Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon. (Be sure to click on the link and watch the video on Bayou Home Care’s page. You will understand why I am proud to be known a swamp rat).
Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement. The proposed changes are as follows:
- Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit. Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
- Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
- Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.
The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status. I’m not too worried but be very aware of this in the future should these changes come into law.
If you are interested in what your physicians bill for home health certification, check out Propublica’s Treatment Tracker and find your docs. Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.
All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.
Word of Caution
I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare. Luckily, I forgot to post this last night and have had time to reconsider my emotional response.
The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes. Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.
In other words, these changes offer no avenue of relief for denials that have occurred in the past. It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.
The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal. If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.
I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct. That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct. In this case appearance does count.
So, welcome the changes. Rest comfortably knowing that there is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police. This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.
Under no circumstances, should you become complacent. The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.
Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.
I’d still sign the petition
• The link to the petition is: https://petitions.whitehouse.gov/petition/remove-barriers-home-health-care-access/JXpCwgG6
1) The F2F egregious narrative provisions and other problems were written into the ACA (Obamacare). How can CMS just propose to change by regulation what was pretty clear in the law? Not that I would mind, but I’m not sure it can be done that way.
2) I am very concerned about them relying on the Physician documentation for eligibility. E.g., I’ve seen some documentation that never mentioned the patient was dependent on a walker and another person to ambulate. They don’t do a very good job with recording the things that would justify home health (and I would bet would also get themselves more money).
Regarding number 1; the law simply states that a physician must see the patient within a reasonable time frame and I believe they gave six months as an example or outside range and then tasked CMS or DHS with writing regulations to meet the law. That’s why it can be changed.
Regarding number 2; your concerns are shared by many. I think that they will somehow have to be refined before anything is written in stone. For what it is worth, I didn’t read it that the physician records or acute care records would be the only source but that no other physician records could be drawn upon to support necessity. AFter seeing many of comments like yours, I think I may have misread it but there certainly is enough ambiguity to interpret it anyway we want.
Beware. It’s not complete relief from F2F narrative. Still required in detail for M&E (mgt & eval) skilled services. Plus the issue of MACs using only Doc or hospital discharge records is troublesome for claim teview. What discharge record really includes discussion of homebound status or wht services are medically necessary. A whole new wrinkle! And do agencies normally get these records – well you will need to now! And how easy will that be?
In short – land mines are being planted!
My concern along with the lack of documentation in the hospital record is how is CMS going to accesst the medical record? Do we as the agency now have to provide that when we appeal a denial? We often have issues getting referral information from some of our referrals, let alone visit notes or a complete medical record.
Kelly, as hard as it is, my suggestion would be for you to refuse referrals from docs who don’t give up information. Your ICD-9 coding needs support from the MD. If you aren’t getting it, any claim that is increased by a diagnosis code will be down coded.
I would ask, upon referral, for the most recent clinic visit, lab and med list. If there are meds or conditions that require monitoring with lab, establish who will draw the lab and how results will be shared. It is amazing what physician EHR will spit out.
The alternative is to blindly attempt to take care of a patient.
Think about what you actually DO for patients. With the exception of complicated wound care, most ‘tasks’ involved in nursing can be automated. I am certain the Walgreen’s blood pressure machine hears that lowest diastolic better than me. The average heroin addict can get a line much better.
You are in the house the critically think about your patient. That includes anticipating any serious complications such as say, a massive bleed into the brain for patients on Coumadin or a broken hip for an anemic patient who falls due to weakness.
Your choice. Refuse to work with other professionals who do not give up the goods or put your patients, yourself and your agency at risk. You will make less money if you follow my advice but you will be able to keep it. Lawyers are expensive and you will quickly blow through what little money you were able to keep. Public defenders will not do for malpractice or fraud cases. If this decision is made by someone else in your agency and you are without the power to change it, might I suggest a full out job search?
I don’t mean to be so harsh. Many times when we read clinical records we are bemystified by what we find in them because there is no suitable history of the patient. Everything is out of context. Other times the MD sends over volumes of good information but nursing documentation makes it abundantly clear the nurse never read it. Patients don’t wake up and decide to join a home health. It’s not like the gym. Something happened to them. You cannot take care of your patient to the best of your ability unless you know the details.
Oh, your original question… It could be that the physician will receive the ADR. In that case, every admit, revert assessment and anything you have in your chart should go to the doc prior to obtaining signatures. This part of the proposed changes really needs a lot of clarification.
Thanks for keeping us in your list for updates and it really helped me a lot. I have gone to CMS website and read everything to understand. Also I have gone through your replies to questions. They are very valuable to me.
As you know I am suffering with the second denial code of 55HTB or 55HTW after first denial code of 56900 ( of course they now identified that there was some problem on their end caused my 70% denials with 56900 initially then changed to as above mentioned after multiple arguments, proofs). I am appealing stating and providing the approved copy of FTF which we have given in our plan of correction to last ADRs but still they are going to Maximus. Do you think is anyway this new decision helps me in my appeals.
I asked Michael to call you. He responded that he had talked to you and worked with you on this. Everything okay now?