additional Development Request (ADR) denied stating the length of certification was unclear. The length stated was indefinite. This patient is a long term patient who receives catheter management. Why was this denied?
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In the past we were able to accept “indefinite” as a length of time in specific certifications. Unfortunately, we are no longer able to do that and a specific length of time must be stated. Keep in mind, beginning January 1, 2019 an estimate of home care length of stay is no longer required for certification periods beginning on or after January 1, 2019. All episodes with start dates prior to January 1, 2019 will still need to include the estimate of length of stay.
Published: 01.15.19
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- If the nurse lists the homebound status in the OASIS and the doctor signs certifying the homebound status on the OASIS,do we need to get a copy of the doctor’s notes with the wording "homebound due to___"?
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The reason the patient is homebound must be included in the face-to-face documentation.
Published: 01.15.19
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- Does a patient need to be homebound if they are only on service for catheter care?
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All patients who receive payment from the Medicare home health benefit must be homebound.
Published: 01.15.19
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- Does the 30-day requirement go with the 30 days that we have to get a signed 485 back from the certifying physician? Is that the same as the patient has 30 days prior to get a face-to-face encounter done?
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A face-to-face encounter must occur either 90 days prior to the start of care or within 30 days after the start of care. Also, Medicare does not require the 485 be signed and returned by the certifying physician within 30 days.
Published: 01.15.19
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- A patient is admitted today, and tomorrow the home health agency creates and sends the 485 to the physician for signature. However the patient isn't scheduled to see the physician for the face-to-face encounter until 3 weeks from today which is within the 30 day time frame from start of care (SOC). Is it correct the physician can't date/sign the 485 until after he/she sees the patient for that visit? Should we just hold the 485 and not send it until after the face-to-face encounter visit is completed?
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The certification (included as part of the 485) cannot be signed by the physician until after the face-to-face encounter has been completed. If the 485 is sent prior to then, it is probable it will be signed prior to the face-to-face encounter and will be incorrect. It would be a best practice to not send the 485 for signature until after the completion of the face-to-face encounter.
Published: 01.15.19
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- I am unclear about the 485 needing a signature after the face-to-face encounter. If we have an acute care patient (i.e. dressings) and they do not have an encounter till day 23, we would complete a 485 and send for signature then have a verbal order with the face to face.
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The certification (included as part of the 485) cannot be signed by the physician until after the face-to-face encounter has been completed. You may use physician orders for the patient care without the 485 being signed.
Published: 01.15.19
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- Can a resident in an acute care setting perform the face-to-face encounter?
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Yes, a physician who cared for the patient in an acute or post-acute care setting from which the patient was directly admitted to home health may perform the face-to-face encounter.
Published: 01.15.19
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- Does the primary code on the 485 need to be the first reason on the face-to-face encounter--not in the top six diagnoses on the face-to-face encounter?
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The face-to-face encounter documentation must show the face-to-face encounter was related to the primary reason the patient requires home health care. Other diagnoses may be discussed in the clinical note and are not required to be in any certain order.
Published: 01.15.19
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- By our state regulations, the 485 (plan of care) must be signed within 7 days of the start of care date. How is it possible to follow up with the 30 days face-to-face regulation? If the face-to-face encounter date is scheduled on the 20th day after the start of care, we would be out of compliance when we waiting for face to face to be filled out. How we should proceed?
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If state regulations are stricter than Medicare regulations, you need to follow the strictest regulations. In this example, the face-to-face encounter would need to be completed within 7 days from the start of care, so the 485 can be signed timely to meet the state regulations.
Published: 01.15.19
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