Home Health Face-to-Face Persistent Concerns Ask-the-Contractor Teleconference (ACT)
View the handout for the June 25, 2018, Home Health Face-to-Face Persistent Concerns Ask-the-Contractor Teleconference (ACT).
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- We have incorporated the face-to-face statement on the 485 as directed. Can we also add the homebound reason documentation to the 485 so the MD gets one document to sign instead of sending additional paperwork (assuming this goes to the same doctor)?
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The face-to-face documentation and the 485 are two separate documents. The homebound reason documentation should be part of the face-to-face documentation. Remember the face-to-face must be completed before the 485 is signed.
Published: 08.03.18
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- In cases where a Certified Registered Nurse Practitioner (CRNP) or Physician Assistant (PA) completes the face-to-face encounter and also completes orders for home health services, is it necessary to obtain a physician co-signature on the orders?
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When a nurse practitioner or physician assistant completes orders, there must be a physician co-signature on those orders.
Further discussion: When a CRNP or PA performs the face-to-face encounter, the certifying physician or physician the CRNP or PA is working with does not have to cosign. The provider must show the CRNP or PA is working under the supervision of or in collaboration with either the certifying physician or the hospitalist. Put information in the documentation to let us know who it is. The doctor doesn't need to co-sign a face-to-face, but he/she does need to co-sign an order.
Published: 08.03.18
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- Do we need to obtain a physician co-signature on a clinical note or discharge summary (that supports the encounter was made and why home health is necessary) that was written by a CRNP or PA?
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A co-signature from a physician is not required on the clinical note or discharge summary. The provider must show the CRNP or PA is working under the supervision of or in collaboration with either the certifying physician or the hospitalist.
Published: 08.03.18
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- A face-to-face encounter is completed on a discharge summary by a CRNP or PA. A physician co-signs the discharge summary. On the attestation statement on the 485, whose name is in the attestation statement? The CRNP/PA that made the encounter or the MD?
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The name of the person who completed the face-to-face encounter is given credit for it. It is not required to put the name of the person who performed the face-to-face on the 485. Only the date of the face-to-face encounter is required. However, remember a CRNP or PA cannot sign a 485. The 485 must be signed by a physician.
Published: 08.03.18
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- If a CRNP or PA completes HHC orders for a commercial insurance patient, is it necessary to obtain an MD co-signature?
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We are not allowed to provide information for commercial insurance payers – only for Medicare payers.
Published: 08.03.18
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- When orders are received with a referral for things such as wound care and lab draws that are signed by a CRNP or PA, is a physician co-signature required?
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Orders require a physician co-signature.
Published: 08.03.18
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- On the supporting information requirement - if the actual documentation from the F2F encounter visit does not specify homebound status and has limited information on skilled need for home health services, can this information (homebound / skilled need) be included on the 485/POC that the certifying physician signs and will this be enough?
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No it will not. If the face-to-face documentation itself does not at least minimally address the homebound status and the need for skilled care, then supporting documentation will not be allowed. Supporting documentation is to support information that is already there but not complete.
Published: 08.03.18
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- On the question of the discharge note and being dictated versus signed. If they sign it electronically then it is signed and not only dictated right?
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An electronic signature is considered a signature if it meets the requirements for an electronic signature. Please use the link below for further information on signature requirements.
Complying with Medicare Signature Requirements
Published: 08.03.18
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- A physician assistant or nurse practitioner can sign the face to face without a co-signature. Is the face to face considered an order if it is not cosigned?
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The face to face is not considered an order.
Published: 08.03.18
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- If we fail to put the face-to-face encounter date on the Form 485 (Plan of Treatment) can we write a verbal order stating this, as long as it is signed before the billing is done?
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Yes you can - the key is to make sure the verbal order is signed before documentation is submitted for billing and the face-to-face encounter is completed before the 485 is signed and dated.
Published: 08.03.18
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- If a hospitalist completed the face-to-face encounter but does not specify the physician following in the community, how can we fix this?
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The face-to-face does not need to specify the community physician unless a face-to-face form is used which has verbiage indicating the face-to-face form could also be a certification. If this is the case, you can contact the hospitalist who performed the face-to-face encounter and request an addendum that includes the missing information.
Published: 08.03.18
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- Are you aware of upcoming changes to the F2F requirement?
