Facing the new face-to-face requirement for Medicare home health services

Did you know that Medicare will soon begin enforcing a requirement that a physician who certifies a patient as eligible for Medicare home health services must see the patient either within 90 days prior or 30 days after the start of home health care? If not, read on. If so, you may still want to read on for more information.   

As an outgrowth of section 6407 of the Patient Protection and Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is requiring that a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician. The provision was effective as of Jan. 1, 2011, but CMS agreed in December to delay enforcement until April 1, 2011. 

The provision requires that, as part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. As noted, the face-to-face encounter must occur within the 90 days prior to the start of home health care or the 30 days after the start of care. When a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.

The new requirement includes several features intended to accommodate physician practices. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare will allow a physician who attends to the patient but does not follow the patient in the community, such as a hospitalist, to certify the need for home health care based on their face-to-face contact in the hospital and to establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face-to-face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.

The American Academy of Family Physicians and others are advocating with CMS to extend the enforcement date to no earlier than July 1, 2011, based on confusion with and resistance to the paperwork obligations for physicians, still evolving policy interpretations and guidance on the part of CMS, and the simple need for more time to ensure that physicians and NPPs understand the rule. A decision by CMS on this request is still pending, so as of now, April 1, 2011, remains the key date.   

CMS has made additional guidance available via an article (PDF download) on the Medicare Learning Network web site.  Additionally, CMS has posted frequently asked questions and answers regarding this requirement in the Spotlights section of the Home Health Agency Center section of the CMS web site.