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Posts from the ‘face to face requirements’ Category

47 Days


Every quarter, Palmetto GBA publishes the top reasons for denial and ways to prevent denials on their website. This is their advice about Face-to-Face Encounter documentation which is the second most frequent reason for denial after non-submission of records.

The face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
  • The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed 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 on a signed addendum to the certification
  • The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

On November 1, I contacted Palmetto GBA through their website. I prefer written responses I can refer to in the future. As a consultant, I find it useful to give clients accurate advice that I can back up with references.  That kind of attention to detail gets me paid.  Specifically, I wrote:

Please review the information provided under the list of April – June HH Medical Review Top Denial Codes. Your advice states that a narrative is still warranted and says nothing about supplemental documentation. When clicking on the link to ‘General Medical Review’, it provides pre-2015 instructions. And the third link is blog post by Dr. Feliciano with a 2013 date. The first link does go to the current manual but it conflicts with the information you are providing. Since providers are being denied at an alarming rate for F2F, it is abundantly clear that correct information be Provided.

Yesterday marked 47 days after my initial email. I received the following email from Palmetto:

Thank you for your e-mail received on November 01, 2018. You wrote to us regarding F2F information. You indicated there was some conflicting information in the April – June 2018 Home Health Medical Review Top Denial Reason Codes article.

Thank you for your information. We have submitted the information you provided to the Provider Outreach and Education Department for them to review the information provided.

By way of reference, e-mails are answered within 45 business days. Anytime you need immediate assistance, please call us at the telephone number listed below so that a representative can assist you with your questions quickly. You may also use our secure eChat feature that is available on our website at www.PalmettoGBA.com/hhh.

As a Medicare contractor, it is Palmetto GBA’s goal to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service. For claim status and eligibility or to speak to a Customer Service Advocate (CSA) about more complex issues, please call 1-855-696-0705. You may also visit the Palmetto GBA eServices to view claim status and eligibility at htps://www.onlineproviderservices.com/ecx_improvev2/. For up to date Medicare news and policy information, please visit our website at http://www.palmettogba.com/Medicare. Medicare beneficiaries should contact 1-800-MEDICARE (1-800-633-4227) for assistance.

I have so many problems with this email that if they were lined up they would reach the moon. Nevermind that. Let’s get you paid.

Know that if you follow the information on Palmetto GBA’s webpage about denials, your claim will be denied because four years ago, the Face-to-Face encounter documentation guidelines changed. The Medicare Benefit Policy Manual, chapter seven, section 30.5.1.2 instructs providers:

As of January 1, 2015, documentation in the certifying physician’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.

This does not mean that you may not use a traditional F2F form or attestation statement and the physician can write as much as he or she wants as a narrative, but even if it is perfect, your claim will not payable unless you also submit the physician or hospital documentation. Furthermore, the dates must match. If the physician inadvertently dates the form on the day he signs it instead of the date of the encounter, the documentation will be invalid. The physician names must match, too. If a qualified practitioner other than the certifying physician performs the encounter and prepares the documentation, the certifying physician should sign or initial the documentation to demonstrate that the information was communicated to him or her.  (A link to the manual follows this post with complete instructions.)

I see nothing in Palmetto GBA’s instructions about hospital documentation.  I see nothing in the coverage manual about a narrative.  

I do not feel good about pointing out Palmetto GBA’s lack of response to what I believe to be a legitimate concern on the internet.  Then again, I absolutely hate to see claims for excellent care provided by eligible beneficiaries denied because of stupid stuff. When agencies are taught stupid stuff by the contractors responsible for paying their claims, I get angry. Worse is when contractors are contacted and they take 47 days to say they are passing on my question to a different department. It took 47 days to forward an email? All of that kind of negates the claim that Palmetto GBA’s goal is to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service.  Have Mercy!

For complete instructions regarding the Medicare requirements for documentation of the face-to-face encounter, go to section 30.1 in the coverage manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf.  If you are new to home health, take a minute and familiarize yourself with sections 20, 30, and 40.

MLN Clarification


Jennifer Barker, a dear friend and the administrator at Audubon Home Health knows me well.  She gets that I do not open emails without a compelling reason to do so and she made sure her I opened hers today.  The subject line was:  WTH?!?  If there had been even one more exclamation point, I suspect the email would have opened itself.

Her concern was with the most recent MLN guidance for the Face-to-Face document which was updated with examples on January 15, 2014.  I read it briefly and did not fully understand her concern until I went back to her email.

Before I tell you Jen’s concerns, go look at page 10 and 11 of the MLN guidance

Did you see it? 

Jen pointed out that apparently MLN matters doesn’t realize that home health agencies type up the plan of care.  In MLN’s defense, there is a line that states that MD ‘documents’ the face to face encounter on the plan of care but since there is no change in font or color, it appears as though the encounter documentation is part of the original information sent to the MD for signature.

WARNING:  YOU – AS A HOME HEALTH AGENCY OR HOME HEALTH AGENCY EMPLOYEE – MAY NOT CONTRIBUTE TO THE DOCUMENTATION REQUIREMENTS OF THE FACE-TO-FACE ENCOUNTER.

