Ask-the-Contractor (ACT) Questions and Answers
June 24, 2015, "CR 9119: Requirements for Physician Certification/Recertification of Patient Eligibility for HH Ask-the-Contractor Teleconference (ACT)"
To access the handouts from this event, click here
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- A referral received on Friday requested home health services with physical therapy to begin on Monday. The patient had a total knee replacement on Friday. The surgeon conducted the face-to-face, but declined to sign orders or follow the patient after hospital discharge. The primary care physician (PCP) had seen the patient 10 days prior for the pre authorization physical. The PCP was contacted on Friday but was out of the office until Monday. How can services begin on Monday?
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The surgeon completed the face-to-face encounter, and can write orders to see the patient and conduct the physical therapy evaluation. This would allow the agency to go see and admit the patient. A plan of care can be created to include the orders for physical therapy. The plan of care would then be sent to the primary care physician for review and signature.
Reviewed: 09.28.16
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- If the physician is signing a multiple page Center for Medicare and Medicaid Services (CMS) form 485, does the physician have to sign every page to be considered as reviewed and approved by the physician?
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With a multiple page document, each page should be identified as being part of the entire document. For example; page 1 of 4, page 2 of 4, page 3 of 4 and page 4 of 4. The physician is aware he/she is signing the entire document and only needs to affix their signature to one page of the document.
Reviewed: 09.28.16
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- Can you give an example of home health documents not conflicting with documents in the physician's medical record?
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For example, the physician's encounter document notes the patient was able to ambulate without difficulty. The home health agency summary notes balance issues and painful ambulation.
Reviewed: 09.28.16
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- If a document is issued from CMS on April 22, 2015; effective January 1, 2015, with implementation on May 11, 2015, does that mean it won't be enforced until May 11. 2015?
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The recertification requirement is not currently part of CGS Medical Review (MR) strategy but will be later on this summer. However, agencies are recommended to abide by these requirements beginning with dates of service after 05/11/2015.
Reviewed: 09.28.16
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- The physician certification must be signed prior to billing. Does that mean that final claim or before the RAP also?
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The physician certification must be signed before the final claim is submitted. The RAP can be billed before the certification is signed.
Reviewed: 09.28.16
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- Do you have any recommendations for how to get the estimate documented? Is that going to be a narrative the physician is writing in themselves?
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CMS does not require any specific form or format for the physician recertification estimate. Estimates could be included in a verbal order or as a statement on the certification/plan of care. Unless specifically prohibited by CMS, CGS will allow the provider to include the estimate on the certification for the physician to sign.
Reviewed: 09.28.16
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- Is CMS form 485 required for the physician certification?
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The 485 is not a required form, but is used frequently by home health agencies.
Reviewed: 09.28.16
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- What should the physician certification include?
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The physician certification should state the patient is confined to their home, needs skilled services, a plan of care is established and periodically reviewed and that the patient is under the care of a physician.
Reviewed: 09.28.16
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- When does the hospitalist need to identify the community physician who will be following the patient?
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If the hospitalist certifies the patient for home health but will not follow the patient after discharge, he/she must identify the community physician who will follow the patient.
Reviewed: 09.28.16
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- The hospitalist completed the face-to-face, but will not be the certifying physician. Does the certifying physician also have to cosign the hospitalist's face-to-face encounter?
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The certifying physician does not need to cosign the face-to-face document. The certifying physician just needs to have the date the face-to-face encounter was completed.
Reviewed: 09.28.16
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- How do you recommend we get the estimate from the physician? Since we can't use the frequency from the 485, can we put a statement on there from the physician, and does that count or does it have to be a verbal order?
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CMS does not require any specific form or format for the physician recertification estimate. Estimates could be included in a verbal order or as a statement on the certification/plan of care. Unless specifically prohibited by CMS, CGS will allow the provider to include the estimate on the certification for the physician to sign.
Reviewed: 09.28.16
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- What is meant by the physician dated signature on documentation from the HHA must be on or before the dated signature on the physician certification?
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When the physician determines a patient is eligible for home health services, he/she must review all information available to them to make a good decision. Any documentation provided to them to enable them in that decision must be available on or before the date of the signed physician certification.
Reviewed: 09.28.16
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- How can the physician certification be signed before the start of care?
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The physician certification isn't signed before the start of care. The start of care begins when a skilled nurse or therapist assesses the patient in his/her home and the start of care OASIS is completed. Start of care is also the first billable visit or first visit skilled care is performed. The plan of care is completed using the information from the start of care OASIS.
Reviewed: 09.28.16
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- The face-to-face encounter was completed by a nurse practitioner and cosigned by the physician. Can a different physician sign the physician certification on CMS form 485?
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Yes, the face-to-face and the physician certification can be completed and signed by different physicians.
Reviewed: 09.28.16
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- If we get a face-to-face for the initial episode, then do we need to get another face-to-face for every recertification, or just the clarification from the physician for additional visits for the next certification period?
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There only needs to be a face-to-face encounter if there's a need for a start of care (SOC) Oasis.
Reviewed: 09.28.16
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- With implementation of May 11, 2015 for the physician estimate of length of service, if we have not billed yet, is it permissible to go back and request that from the physician even thought it would have a current date for that episode?
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The physician could attest what he would have estimated the amount of time for services back at the time of the physician recertification.
Reviewed: 09.28.16
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- If the medical records from the clinic of the hospital are incomplete, can we ask the physician for an addendum?
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If the face-to-face encounter documentation is complete, if is acceptable to include an addendum for additional information.
Reviewed: 09.28.16
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- Can I use the face-to-face forms we have been using?
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There are no specific forms required for face-to-face documentation. The encounter note from the physician is required. Your face-to-face form that you used to use is optional.