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I am not aware of anything new coming up for the face-to-face requirement. We will make sure to get any new information out in ListServ messages. This is a good reason to sign up for ListServ emails. Here is the link to sign up if you haven't already done so.
Published: 08.03.18
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- Can the history and physical (H&P) be used as the face-to-face?
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Yes - if the H&P meets all requirements for a face-to-face.
Published: 08.03.18
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- Did I just hear that an NP or PA can sign orders, if the MD cosigns the order? We've always been told no, that orders can ONLY be given by, and signed by, the MD (or DO or podiatrist). If co-signed, CMS can interpret that as NPP orders that the MD simply 'agrees' or 'concurs' with.
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CMS Medicare regulations state the orders should be co-signed by a physician. If you may have other regulations in effect that tell you differently, you would be required to go by the most stringent of the conflicting regulations.
Published: 08.03.18
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- The primary reason just needs to be addressed in the encounter, not necessarily the main reason for the visit?
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That is correct. As long as the face-to-face documentation verifies the primary diagnosis was addressed it meets the requirement. Other concerns can also be addressed during the face-to-face visit.
Published: 08.03.18
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- "Certifying" becomes confusing for me. Is "Certifying" Physician the one who signs the 485 or the one who signs the face-to-face and do they need to be the same person?
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The certifying physician is the one who signs the 485. The reason they're called the certifying physician is because the cert is preprinted on 485 in locator box 26. It can be found in the lower right hand corner of the last page of the 485 and is preprinted. The certifying physician is not required to be the person who performs the face-to-face.
Published: 08.03.18
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- Please clarify what you said in slide #14. Does the encounter note have to have the term "Homebound" used in the note before supporting documentation can be used or can documentation such as gait instability, increased pain work to support homebound status without having the actual term "homebound" being used.
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The encounter note does not have to use the word "homebound".
Published: 08.03.18
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- Our software utilizes a face-to-face form that is auto generated to include: encounter date, primary reason, reason for skilled services and homebound status. If our encounter note is missing one or two of the required elements, can we cross off the areas that we already have supported in the encounter note and just ask the physician to complete the missing items, such as HB status and reason for skilled service.
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Yes, you can ask for information that was not included in the original face-to-face documentation. Just make sure you are not crossing off something on a document that has already been completed and signed – that would be considered altering a document.
Published: 08.03.18
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- We have great discharge summaries come to us, however will list an encounter date, that is included in the date range that they were hospitalized, but there is not actual dated note for that date. Is it assumed that the physician sees the patient every day that they are hospitalized or does there need to be an actual encounter with that documented date?
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The face-to-face encounter has to have an actual encounter that occurred with an allowed provider type. There should be a date for that encounter.
Published: 08.03.18
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- The 485 and the face-to-face encounter are 2 different forms, but they both seem to be described as the "certification". Is the face-to-face documentation the certification or is the signed POC (485) the certification?
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The 485 is the certification. The certification information is preprinted on the 485 form in locator box 26.
Published: 08.03.18
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- Our software generates a blank F2F form, with blanks for all required areas, but we don't always need all of those blanks completed because they are addressed in the encounter note. Our office cannot remove those areas that aren't needed so we are just crossing through them and indicating "found on encounter note" so the doctor knows he does not have to re-write the information we already have.
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That is acceptable.
Published: 08.03.18
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- Our 485 states the certifying physician indicates… I attest that the Face to Face encounter has been (or will occur) within timeframe requirements and it is related to primary reason the patient requires home health. Is this a sufficient statement to allow the physician to sign the 485 before the Face to Face visit happens?
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That is not sufficient. The exact date of the face-to-face encounter must be stated.
Published: 08.03.18
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- Would it be allowable for the physician to sign just the applicable page of the Oasis and not the entire form.
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As long as the multi page document is numbered page 1 of 3, page 2 of 3 etc., then it's fine to just sign on one page. If that numbering isn't there then each page must be signed and dated. It must be apparent all the pages belong to one document for the physician to just sign one page.
Published: 08.03.18
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- If the certifying physician is the physician performing the face-to-face encounter and signing the 485, does the date of the face-to-face have to also be on the 485? And does it have to be before the signing date of 485 they are doing both?
