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F2F Denials Still Going Strong


Have you ever seen something like this before on a letter denying payment for your ADR?

The face-to-face encounter verification was incomplete as it lacked a valid physician narrative of beneficiary-specific clinical conditions as seen during the encounter and how they supported the need for skilled services. Use of general phrases is insufficient to satisfy the requirement for a brief narrative statement that describes how the beneficiary’s clinical condition as seen during that encounter supports the need for skilled services. Since requirements for admission were not met, the beneficiary did not qualify for subsequent services. Therefore, denial of the episode must be affirmed as face-to-face requirements were not met. (Italics added.)

General Terms

In the unlikely event that Palmetto actually has the authority to prohibit ‘general’ terms, let’s look at the definition of ‘general’ – you know, just for fun.  Here is what the Oxford English Dictionary – the only dictionary you should ever use – says.

Definition of general in English:
adjective

1              Affecting or concerning all or most people, places, or things; widespread:
 1.1          Not specialized or limited in range of subject, application, activity, etc.
1.2          (Of a rule, principle, etc.) true for all or most cases
1.3          Normal or usual:

As critical thinkers, we need to understand the intent of the language used in a denial.  A patient who cannot leave home without assistance does not describe the patient but rather recites Medicare’s own definition of homebound status.  However, a patient who has had a knee replaced might be considered homebound because of an ‘unsteady gait’.  How many ways can you say that a patient has an unsteady gait?

The real question is why Palmetto GBA believes that it is acceptable to prohibit general terms.  In order to answer that question, I went to the list of references in the very same letter that Palmetto GBA sent with most denials regarding homebound status.  They all follow and I assure you they are boring.  If you have never received a denial for a Face-to-Face document, please disregard and talk amongst yourselves.  If you have been getting ADRs, I suggest you read until the end even if you are 80 when you finish.  There is a lesson in this post and to save you the time on a Monday, let me just tell you that it is never, ever a good idea to take references at face value.  Never.

Use the following information as you please.  Medicare appeals for Face-to-Face denials comes to mind immediately.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Intemet-Only-Manuals-IOMs.html
Face to Face Requirements: Affordable Care Act (ACA) Section 6407; CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.4, 30.5.1, J0.5.1. l; 42 CFR 424.22

The first link does not work for me but when I went to the Internet Only Manuals, the address bar contained the same information.  If the link doesn’t work for you, try cutting and pasting it into the address bar in your browser.  Or you can trust me that it leads to an index of all Internet Only Manuals from CMS.  This is a good link to have for all of the 26 online manuals including ones for End Stage Renal Disease, Program Integrity, and the CMS Business Partners Security Manual.  I suspect the link is given so that you can find the Medicare Benefits Manual.

The next reference is more specific.

SECTION 6407 OF THE AFFORDABLE CARE ACT

Requires physicians to have a face-to-face encounter with the individual prior to issuing a certification for home health services. The Secretary would be authorized to apply the face-to-face encounter requirement to other items and services based upon a finding that doing so would reduce the risk of fraud, waste, and abuse. This provision also applies to Medicaid. 

This section of the ACA clearly states that physicians must have a F2F.  It says nothing about the content or the use of general terms.  It doesn’t not even reference a time frame.

Next:

Medicare Benefits Manual; Chapter 7

Section 30.2.4:

  1. Initial Percentage Payment If a physician signed plan of care is not available at the beginning of the episode, the HHA may submit a RAP for the initial percentage payment based on physician verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician. If the RAP submission is based on physician verbal orders, the verbal order must be recorded in the plan of care, include a description of the patient’s condition and the services to be provided by the home health agency, include an attestation (relating to the physician’s orders and the date received per 42 CFR 409.43), and the plan of care is copied and immediately submitted to the physician. A billable visit must be rendered prior to the submission of a RAP.
  2. Final Percentage Payment The plan of  care  must  be  signed  and  dated  by  a  physician  as  described  who  meets  the  certification  and recertification requirements of 42 CFR 424.22 and before the claim for each episode for services is submitted for the final percentage payment. Any changes in the plan of care must be signed and dated by a physician.

I am not a lawyer but I see nothing that prohibits the use of ‘general’ terms.  Do you?

