CMS Clarifies Role of Hospitalist in Physician Face-to-Face Rule

CMS Provides Details for Face to Face Encounter by Hospitalist, Other Clarifications

Effective January 1, 2011, home health agencies will be required to meet current certification and plan of care requirements and new face to face encounter requirements.

During a lengthy conference call, a representative from the Centers for Medicare & Medicaid Services (CMS) provided detailed information to the National Association for Home Care & Hospice (NAHC) as to how home health agencies will be able to meet face-to-face encounter requirements for patients referred to home health from institutional settings. CMS explained that this policy will apply not only to patients referred by hospitalist, but to patients referred by physicians from all inpatient settings, such as rehab facilities and skilled nursing facilities.

Generally patients are referred to home health agencies as follows:

  1. By a community physician who is caring for the patients in an institutional setting or in the community, or
  2. By an inpatient facility physician who is willing to continue to be responsible for patients after their discharge from institutions until they see a community physician, or
  3. By an inpatient facility physicians who is unwilling to be responsible for patients after their discharge from institutions.

When referred by community physician, whether the patient is in an institutional setting or the community, that physician will document face to face encounters and continue to meet all certification and home health plan of care requirements as they do today. When inpatient facility physicians refer patients and are willing to continue to be responsible for those patients after discharge from institutions until they see a community physician, those physicians will document face to face encounters and continue to meet all certification and home health plan of care requirements, as they do today.

It is in those cases where an inpatient facility physician is unwilling to be responsible for patients after discharge from the facility that will present problems for home health agencies in meeting face to face encounter requirements. In order to remove roadblocks for these patients, CMS announced that it will amend the longstanding policy in Pub 100-02 Chapter 4, Section 30 that “since the certification is closely associated with the plan of care (POC), the same physician who establishes the plan of care must also certify to the necessity for home health services.”

According to CMS, since the certification and plan of care regulations do not specify that these functions be performed by the same physician, CMS will amend the policy and allow different physicians to perform each of these functions. As a result, facility physicians will end their responsibility for patients upon discharge from the inpatient setting will be permitted to complete the required face to face encounter documentation based on the patients clinical condition while under their care, and to certify that the patient is homebound and requires intermittent skilled nursing or therapy services. The community physicians will establish the home health plan of care, as they do at the present time.

Unresolved Issue

According to 42 CFR 424.22, as a condition for payment, the content of a home health certification includes a signed statement that:

  • The patient needs intermittent skilled nursing or therapy
  • Home health services are required because the patient is confined to home
  • A plan for furnishing the services has been established
  • Services were furnished while the patient was under the care of a physician

The first two bullets under certification requirements are not at issue. However, NAHC has asked CMS to respond as to how it intends for inpatient facility physicians who end their responsibility patients will be able to meet the plan and attestation about services furnished requirements in the third and fourth bullet.  This information will be shared with home health agencies once a response if received from CMS.

Travel Together Requirement

In regard to the CMS Open Door Forum statement that the face to face encounter documentation and certification (versus plan of care) must “travel together” CMS explained that certification and plan of care are two separate requirements: CMS wrote in to an email inquiry:

The “traveling together” discussion may be the source of the confusion. Our intent was to describe that the face to face encounter documentation is a part of the certification.  It isn’t a separate thing.  Although we allow the documentation to be on an addendum, that addendum is still part of the certification.  The entire certification is also part of the patient’s entire medical record documentation, and of course the physician who assumes POC responsibility would need to have access to the documentation associated with the encounter, as would the HHA.

Face to Face Encounter Guide

In regard to agencies concerns as to whether a guide or template is acceptable, similar to that found on the NAHC web site, CMS was asked by a home health agency whether “it would be acceptable to label the section of the plan of care or addendum where the physician’s documentation should be placed, titling it and include subheadings such as: Date of Encounter, Medical Condition for Encounter, Services Needed, Clinical Findings, Homebound Status, Physician Signature, Date.”  CMS responded:

“Yes, this is fine.  As long as the info/clinical findings and how the findings support eligibility are documented by the physician,  in his/her own words.”

Certification Statement on Home Health Plans of Care

NAHC advised home health agencies to retain the certification statements for intermittent skilled nursing and therapy services and homebound statement on plans of care when another physician does the face to face encounter and initial certification. Also, although face to face encounters are not required at recertification, the homebound and medical necessity statements are required for recertification plans of care.

Face to Face Encounters After Start of Care

In response to inquiries from home health agencies as to what steps to follow when face to face encounters are to occur after the start of care and before day 30, NAHC suggests that the following steps:

  1. HHA obtains verbal orders
  2. HHA documents the orders on the plan of care, which includes a “box” or “addendum” with directions to the physician to document the face to face when it occurs and identify what information that must be included in the narrative.
  3. HHA drops the RAP once the plan of care, “certification,” form has been sent to the physician.
  4. Physician has an encounter with the patient
  5. Physician completes the encounter documentation, signs and DATES the plan of care and certification of the encounter/homebound status/medical necessity and returns it to the agency
  6. HHA agency files final claim.

Enforcement Effective Date

NAHC has been urging members of Congress and CMS via letters to Dr. Donald Berwick, the CMS Administrator, to delay enforcement of face-to-face encounter requirements for six months after the January 1st effective date. This endeavor is similar to that undertaken by NAHC regarding PECOS, whereby the effective date of the regulation will remain unchanged but CMS will not impose penalties for failure to comply until a time when physician education has taken place and home health agency questions have been adequately addressed.

NAHC and the Home Care Alliance will provide updates on progress toward achieving this end.

Materials for educating physicians, patients and home health agencies are available here in a previous newsfeed post.

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3 thoughts on “CMS Clarifies Role of Hospitalist in Physician Face-to-Face Rule”

  1. I strongly believe that all of us in home health need to be forcefully protesting this latest governmental requirement – never mind DELAYING the implementation of face-to-face MD encounters; we should be demanding WITHDRAWAL of this face-to-face requirement. For all the reasons that many of us, and our physician colleagues, have delineated previously.
    Home care agencies have a history of rolling over and just going along with whatever comes our way, with the rationalization of, “we’ve survived a lot over the years; we can deal with this, too.”
    One can speculate that this latest rash of changes to the Medicare “rules of engagement” is an attempt to cull the number of Medicare-certified home care agencies, not necessarily to “improve compliance with the COPs or to improve patient care.” It will most assuredly further decrease patients’ access to home care and also further decrease expenditures for Medicare home care.
    This particular face-to-face MD encounter requirement should be placed on those home care providers who have already been identified by Medicare as not ‘playing by the rules.’ Again, the innocent are caught under a blanket response to a problem that is not pertinent to the majority of us who have been providing care for over 100 years, without incident, inaccuracy, and/or inappropriateness.

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