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If the certifying physician is the one performing the face-to-face the date of the encounter does not have to be added to the 485. The face-to-face encounter must have occurred before the 485 is signed.
Published: 08.03.18
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- Can you clarify then if the Certifying physician signing the 485 performs the F2F encounter, then the date does not need to be on the 485, as the signature on the encounter documentation alone is proof alone the encounter occurred on that date?
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If the certifying physician is the one performing the face-to-face the date of the encounter does not have to be added to the 485. The face-to-face encounter must have occurred before the 485 is signed.
Published: 08.03.18
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- If using the hospital discharge summary, and there are notes from hospital physical therapist that speak to the homebound status, does the homebound status have to be in the note, or is the PT facility note sufficient?
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A physical therapist cannot perform a face-to-face encounter. The homebound status must be mentioned in the face-to-face documentation by the person who performed the face-to-face encounter. The physical therapist notes could be used as supporting documentation if the face-to-face documentation mentions homebound status but is not complete.
Published: 08.03.18
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- If the face-to-face encounter date submitted by the ordering physician does not come with an encounter, but the patient has a beautiful compliant discharge summary, can we use that discharge summary as the face-to-face encounter documentation, is there anything we need to do to be able to use that note?
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The discharge summary can be used as the face-to-face encounter documentation if it meets all criteria.
Published: 08.03.18
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- If the physician signing the 485 will not be the physician that was printed on the 485, do we need to reprint the 485, or can we manually change the MD name/address?
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You should reprint the 485 so the name listed in locator box 24 matches the signature in locator box 27.
Published: 08.03.18
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- If we receive a face-to-face that is missing a component, perhaps the doctor forgot to order a discipline, could the doctor or RN care manager enter an addendum and then have the doctor sign and date?
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Only the author of a document can make amendments of changes to the document. It would be allowable to ask the doctor for an addendum, but it cannot be created by another person. In addition, the face-to-face encounter does not need to order disciplines.
Published: 08.03.18
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- If we have a face-to-face performed by a hospitalist, but the order for home health care was completed by primary care physician at a later date, is that ok?
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That is allowable if the face-to-face meets all requirements and the face-to-face information is still correct.
Published: 08.03.18
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- I create a Face to Face Summary report that pulls in specific OASIS items to supplement the homebound status. I was told this was OK. Is this true? The pages are numbered by our system.
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Be clear in your summary report where you received the information. For example, in this instance state the date of the OASIS and the specific location of the information. This would be considered supporting documentation for the face-to-face.
Published: 08.03.18
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- If the hospitalist is the certifying physician and signing the initial 485 as well as the physician performing the F2F, do we still need to add the info about the community physician on the 485?
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The hospitalist should not sign the 485 unless they plan on being the community physician following the patient after they leave the hospital.
Published: 08.03.18
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- If documentation of the homebound status is not addressed in the FTF visit note, but is documented on the FTF form, will this suffice for documentation of homebound status by the physician?
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Yes it does. We are going to look at all documentation submitted for to make sure somewhere in that documentation requirements are met.
Published: 08.03.18
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- If my software documents the home bound & face-to-face information onto the plan of care, why does the OASIS have to be signed?
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The OASIS only needs to be signed by the certifying physician if it is being used as supporting documentation for the face-to-face.
Published: 08.03.18
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- Sometimes a physician will sign the plan of care with the start date of the plan of care even though they are not receiving it until a later date. The physician is back dating the plan of care even though he has been told to date it the date received. When this happens we are re-sending it and trying to clarify with him to sign it upon receipt. Sometimes this affects the face-to-face encounter date. Is this the correct action to take?
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A document cannot be backdated. Any signature should be dated as the date it was signed. You should never accept a backdated document.
Published: 08.03.18
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- If the plan of care (485) form contains a section "home bound narrative" that is completed by the home health agency clinician and the certifying physician signs the 485, would it meet a requirement for a physician to certify the patient's homebound status?
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Keep in mind that reviewers look at all documentation, but the face-to-face encounter and the 485 are two separate documents. The face-to-face has to occur before 485 is signed. The homebound status must be discussed during the face-to-face encounter.
Published: 08.03.18
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- Sometimes it is difficult to secure a second face to face on coverage change patients. Are face to face encounters always needed for coverage change patients?
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If Medicare is a payer, there must be a face-to-face encounter.