So, I started looking some more.  The MLN matters document mentions a couple of times about the MD dating the signature of the face to face documentation.  Did that change?  Why on page eleven is it necessary for the MD to sign twice?  I’m just curious.  The Medicare Benefit Manual, chapter 7 pertaining to home health states:

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.

There is certainly nothing at all wrong with a dated signature and by far, two signatures are better than none.  However, do not be misled into thinking that your face-to-face documentation is incorrect if your:

    1. Face-to-face encounter is documented on the plan of care which is signed and dated by the physician (in which case only one signature is required and that signature is dated)
    2. An addendum is attached to the plan of care documenting the the face-to-face encounter which is signed by the physician (a date is not incorrect but is not mandated according to the Benefit Manual).

The note on page 2 of the MLN matters information may contradict the manual although due to the sentence structure, I am not sure what the note actually means.  It reads:

Note: The homebound status of the patient and his/her need for skilled services must be written in a brief narrative, signed by the physician, titled “Home Health Face to Face Encounter”, and dated.  (Exactly what must be dated in that statement?)

Remember, these are the instructions that your referring physicians are receiving.  There is no point in contradicting them as a date will not invalidate the face-to-face documentation.  However, I do not suggest going back for a revision if a face to face encounter document does not have a dated signature.

Hey, I have an idea…..  Let’s focus on taking care of patients next week.  Any ideas of how we can help each other become better nurses?

New Kids on the Block


 

Strategic Health Solutions is a Medicare Supplemental Review Contractor.  If you haven’t heard of them yet, chances are you will.  They have been ‘encouraging’ agencies to send them clinical records with letters that read as follows:

Effective April 1, 2011 , Section 6407 of the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare Home Health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA via the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule states that documentation of the face-to-face encounter must be present on certifications for patients with starts of care on or after January 1, 2011 .

Office of Inspector General (OIG) work conducted, before the ACA mandate went into effect, found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this information CMS has directed Strategic to perform postpayment review of Medicare Part A Claims billed for home health services.

As you well know, it is most unlike me to be argumentative but I googled ‘home health referral sources’.  As it turns out, the CDC information from 2010 is in stark contrast to the information provided by the OIG via Strategic Health Solutions.

referral sources

This graph states that providers who only offer home health services have 40 percent of their admissions from a hospital.  It says that 30 percent were from physicians but not that they were the outcome of actual physician visits so lets assume none of them were.  Sadly, the CDC’s 2010 report references 2007 data.

Lets move on to MedPac.  They write reports twice a year for the Congress about how much we are overpaid.  They increase our confusion by writing about how many episodes are preceded by a hospital stay but their data reflects 2010 so that’s a plus.  They say that 27 percent of initial episodes are preceded by a hospital stay and the average length of stay for those patients was 1.4 episodes.  That means that 38 percent of patients come from a hospital.

Neither MedPac or the CDC differentiate between patients  who were in the hospital seen by physicians who did not order their home health and those that did.  If a patient was from out of state, it might be that their personal doctor ordered home health or that a hospitalist saved that special joy for the primary physician.   This is important because it shows how accurate data could potentially be manipulated to paint an inaccurate picture of our industry.

In any event, I can say with confidence that at least 38 percent of patients were seen by a physician because that’s what happens in hospitals.  Doctors come write orders, nurses carry out the orders and the cafeteria always closes five minutes before you can get away to lunch.

So, we have huge discrepancies between the CDC, the OIG/SHS and MedPac.  Who are you going to believe?  My money is on the OIG because the CDC and MedPac do not have the authority to arrest me or monitor my email or phone calls.

So, after that long and rambling trip through the unfamiliar territory of numbers, we are back at the 30 percent mark referenced in the letter reproduced above sent by the OIG/SHS.  That leaves us with some disturbing facts.

We have an entity that looks like a RAC, walks like a RAC and quacks like a RAC but is really a Medicare Supplemental Review Contractor.

The RAC lookalike has noted that in 2010 providers did not adhere to guidance that was effective in 2011.

This non-adherence from 2010 constitutes NEW AND MATERIAL evidence that is being used as grounds to investigate home health care agencies for fraud.

And they will find it.   And it will not in any way, shape or form improve the care that our patients receive.

Note:   Pre-Nursing was the only curriculum that did not require math when I was in college which is why I chose nursing as a career.  Please feel free to correct any mathematical errors – politely, of course.

God Bless Tech Support


Click Here for New Inservice designed to help you avoid F2F denials. 

I carefully considered the requests I received from those you who wanted to know if I had the time and ability to provide an inservice on the Face-to-Face document.  The problem is that the expense for travel as well as the practicality of travelling to multiple states presents a daunting challenge.  Obviously, you would pay the travel expenses but who would sit here and write appeals if I were away?