Moving right along:

30.5.1-CONTENT OF THE PHYSICIAN CERTIFICATION (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

The physician must certify that:

  1. The home health services are or were needed because the patient is or was confined to the home as defined in §20.1;
  2. The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §40.1.2.2), the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
  3. A plan of care has been established and is periodically reviewed by a physician;
  4. The services are or were furnished while the patient is or was under the care of a physician;
  5. For episodes with starts of care beginning January 1, 2011 and later, prior to initially certifying the home health patient’s eligibility, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient as described in §30.5.1.1. The encounter and documentation are a condition of payment. The initial certification is incomplete without them.

Then we get to:

30.5.1.1 – Face-to-Face Encounter (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

This section of the Benefit manual offers detailed instructions for the Face-to-Face encounter.  It reads as follows.  In our review, we do not see any reference prohibiting the use of ‘General terms’.

  1. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient.
  • Certain NPPs may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. NPPs who are allowed to perform the encounter are:
  • A nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law;
  • A certified nurse-midwife as authorized by State law;
  • A physician assistant under the supervision of the certifying physician
  • NPPs performing the encounter are subject to the same financial restrictions with the HHA as the certifying physician, as described in 42CFR 424.22(d).
  1. Encounter Documentation Requirements:
  • 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.

This is the only reference in the letter that directly addresses the content of the Face-to-Face.  It says that a brief narrative composed by the physician is required.  There are no further clarifications as to what constitutes a brief narrative.

Finally, there is 42 CFR.22 which you already know even though you may not use numbers and abbreviations to label it.  It is the longest and reads:

42 CFR 424.22 – Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.

(a) Certification—

(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify as follows:

(i) The individual needs or needed intermittent skilled nursing care, or physical or speech therapy, or (for the period from July through November 30, 1981) occupational therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum.

(ii) Home health services were required because the individual was confined to the home except when receiving outpatient services.

(iii) A plan for furnishing the services has been established and is periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)

(iv) The services were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. 1

(v) The physician responsible for performing the initial certification must document that the face-to-face patient encounter, which is related to the primary reason the patient requires home health services, has occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter, and including an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in § 409.42(a) and (c) of this chapter, respectively. The face-to-face encounter must be performed by the certifying physician himself or herself, by a nurse practitioner, a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in collaboration with the physician in accordance with State law, a certified nurse midwife (as defined in section 1861(gg)of the Act) as authorized by State law, a physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the physician, or, for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in an acute or post-acute facility and who has privileges at the facility. The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled, dated and signed by the certifying physician.

(A) If the certifying physician does not perform the face-to-face encounter himself or herself, the nonphysician practitioner or the physician who cared for the patient in an acute or post-acute facility performing the face-to-face encounter must communicate the clinical findings of that face-to-face patient encounter to such certifying physician.

(B) If a face-to-face patient encounter occurred within 90 days of the start of care but is not related to the primary reason the patient requires home health services, or the patient has not seen the certifying physician or allowed nonphysician practitioner within the 90 days prior to the start of the home health episode, the certifying physician or nonphysician practitioner must have a face to face encounter with the patient within 30 days of the start of the home health care.

(C) The face-to-face patient encounter may occur through telehealth, in compliance with Section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.

(D) The physician responsible for certifying the patient for home care must document the face-to-face encounter on the certification itself, or as an addendum to the certification (as described in paragraph (a)(1)(v) of this section), that the condition for which the patient was being treated in the face-to-face patient encounter is related to the primary reason the patient requires home health services, and why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in § 409.42(a) and (c) respectively. The documentation must be clearly titled, dated and signed by the certifying physician.

(2) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.

(b) Recertification—

(1) Timing and signature of recertification. Recertification is required at least every 60 days, preferably at the time the plan is reviewed, and must be signed and dated by the physician who reviews the plan of care. The recertification is required at least every 60 days when there is a—

(i) Beneficiary elected transfer; or

(ii) Discharge and return to the same HHA during the 60-day episode.

(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum.

(c) [Reserved]

(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in § 411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.

(1) If a physician has a financial relationship as defined in § 411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in § 411.355 through § 411.357 of this chapter.

(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(i) if the nonphysician practitioner were a physician.

[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011]

Footnote(s):

1 As a condition of Medicare Part A payment for home health services furnished before July 1981, the physician was also required to certify that the services were needed for a condition for which the individual had received inpatient hospital or SNF services.

2 Comments Post a comment
  1. Elaine #

    Just curious–was this for an episode before or after 01/01/15

    Like

    April 27, 2015
    • All the denials are for episodes prior to Jan 1. The dates are anywhere from 2012 through 2014 depending on who wants to see the chart.

      Like

      April 28, 2015

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