Published: 08.03.18
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- Regarding having the F2F 30 days after, Are you saying the Plan of Care would not be signed until after, for example the F2F visit was completed on day #29 (if no other state requirements apply)?
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Yes that is correct. The cert or 485 should not be signed until after the face-to-face encounter. That doesn't mean the date the face-to-face was signed, but the actual date of the F2F encounter itself.
Published: 08.03.18
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- If my software company pulls over the homebound narrative, face-to-face addendum from the OASIS is that sufficient or do you still need an actual copy of the OASIS?
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Yes, we need a copy of the OASIS in the documentation submitted.
Published: 08.03.18
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- Since the Medicare Advantage Plan(s) need to follow Medicare requirements, if the payer changes from the Medicare Advantage plan to traditional Medicare, can/is the original F2F acceptable?
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If the face-to-face from the Medicare Advantage Plan meets all the requirements including timeliness, it would be acceptable.
Published: 08.03.18
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- Does the word "homebound" have to be in the F2F documentation or does clinical information that makes it clear that the patient is confined to home count?
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The word "homebound" is not required if it's very clear the information provided supports the homebound status. Such as "the patient is unable to walk due to pain after knee replacement".
Published: 08.03.18
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- To clarify an earlier answer, in acute facility discharges, does the hospitalist have to state the name of the certifying (community) physician in the notes for the face-to-face encounter?
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Only if a face-to-face form is used that is also a certification.
Published: 08.03.18
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- A physician assistant or nurse practitioner cannot be on the 485?
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Only a physician can sign the 485 because it is also the certification and orders.
Published: 08.03.18
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- If a physician other than the certifying physician performs the face-to-face encounter and we add the face-to-face statement on the 485, do we need to provide the certifying physician with a copy of the face-to-face documentation?
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The regulations do not require this but I would encourage you to provide the face-to-face encounter documentation to the certifying physician. The certification for home health care should be based on the clinical findings from the face-to-face encounter
Published: 08.03.18
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- Does the certifying physician have to sign the encounter visit if done by a hospitalist?
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No, that is not required.
Published: 08.03.18
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- We get a lot of referrals from wound care doctors, who will not sign the plan of care. They perform the face-to-face, but then request the primary care physician sign the plan of care. But often times the patient has not seen the primary care physician within required time frames. Can we use the specialist face-to-face even if he won't sign the POC?
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The primary care physician does not have to perform the face-to-face. The face-to-face may be performed by wound care doctor if the wound care doctor took care of the patient in an acute or post acute care facility. Please refer to this link for more information in Section 30.5.1.1. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf
Published: 08.03.18
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- Can a clinical nurse specialist perform the face to face?
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Yes a clinical nurse specialist may perform the face-to-face encounter.
Published: 08.03.18
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- What has to be minimally addressed on the actual face to face form versus supporting documentation?
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A form is not required for a face-to-face encounter. The face-to-face documentation should show the need for skilled services, homebound status, timeliness of the face-to-face encounter, discussion of the primary reason the patient requires home health services and that the encounter was performed by an allowed provider type.
Published: 08.03.18
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- Is it a requirement to have the face to face encounter date on the 485 if the same physician signing the cert also performed the face to face encounter?
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No – not if the certifying physician performed the face-to-face encounter.
Published: 08.03.18
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- What is our recourse if the patient does not have a face-to-face encounter within 30 days after the start of care?
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Category 2 – Comprehensive Assessment
Published: 08.03.18
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- If the face-to-face encounter happens after the 485 is sent out (with out a F2F date), will an attestation statement signed by the certifying MD meet the requirement?
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The face-to-face encounter must happen before the 485 is signed. If the signature is timely on the 485, you can have additional documentation to show the certifying physician documents the date of the face-to-face encounter.
Published: 08.03.18
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- What if you have a 485 that is returned with a physician assistant or nurse practitioner signature is a co-signature acceptable from the physician certifying in collaboration?
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No, that would not be acceptable. You would need to send a new 485 back for only the certifying physician signature.
Published: 08.03.18
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- How can we avoid a doctor who doesn't see the patient on discharge but wrote the discharge summary - and then we don't know for sure the correct date of face-to-face?
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If you don't feel confident the face-to-face is actually what you need to get paid, I would encourage you to get a new face-to-face.
