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Face to Face Documentation Guidance

I have received several denials on face to face documents because the signature was not dated.  Would somebody please tell Palmetto GBA to lighten up a minute and read the regulations?   I would do it myself but I am busy trying to get y’all paid.

The Benefit Integrity Manual Section reads as follows:

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered.

If you read carefully the actual face-to-face guidance, it is, in fact, silent on the whether the signature must be dated.  Here is what I cut and pasted from the Benefit manual. 

The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.

The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.

It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.

It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

Not only is the regulation silent about dating the signature on the face-to-face document, it references the signed and dated certification which for most agencies is the 485.  I am unable to infer that the regulations imply that the signature on the face-to-face document must be dated because it is illogical for the guidance to reference one mandated date and not the other. 

Does anyone disagree with me?  If the face-to-face document is sent after the 485, it would be difficult to prove that it was received prior to billing if it was not dated.  That is not my problem.  My problem lies in trying to figure out why Palmetto is playing so dirty with providers and working around their attitude to get my clients paid.

Let’s move on, shall we?  If they can play dirty, so can I.  Louisiana is home to swamps and New Orleans.  I know dirty.

The following are some examples of what Palmetto GBA considers to be inadequate documentation.

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
  • ‘Gait abnormality’ without specific clinical findings
  • ‘Weakness’ without specific clinical findings

In the first three bullets, note the word, ‘alone’.  I wholeheartedly concur with them.  But, what if the diagnosis is accompanied by the procedure and the injury.  Suddenly, they are not alone.

The Medicare Benefit Manual defines homebound status for us as such:

An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.

I am fairly certain many of you have read that before.  If the definition suits Medicare, why is Palmetto above accepting it.  I understand that I can cut and paste those words anywhere.  If I saw a face-to-face with a single diagnosis of hypertension and the Medicare language for homebound, I would think twice about the validity of the document but that’s not what is happening.

I just finished with an appeal for a patient who was admitted post discharge from the hospital for pneumonia, sepsis, COPD and CHF.  The physician wrote that it was a taxing effort for this 85 year old to leave the home.  Well, I guess so.  Evidently, Palmetto GBA needs more information to arrive at the same conclusion.

Would a reviewer who could not understand why a patient with Sepsis, pneumonia, COPD and CHF would be short of breath, could they possibly distinguish between the eight different types of gait abnormalities related to neurologic conditions alone.   See 5th bullet.  (hemiplegic, spastic diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar) and sensory.)

Weakness – last bullet – is a good reason to stay home.  I don’t see the issue here.  Obviously, there should be something wrong with the patient that causes weakness but what specific clinical findings go with weakness?  “Patient was unable to complete ten reps with 20 pound bar?”

If I wrote a face to face, I would put something like:

Ms. Jane Deaux was seen by me on September 16, 2013 on the last day of her hospitalization for sepsis, pneumonia, COPD and CHF.  She spent 9 days in the ICU in a condition that is generally considered to be incompatible with life.   Without any regard to the rising cost of health care, the old woman refused to die.

She continues to complain about being short of breath and tired and refuses to accept that this is part of the aging process.    She has also called the office complaining of falls.  Reluctantly, I ordered physical therapy even though it is an expensive treatment modality for someone who might very well end up dying in less than a year.

She is confined to the home because she cannot breath very well when ambulating and getting to her car requires her to walk a short distance.  This ‘shortness of breath’ is caused by the inability oxygen to cross the alveolar membranes in the lung tissue resulting in a very low partial pressure of oxygen in her arterial blood.  The low PO2 manifests itself in a bluish cyanotic pallor which causes the patient to be self conscious as it draws unwanted attention from strangers.  Because carbon dioxide is not blown off in normal respiratory effort, her pH decreases causing her to become acidotic which leads to extreme electrolyte imbalances resulting in cardiac dysrhythmias expressed outwardly by symptoms of lightheadedness, falling, loss of consciousness, broken bones on impact and death.  As such I certify that it requires a considerable and taxing effort for this patient to leave the home.

I dare you.  I double dare you.  Find a doc and let him use this as a template.  Have the physician edit to fit the patient and see if it gets paid.  Just sayin…

10 Comments Post a comment

  1. We have been at my office going into the in depth on home bound status , descriptive dxs, and all around triplicate documentation !!! You are sooo right !!! I guess anyone can question a physician integrity , documentation , or schooling !!!! They generate their paychecks on our dime

    September 17, 2013

    • I concur with one exception. They are generating pay checks with funds that should be paying for healthcare for our seniors.

      September 17, 2013
      • Sheila #

        And now they are going to require them for all SOC’s even if there has not been a 60 day gap between episodes.

        September 17, 2013

        • Where did you read that? I do not like that.

          September 17, 2013
  2. Marilyn J Magee #

    Julianne, I have followed your posts on the Face to Face situation with interest. I certainly hope that you plan to share the results of your study with NAHC. It is my understanding that they are gathering date to take to Congress.

    September 17, 2013
  3. Maureen Burke, RN #

    Agree with it all. With all the denial money going back to Medicare I would have expected a refund on my taxes that pay for Medicare! How is it that submitting a perfect F2F is on the backs of Home Care. Physicians ought to have to include a F2F when billing for Care Plan oversight!

    September 17, 2013

    • Maureen,

      I sent to Bill Dombi the results of my quiz and I have emailed him a number of times. He has not responded but I’m certain that he has ample information all on his own. I would suspect that NAHC is overwhelmed by providers who are seeking relief from this abuse of a regulation designed to prevent fraud. The agencies are definitely hurting but more importantly, our industry at large cannot afford the false image that the high denial rates reported by Palmetto GBA portray. I am hopeful that NAHC’s political connections are able to effect some sort of resolution to ‘The Face-to-Face Crisis of 2013’.

      September 17, 2013

    • Maureen, if you think about it, this is a politically savvy way to reduce benefits without reducing benefits. How can the AARP and all the other organizations that might take objections to the ACA complain since they are still entitled to the same services. The patients would probably care if the knew you weren’t getting paid but the burden is not on them.

      In fact, not only does this relieve Medicare and the patients of the burden, it supports the ACA because now someone is going to say how very needed the anti fraud efforts are in light of the huge percentage of fraudulent claims submitted by home health agencies. In other words, it’s our fault. Yes, indeed. We are criminals in scrubs. We should have changed attire when prisoners started wearing scrubs.

      September 17, 2013
  4. Cheryl Pelaccio #

    Has anyone had a F2F form pass Palmetto GBA audits or are they only excepting dictations from physicians. We have submitted 5 forms created by hospitals and physicians and they have denied all of them.

    September 19, 2013

    • I usually only see the ones that are denied. That’s a good question. I have seen forms created by hospitals that are excellent but are not labeled ‘face-to-face encounter’. Anyone have an answer for Cheryl?

      October 3, 2013

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