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On Dec. 16, the Centers for Medicare &Medicaid Services (CMS) presented an open door forum on the new home health certification requirement that becomes effective on Jan. 1, 2015. The 2015 Home Care Prospective Payment Final Rule, CMS-1611-F, made significant changes to the face-to-face requirement that was mandated by the Patient Protection and Affordable Care Act (PPACA).

Noting that the improper payment rate for home health services far exceeded the rates for other Medicare services, and that most of those improper payments were for “insufficient documentation,” CMS responded to the home health industry concerns.

 “In an effort to simplify the face-to-face encounter regulations, reduce burden for HHAs and physicians, and to mitigate instances where physicians and HHAs (home health agencies) unintentionally fail to comply with certification requirements,” the agency explained, it modified the documentation requirements. CMS now specifies that there will no longer be a need for a physician narrative, except when the physician is ordering home care solely for skilled nursing visits for management and evaluation of the patient’s care plan.

This means there is no longer a requirement for a face-to-face form with a narrative description by the physician of the homebound status and need for home care.

While the face-to-face form being completed and signed by the ordering physician is no longer required, the same elements contained in that form are still required for certification of home care services. That is, there must be a qualifying visit by a physician or non-physician practitioner (NPP) within 90 days prior to the start of home care or within 30 days of the start of home care. When the primary reason for the home care services is addressed, there must be an order for home care services and there must be documentation of the patient’s homebound status and need for skilled services.

Looking at each required element, there must be a physician visit related to the problem that warrants home care within the specified time frame. This requirement would be met by a signed and dated progress note or discharge summary from any qualifying physician or NPP that indicates the reason for home care, such as “stroke,” or “OA hip, post-THR,” or “end stage COPD.” If the primary care physician saw the patient for a preoperative clearance for a hip replacement, that note would meet this requirement, as would a note from the surgeon or a hospitalist, as every note is sure to document “s/p THR.” If the patient was not hospitalized when referred from home care, the most recent office note from the physician addressing that issue would meet the requirement.

There also needs to be a description of why the patient is homebound, fulfilling CMS’s two criteria introduced in MLN Matters SE1405 in late 2103. These two criteria are actually three: a) because of illness or injury, need for the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence; b) when a condition exists such that leaving the home is medically contraindicated; and c) when there exists a normal inability to leave home (and/or when leaving home requires a considerable and taxing effort).

Then there must be a description of the skilled home care services needed and why they are needed. It is not enough to write “PT for ambulation;” a specific description is required. CMS presented this example: “PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition (sic) and teaching of Lovenox injections.”

While reading the list of requirements makes it sound like nothing has changed, the requirement that the physician document all these elements has been removed. As of Jan. 1, 2015, CMS is allowing HHAs to prepare all the documentation indicating homebound status qualification and need for skilled services and just have the physician review, sign, and date it – that will meet certification. The agency will even allow a primary care doctor in the office to certify home care if the progress note or discharge summary was performed by the hospitalist or operating surgeon, as long as the certification indicates the name and date of that doctor’s visit. And to make it even easier, the HHA can even put all this information in the plan of care that is signed by the certifying physician, so one form will do it all. In response to a question from NGS, one of the Medicare Administrative Contractors (MACs), CMS did note that although many HHAs use a version of the CMS485 form for home care plan certification, that form is not a requirement (nor endorsed by CMS), but it is acceptable.

CMS also specified that HHAs can create a separate form for the required elements or even have the doctor sign the OASIS and use that. But the caveat is that whatever method is used, a copy must reside in the physician’s records, and the clinical notes related to the patient’s care must substantiate the information. In other words, CMS will ask its auditors to ensure that the qualifications indicated in the certification are a true representation of the patient’s condition and are not falsified and thus fraudulent. As an example, if a patient is receiving home care for end-stage Parkinson’s disease with frequent falls and the physician notes indicate that the patient has a normal gait, the claim will be denied. In this case, if the physician submitted a claim for HCPCS G0180, physician certification of home care, then that claim would also be denied.

So what are the practical implications of this? My personal recommendation, as a primary care physician, past chairman of the board of directors of a home health agency, and an advocate for hospitals, case managers, and physicians, (and not endorsed by CMS, my employer, or any other agency) would be to do the following:

  1. Hospitals should do nothing beyond get an order for home care with the appropriate modalities indicated (PT, SLP, nursing), supply that signed and dated order and a copy of a signed and dated progress note or summary from the ordering physician that includes mention of the problem that warrants home care (which should be every progress note), and leave the rest to the home care agency. 
  2. Home care agencies, when receiving a referral, should get a copy of the order and the note signed by the qualifying physician and review the patient’s needs and condition to determine if he or she is indeed homebound and has a need for skilled services. If so, the referral should be accepted. When the patient is first evaluated, the nurse should include information on homebound status and skilled care needs in the documentation and modify the plan of care certification document to include specific language on why the patient is homebound and the specific skilled needs of the patient. If a hospital-based physician performed the face-to-face visit that is used to qualify the patient for home care, indicate that doctor’s name and the date of the visit. The primary care doctor (or whomever the HHA designates to be the certifying physician) already signs that certification form and keeps a copy of the signed form in his or her medical record, since billing is being done for the review of that care plan. CMS indicated that it is acceptable that this information is not available at the start of services; it can be done after home care services have started, but not on day 60, at the end of the episode of care. If the physician is ordering skilled nursing visits solely for management and evaluation of the patient’s care plan with no other skilled services, then a physician-written narrative is required, but these instances should be rare.

These two steps fulfill all the requirements and demand less work by the hospital physicians and case managers by eliminating the face-to-face form, not creating a new form, and not creating any extra work for the primary care physician/certifying physician beyond reviewing the new information in the plan of care. Furthermore, the HHAs tend to be much better versed in the nuances of wording for the documentation of homebound status and need for skilled services than any hospital-based personnel; the many denials for inadequate documentation show that it is not reasonable for a physician or hospital care manager to accomplish this.

As with the elimination of the inpatient admission certification requirement, CMS has handed hospitals a gift for the New Year. They had good intentions; home care fraud is rampant, with criminals setting up sham agencies and recruiting patients, but the old face-to-face requirement was a hindrance to getting home care to patients who needed it. The National Association for Home Care & Hospice recently called for a delay of the new requirements; there does not appear to be any justification for such. As outlined above, the new rule is clear and the guidance provided is easy to understand. Delaying the removal of an onerous requirement that has stymied physicians, case managers, hospitals, and home care agencies makes no sense at all.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians. 

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2015 Home Care Rule at: http://goo.gl/Dlkbom

CMS presentation at: http://goo.gl/iYW05a

CMS examples at: http://goo.gl/oKnK2Q

SE1405 at: http://goo.gl/5B0Wjd

NAHC request for delay at: http://goo.gl/iBg0Os


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