Published: 08.03.18
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- Do printed face-to-face documentation hospital referrals have to have a signature of provider or does the progress note cover this?
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The face-to-face encounter note must be signed and dated by the person who performed the face-to-face.
Published: 08.03.18
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- A physician assistant can perform the face-to-face, correct?
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Yes they can – remember we need to know who the physician is they're working with.
Published: 08.03.18
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- Please clarify the date of the face-to-face on the 485. If a hospitalist conducts the face-to-face but the primary care physician will be signing the 485, what has to appear on the 485?
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The certifying physician must acknowledge the date of the face-to-face encounter. You can put the information on the 485 as simply as stating "The face-to-face encounter occurred on June 25, 2018". You can add the name of who performed the encounter if you want, but all we require is the date of the face-to-face encounter
Published: 08.03.18
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- Does the visit note for the F2F encounter need to include the words 'face to face encounter'?
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I highly encourage the face-to-face documentation to have a title stating it is face-to-face. Our medical reviewers need to know for sure what the face-to-face documentation is. It's fine to handwrite a title on the documentation. This is simply putting a title on the document and is not considered altering the document.
Published: 08.03.18
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- If hospitalist does not know who will be certifying/following physician for home health, does the F2F visit date on the 485 cover the hand off from the hospitalist to the certifying physician?
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The hospitalist does not need to state who the primary care physician will be unless a form is used that is also a certification. If a form is used that is also a certification, then it is required for the hospitalist to state who the primary care physician will be to show continuity of care. A face-to-face form is not required.
Published: 08.03.18
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- We have received 485's signed by doctors who are taking call for the doctor that is listed on the 485. Typically they will write "Dr. Smith on call for Dr. Johns". Is this acceptable? Or do we need to get the certifying physician to sign the 485 as well?
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The signature of the physician on the 485 must match the name of the physician in locator box 24.
Published: 08.03.18
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- Some physicians refuse to provide agency with clinical note from their FTF encounter, is there any way to encourage that?
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Perhaps letting them know you will not get paid for your services without it will make them give you the documentation you require. Unfortunately, if they still refuse you will have to have another face-to-face encounter performed.
Published: 08.03.18
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- If a F2F encounter is being completed by a resident and the attending physician is present with attestation included with their agreement with the content, is that permissible?
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The face-to-face must be performed by a physician who cared for the patient in an acute or post acute facility. This physician must also be registered in PECOS, which the resident probably is not registered.
Published: 08.03.18
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- The physician face-to-face encounter note mentions patient ambulates with cane and has unsteady gait. Is this acceptable for homebound status?
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This documentation indicates the patient ambulates unsteadily, but does not indicate they are homebound.
Published: 08.03.18
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- The doctor's office sends us an electronically produced face-to-face with the "I certify" statement and hands off to the certifying physician.
It does not state electronically signed but instead states Ordering User and authorizing provider: with the doctor's name listed next to it.
We are told by the doctor's office that is their electronic signature.
Is this acceptable for an electronic signature?
If the physician office shows us in writing that this is a password protected document and can only be signed by the person who is listed, is that acceptable?-
On electronic signatures, on some software programs, it's very clear that it's an electronic signature. It will show a graphic of a hand with a pen or it may say "electronically signed by". If either of those are not present we need to see the policy from the software program for the electronic signature to show the electronic signature is password protected and can be used only with that specific individual's password.
Published: 08.03.18
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- What if the primary diagnosis for the home health referral has been resolved by the time they are admitted? For example pneumonia is resolved by the time HH admits patient?
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If there is still a reason other than pneumonia for home health care, you will need to have a face-to-face encounter that addresses the main reason they are coming to you for your home health services.
Published: 08.03.18
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- Does the primary diagnosis on the 485 need to be the surgical code or the aftercare code? We had a CABG referral, what would an appropriate primary diagnosis be?
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Unfortunately, we are not allowed to give advice on coding or choosing of a diagnosis.
Published: 08.03.18
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- We were denied due to the face-to-face reason was not the same as the primary diagnosis. Patient was hospitalized for urosepsis and was on home health for exacerbation of Parkinson's. This was a result of the hospitalization for urosepsis. Our primary diagnosis could not be urosepsis because that condition was resolved at the time of the discharge from the hospital. According to home health coding guidelines, the primary diagnosis can't be something that was resolved in the hospital. Our primary diagnosis was exacerbation of Parkinson's. The urosepsis was coded lower on the list. What would you suggest in this situation? It seems very silly to have the patient make another appt.
