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End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

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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…

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.


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. 


Battle Scarred

war against fraud

Normally, I try not to be so very outwardly hostile towards CMS but lately, it seems as though the feds don’t really need to justify intruding on my privacy or the bank accounts of legitimate health care providers, so, whatever. The fact is that the face to face document has become the equivalent of a Weapon of Mass Destruction by CMS and their contractors.

You, as a provider, have a lot to lose if you do not honor the provider agreement signed with Medicare.  What everyone forgets is that Medicare signed the very same agreement which guaranteed you payment for rendering skilled care to eligible beneficiaries.

Rightly and wrongly, Palmetto GBA has been denying claims for months with no consideration of the care provided to patients.   This week, CGS announced it planned to follow in the footsteps of PGBA which will radically increase denials for those providers.

The abuse of the Face to Face requirement by CMS contractors has gotten so out of hand that it has become abundantly clear that they are looking for any reason to deny providers regardless of the care that eligible beneficiaries received.

To be clear, there have been agencies who paid a medical director to sign orders blindly for the sake of convenience.  There are other physicians, like Dr. Jacques Roy who sold his signature and his soul for money.  The intent of the document was to ensure that patients were seen by their physicians who were then willing to sign their name to a document stating the patient needed care and was homebound.

So the rationale was sound and initially, it was not much more than an inconvenience for agencies to get an additional document signed upon admission.  Beginning last year, the face to face requirement has been bastardized as a weak excuse to hold onto money that good providers earned providing skilled care to eligible beneficiaries.

There is not a day that goes by that I don’t hear from someone about a denial related to face to face document and more importantly, it is rare that a day goes by that I am not made aware of very real fraud.

I have no idea why Palmetto and CGS have decided to wage a campaign of hostility towards providers.   In the ‘good old days’ when FMR was about the worst thing that could happen to an agency, the solution was simple.  Document well and follow the guidelines.  Lately it doesn’t seem to matter how good or bad your chart is.

One physician wrote in the reason homebound section, the ICD-9 codes for Parkinson’s Disease and scribbled ORIF.  I get that the document did not meet all the requirements for a narrative.  Also included on the document was the patient’s age (85), the fact that he had PEG orders.  Perhaps I am reading too much into the information.  Maybe it is reasonable to believe that an 85 year old patient with Parkinson’s Disease, and a hip replacement could leave the house unattended to play bingo.   Or softball.

Another physician wrote the reason for home health was paralysis.  Skilled nursing was ordered for catheter care and so the claim was denied.  The MD did not realize the nuances of home health coding apparently and the claim was denied because we can’t fix paralysis.

We can’t fix lazy and stupid, either.   It certainly relieves Medicare contractors of the burden of reviewing records if a face to face is not completely accurate or grammatically correct and it has become abundantly clear that many of the records sent are not even read.

The sophistication of the Medicare IT has grown exponentially in recent years.  They are able to tell if the physician who signed the 485 is not listed as the patient’s physician in the database but they cannot see a Part B claim from a physician and determine that the patient was seen timely.  Do they really believe that all those patients admitted from the hospital were not seen by a physician?

Not one single Medicare beneficiary has received better care because of this insane demand on agencies.  In fact, time and resources that could be used to teach nurses about the new Diabetic protocols (bet you didn’t know they were published) or otherwise enhance the clinical skills of nurses are being devoted to getting the physician to document one encounter multiple times to ensure the agency gets paid.  In some cases, the agencies are simply completing the form for the physician’s signature.  They get paid.

I strongly encourage you to play by the rules but also to fight every single denial for a face to face to the level of an ALJ.  The days when the cost of appeal was taken into consideration when determining whether or not to fight it are now part of our rich home health history.  Fight everything until an ALJ or two sees how very abusive these practices are.

Don’t call or email me for a couple of weeks if you have something confidential to say.  I figure after about two weeks, the feds will see how very boring my life is and remove the wire taps. And try to find some time in between ADRs and running down face to face documents to, you know, take care of a patient or two.  Remember them?  Patients?  Elderly, lots of DME and a ton of pill bottles; none of which contain the pill she thinks she takes for sugar.

Please tell us about any face to face horror stories below or email them to me privately.  If you are a client and anyone asks who your consultant is, tell them Jnon Griffin or Lisa Selman Holman.  Just sayin….