So, like you, I had to embrace the technology available to me and find some way to provide you with the required information at an affordable price in a manner that did not take me away from doing the work at hand.  I went through two online vendors last week and finally settled on one called SkyPrep.  Now, to be certain, these guys aren’t bad at all but like all computer vendors, they have issues.

The biggest issue is that they take weekends off.  So, all weekend long, I converted PowerPoint presentations and uploaded them various different formats for your viewing pleasure.  None of them had any audio included.  So, I spoke louder.  You may notice that as you watch the presentation.

Sometime around Saturday afternoon, I decided I was too far in to back out now in terms of time.  I continued to record, increase my volume, slowly upload, convert files and sort files like a trooper.  By Sunday morning, I was like a pointman in the marines determined to lead this adventure to a victorious ending or at least one where there were no casualties.  By two o’clock Monday morning, I realized I was defeated.

So, I came to the office this morning and the nice people had returned from their weekends off and informed that the FoxFire browswer was not supported.  That would have been relevant information, don’t you think?

But at last, I have a presentation for you that costs what it would cost you to pay for my services for one appeal.  The beauty of this, though, is that hopefully, you can prevent future denials.

I am hopeful that other organizations who are taking this battle to Washington have great success in permanently relaxing the regulations regarding the Face-to-Face encounter.  Meanwhile, take advantage of my experience in appealing these denials and learn what it is Medicare is looking for.  More importantly, check out the actual denials.  They are the real McCoy.  It’s one thing to read the instructions but still another to see how they are implemented.   Also, see for yourself denials that should have never happened and learn why so you can be victorious in your appeals.  I assure you there is no way I can do every appeal that needs to be done!

I hope you take the hour to watch the presentation and gain from our experience.  I was having fun putting it together for a little while and then SkyPrep took the weekend off and ruined my in turn.

Let me know what you think.

A Gross Distortion of Truth


Implemented in 2011 as part of the ACA, the Face-to-Face requirement was mandated as a way to prevent Medicare fraud.  Well known cases of fraud involved agencies paying physicians who have never seen a patient to sign orders.  The best known case is that of Jacques Roy in Texas who defrauded the government of 450M by running an orders signing factory. There are more cases like this but these agencies are in the minority.  Although it is inconvenient at times, it should not be too difficult to satisfy this requirement to prevent additional fraud and abuse.

    1. 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.
    2. 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.
    3. 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.
    4. 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.

I received a copy of a face-to-face document last week and posted it below.  This patient has Parkinson’s disease, congestive heart failure and chronic pain.

image

As many of you can guess, it was denied.  Nobody doubts that the patient was eligible for services or that the services provided were reasonable and necessary.  The physician saw the patient on the 26th as indicated in the documentation and also daily while he was hospitalized.  Physical therapy was indicated as the reason for services in a section of the document I could not clip without revealing personal health care information.

So why was payment denied for this patient who met eligibility requirements and received much needed covered services?  The physician did  not write a ‘narrative’ because the silly doctor thought it was self evident why someone with diagnoses of pain, Parkinson’s Disease, congestive heart failure who kept falling despite use of an assist device was confined to the home.

This particular document was appealed recently so it was easy to find but I have scores of them in my computer from numerous clients from all over.  And most will be denied.

Medicare states:

The face to face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Nobody could possibly have more knowledge of the above patient’s condition than the physician who saw the patient daily in the hospital and then signed a face to face document.  Shame on that physician for failing to use verbs and pretty language to describe the patient better.  Perhaps he thought the document to which the face-to-face encounter was attached would be read.  Wrongo.  As with all statutory denials, the work is over when the claim is denied.  Why take your time to read an entire chart or even the care plan if the claim does not meet billing requirements.

Adding to this are the thousands of face to face encounters that meet all requirements and are denied regardless.  When this happens, an appeal is sent to the QIC (the next level of appeal) and often the QIC finds that the face to face encounter did satisfy all requirements but another reason for denial is found.  This tactic essentially robs the agency of one level of the appeals process.  

After working in post acute care for all these years, my faith lies in home health and hospice.  We have not lived up to our potential as a sub segment of the industry, but we are getting closer every day.  It will be a moot point when congress and other policy makers hear information painting a picture of our industry as blatantly fraudulent and unable to follow even the simplest regulation designed to prevent fraud.  That is my concern.  We will be somehow be left behind as new budgets are developed and our reputation is tarnished.

And to this day, I believe that if we did live up to our potential, congress would be lining up to ask how we wanted to be paid instead of  dismissing us as criminals in scrubs.  We will never live up to our potential as long as education, consulting, inservicing budgets are dedicated to teaching nurses how to review the face to face document to fund payroll.

Most importantly, I want copies of all face to face documents that have been denied if you don’t mind sharing.  You can sanitize them by removing personal health information or I can send you a HIPAA agreement so you can send them as is.

I am losing faith that our government, the one who wants to control 20 percent of our economy with the ACA is being truthful when they state that the purpose of the face-to-face encounter is to combat fraud.  Color me cynical but I see it being bastardized as a way to deny providers payment for covered services rendered to eligible providers. 

 

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