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If the face-to-face does not discuss the main reason they come to you for HH or the primary diagnosis, it probably will be denied. Yes, you would need to get another face-to-face.
Published: 08.03.18
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- Is CMS discussing any ways to lessen this burdensome process, particularly for those patients whom were discharged from a facility.
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To my knowledge nothing is in the works. Please work with your state and national home care organizations to let your voice be heard about your concerns.
Published: 08.03.18
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- Does the ordering physician (hospitalist for example) and who completed the face-to-face have to state the name of the certifying physician in their documentation? They do not know who that is normally and write in the discharge summary for the patient to follow up with their primary care physician.
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The hospitalist only needs to give the name of the primary care physician if they are using a face-to-face form that is also a certification.
Published: 08.03.18
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- Do we need to collect a copy of the physician's encounter note at time of admission?
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Yes, if that physician's encounter note is going to be your face-to-face, then you absolutely want to make sure you get that when you admit the patient. You're going to want to know if the face-to-face has all the requirements. If not, you're going to have to get the patient to have another face-to-face completed.
Published: 08.03.18
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- If the wrong encounter date is entered on the 485 certification statement or if it's left blank, is there a way to resolve this without resending the 485 to the physician to re-sign?
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I would recommend you send a new 485 along with a note asking why you are asking for it to be resigned.
Published: 08.03.18
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- Would you deny the claim if the supervising physician of an NP is not identified on the encounter visit note?
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Yes, we are required to know what physician the nurse practitioner is working under.
Published: 08.03.18
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- If the certifying physician performs the face-to-face encounter and date in the 485 certification statement does not match the date of the encounter visit note, do we have to get that date changed to match the encounter visit note?
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If the certifying physician performs the face-to-face encounter, you do not need to also list the date on the 485.
Published: 08.03.18
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- Can documentation like operative notes serve as face-to-face?
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It depends on the operative note. Many will speak more to the actual surgery rather than what is going on with the patient after the surgery and when they re ready for home health services. If they are thorough and go into detail about after the surgery, then the operative note would probably serve as the face-to-face encounter documentation as long as it meets all other criteria.
Published: 08.03.18
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- Can functional and cognitive limitations written by the physician satisfy the homebound requirement on the face-to-face encounter? Even if the word "homebound" is not on the encounter note from the doc?
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The word "homebound" is not required on the face-to-face encounter note.
Published: 08.03.18
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- To clarify, does a physician need to co-sign ALL orders given by a physician assistant or nurse practitioner or just the face-to-face documentation?
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The physician needs to sign all orders completed by a nurse practitioner or physician assistant. The physician does not have to co-sign the face-to-face. We need to know what physician they're working with. They can either co-sign or you can give us the information.
Published: 08.03.18
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- Can the home health agency prepare an attestation statement that says the certifying is incorporating the agency's documentation into their physician's medical record suffice? Or does the certifying physician have to actually sign the agency documents, for instance the OASIS?
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Yes the physician needs to sign the actual documents
Published: 08.03.18
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- Can you clarify re: the 485, are you saying the agency can insert the date of the encounter and the then certifying physician signs the 485?
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Yes, that is correct.
Published: 08.03.18
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- If the patient comes out of facility/rehab, and that physician did not mention the community physician's name, can you fax that for co-signature and be ok?
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If there is a face-to-face form used, and that form is also a certification, the person who performed the face-to-face must indicate who the community physician will be. Sending the form to a community physician for them to add their name is not allowed.
Published: 08.03.18
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- When you get a call from the physician's office asking to go see a patient and a face to face encounter is completed and signed by the physician, when we get an ADR and a copy of the physician's visit note it lists the conditions but is billed by his staff as a regular visit. We get denied saying that the physician visit is billed differently. How can we possibly control the physician visit notes or billing? Why do we have to suffer?
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CGS believes this occurs when the primary reason for the FTF visit does not coincide with the primary reason for homecare. If this does not address your concern, please contact our Provider Contact Center for additional assistance.
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