June 7, 2013
Widespread Home Health Probe – Face-to-Face Encounter Documentation
As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers. The topic code for this review will be 52xxT (‘xx' denotes various numbers) and the edit will select start of care home health claims equally across the provider community. Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.
In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the "face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes." (CMS FAQ #44)
The FTF documentation, which must be a separate and distinct section of or an addendum to the Start of Care Certification must include:
The most common errors identified by the CERT contractor regarding FTF encounter documentation are insufficient documentation of clinical findings by the physician/non-physician-practitioner (NPP) to show the encounter was related to the primary reason for home care, and a description of why the patient was homebound and in need of Medicare covered home health skilled services.
In some cases, the FTF documentation only provided a diagnosis, or the frequency and duration of services to be provided. Below is a list of statements or items frequently used that, alone, would be considered insufficient for documentation of the homebound status and need for skilled services:
As a reminder, the FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or qualified NPP working in conjunction with the certifying physician. An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility. That physician can then report the FTF encounter to the certifying physician. The certifying physician must document the encounter either on the certification, or a signed addendum to the certification. Only the certifying physician may sign the FTF encounter document.
Finally, please remember that as the billing entity, it is your responsibility to:
For more information on FTF requirements please refer to the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (Pub. 100-02), Chapter 7, Section 188.8.131.52and the CMS home health FTF FAQs.
Provider Action Needed to Prepare for the Edit
HHAs should take action now to ensure that they have procedures and processes in place to appropriately identify and respond to claims that are selected for Medical Review by this edit, including:
More information regarding Additional Development Request (ADR) process is available at http://www.cgsmedicare.com/hhh/medreview/adr_process.html
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