Reviewed: 09.28.16
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- If the patient visits the doctor within 90 days prior to the start of care and the reason for the visit relates to the home health services provided, do we need to get another face-to-face encounter completed?
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No, as long as the visit is timely and is focused on the reason for home health services, another face-to-face visit is not required.
Reviewed: 09.28.16
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- What if the face-to-face encounter did not discuss the patient's homebound status?
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You are able to submit additional documentation such as the start of care OASIS, to supplement medical records, including the homebound status of the patient.
Reviewed: 09.28.16
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- If a physician from another town gets us the face-to-face records, does the local physician need to cosign that record to count as the face-to-face if he's the certifying physician?
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According to the Medicare Benefit Policy Manual, Pub. 100-02, Ch 7
, §30.5.1.1, the face-to-face encounter must be performed by the certifying physician himself or herself, a physician that cared for the patient in the acute or post-acute care facility or an allowed non-physician practitioner (NPP). Therefore, the physician from another town would not be able to complete the face-to-face encounter used as part of the certification for the Medicare home health benefit.Reviewed: 09.28.16
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- A progress note is prepared by the home health agency for the physician to sign along with his/her estimate of time the patient will qualify for home health services. If the recertification period is for 60 days and the physician estimates four more weeks of service, does that mean the orders for 60 days are disregarded?
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No, the physician estimate is not a concrete period of time. You do not need to get orders for the remaining four weeks to match the estimate unless the patient is actually still qualified for home care at the end of the four week orders.
Reviewed: 09.28.16
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- If we do not have the physician estimate returned to us when we receive the signed 485, can we bill for that certification or do we have to wait until we have the physician estimate of time the patient will qualify for home health services?
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The physician estimate of time the patient will qualify for home health services is now a requirement for payment.
Reviewed: 09.28.16
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- Does the certifying physician have to state that he/she certifies the patient had a face-to-face encounter?
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No, the certifying physician is not required to do that.
Reviewed: 09.28.16
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- Can the provider manually label the face-to-face encounter document if the physician fails to do so?
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Yes, the provider can label the document as the face-to-face document.
Reviewed: 09.28.16
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- The physician must sign any documentation received from the home health agency on or before the date of the physician certification. If the face-to-face encounter does not happen until the 28th day after the start of care, how does that work?
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The face-to-face encounter can occur up to 30 days after the start of care. The situation described is within that time period. The face-to-face must happen before the physician certifies the patient as eligible for home health services. The physician will use the information from the face-to-face to assist in that decision for certification. The CMS form 485 (not required) usually used for the physician certification is required to be signed before billing, but after the face-to-face encounter has occurred.
Reviewed: 09.28.16
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- If the hospitalist certified they completed the face-to-face and the home health agency provides supplemental documentation to support the patient's homebound status, is another clinical note from the hospital and the same hospitalist needed on the same date of the face-to-face to match?
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The certifying physician is the one to document the face-to-face occurred on the specific date. The visit note for the face-to-face encounter needs to be submitted. Any other documentation to support the homebound status and the need for skilled care is encouraged.
Reviewed: 09.28.16
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- We have a problem where the physician performs the face-to-face, but a discharge summary or other documentation with more information isn't provided. They may have a document stating what occurred and that it was performed, but there may not be a bedside clinical note with it?
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CGS is required to see the face-to-face document showing individual clinical findings found in the face-to-face encounter.
Reviewed: 09.28.16
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- Coding conventions may not follow exactly the primary reason for seeing the patient. Does the primary diagnosis have to match the face-to-face encounter, or can it be in the top 2 or 3 reasons?
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CGS does not require the primary diagnosis to match the face-to-face encounter focus, but the main reason the HHA is seeing the patient. For example, if the face-to-face was dealing with therapy but diabetes was the primary diagnosis, the claim would be re-coded accordingly and if therapy services were not included on the plan of care, the claim could be subject to denial.
Reviewed: 09.28.16
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- One of our nursing homes provides information on a standardized form that includes clinical findings, diagnosis, homebound states, date of face-to-face and everything that's required. But, they are reluctant to give us the actual face-to-face note that matches the date of the encounter. Whose responsibility is it to provide that documentation?
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Unfortunately, that would be the home health agency's responsibility. Since the provider is the one billing the claim, it falls upon the provider to get that information. Center for Medicare and Medicare Services (CMS) requires the medical record must contain the actual clinical note or face-to-face encounter visit that demonstrates the encounter occurred within the required time frame, was related to the primary reason the patient required home health services and was performed by an allowed provider type.
Reviewed: 09.28.16
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- If the provider receives outstanding documentation and a copy of the encounter note, but the encounter note is nothing more than three sentences, does that meet requirements?
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If both the documentation and the copy of the encounter note meets all the requirements. CGS is able to look at anything within the patient's medical record from the acute or post acute care facility, as well as any documentation submitted from the agency, as long as the certifying physician adds is into their medical record that corroborates the overall findings.
Reviewed: 09.28.16
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- Is the physician estimate of time the patient will qualify for home health services required at the time of recertification or also required at the start of care?
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The physician estimate is required only at recertification, not at the start of care.
Reviewed: 09.28.16
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- Change Request (CR) 9119 is effective May 11, 2015. Would it be reasonable that Medicare would not deny claims because of the late rollout? Is there a way Medicare could potentially document a later effective date for requiring that documentation?
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CGS has no control over other contractor's review strategy. The recertification requirement is not currently part of the CGS medical review strategy, but will be later this summer. CGS encourages all providers to include the recertification estimate for any claims with dates of service on or after the implementation of CR 9119.
Reviewed: 09.28.16
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