Patient Abandonment and Face to Face Encounters

Today I have the opportunity to share with you some wise thoughts regarding a potential risk associated with Physician Face to Face encounters that hadn’t occurred to me before. Thanks to Elizabeth Hogue, we can take pre-emptive steps to avoid liability related to patient abandonment.

Face-to-Face Encounters: Avoiding Liability for Abandonment

Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739


Providers are at risk for legal liability when they terminate services to patients.  Termination of services has historically been warranted by the following circumstances, among others: violence or threatened violence, noncompliance by patients and/or primary caregivers, inability to provide adequate assistance, or inappropriateness for services.  Providers are understandably concerned about the possibility of legal liability associated with the termination of beneficial services.

Specifically, they frequently express concern about the possibility of liability for abandonment of patients.  The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS), the primary enforcer of fraud and abuse prohibitions, has indicated that abandonment of patients may also constitute fraudulent conduct.

Providers now have new concerns regarding liability for abandonment in light of requirements for face-to-face encounters.  Specifically, providers may not be paid for services rendered if patients have not had appropriate face-to-face encounters with physicians during required time periods.  It is important, therefore, for providers to understand how to terminate services without liability for abandonment.

Practitioners often speak of abandonment as though it is equivalent to termination of services.  On the contrary, patients who want to hold providers liable for abandonment must show that:

  1. Providers unilaterally terminated the provider/patient relationship;
  2. Without reasonable notice;
  3. When further action was needed.

Patients who fail to prove any one of these requirements are likely to lose their lawsuits against providers.

The second requirement of abandonment provides a key basis for avoiding liability for abandonment.  Providers will not be liable for abandonment as long as they give patients reasonable notice prior to termination of services.  The key question is: what is “reasonable” notice, especially in view of new face to face encounters?

Many providers historically viewed thirty days as the minimum number of days required for reasonable notice.  This period of time is too long for most patients, including patients who have not had required face-to-face encounters.  A more reasonable period of time for most patients, unless a specified period of notice is mandated by state statute or regulation, is probably one to three days.

After staff members agree upon a reasonable notice period, patients and attending physicians should receive verbal and written notice.  Written notices should be hand-delivered to patients’ homes.  Although it is desirable, it is unnecessary to obtain a signature verifying receipt.  Written notices to physicians should be faxed to them.

When the date for termination of services arrives, providers must terminate care as planned.  Practitioners are sometimes tempted to continue in the face of pleas from patients, physicians, and/or family members.  Providers must bear in mind, however, that their organizations, whether for-profit or not-for-profit, simply cannot afford to render unlimited amounts of uncompensated care.  The consequence of lack of attention to fiscal limitations may be the disruption or unavailability of care to many patients.

Finally, providers can defeat claims of abandonment if patients for whom services are discontinued need no further attention.  How do providers know whether further attention is needed?  Is this requirement as subjective as it appears?  On the contrary, judges are likely to make retrospective determinations about whether further attention was needed.  The basis for such determinations will probably be whether patients were injured as a result of termination.

In other words, the law is likely to conclude that no further attention was needed, so long as patients are not injured as a result of termination of services.  What kind of injury must patients prove?  Can patients who attempt to prove emotional damage only as a result of termination of services by case managers win lawsuits?

The “good news” for providers is that courts generally require proof of physical injury or damage before they will find providers liable for abandonment.  Providers must, therefore, take appropriate steps to make certain that patients are not physically injured as a result of termination of services.  In rare instances, appropriate action may include sending an ambulance to take the patient to the nearest hospital.  If the patient refuses transport by ambulance, the patient will have been contributorily negligent or will have assumed the risk, so providers are likely to avoid liability.

Now is the time for providers to educate themselves about the possibility of liability for abandonment.  Positive steps must be taken in order to prevent this type of legal liability in view of the uncertainty of the impact of requirements for face-to-face encounters.

(To obtain a complete set of policies and procedures to use in order to prevent liability for abandonment, send a check for $105.00 that includes shipping and handling made out to Elizabeth E. Hogue, Esq. to Fulfillment, 107 Guilford, Summerville, SC  29483.)

© 2011.
Elizabeth E. Hogue, Esq.  All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.
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