• Medicare simplifying face-to-face encounter requirements for home health certification

    Certifying that a patient is eligible for Medicare-covered home health services got a little simpler under a rule that went into effect Jan. 1. Let’s discuss the changes and what they may mean for your practice.

    Beginning in 2011, the Affordable Care Act required that before a patient was certified as eligible to receive the Medicare home health benefit, the physician or allowed non-physician practitioner had to have a documented face-to-face encounter with the patient. The federal regulations implementing the law required that the face-to-face encounter be related to the primary reason the patient needed home health services and occur no more than 90 days before or 30 days after the date the home health care started. Also, as part of the certification of eligibility, the certifying physician had to document the date of the encounter and include a clinical explanation (i.e., narrative) supporting that the patient is homebound, as defined in the law, and in need of either intermittent skilled nursing services or therapy services, as defined in the regulations.

    Effective for home health episodes that began on or after Jan. 1, 2015, the Centers for Medicare & Medicaid Services (CMS) has generally eliminated the narrative requirement. All other requirements related to certifying the patient’s eligibility for the Medicare home health benefit remain in place. Likewise, CMS will continue to pay physicians for home health certification (code G0180) and recertification (code G0179), as appropriate.

    The one exception is when the physician orders skilled nursing visits for management and evaluation of the patient’s care plan. Because the skilled nurse is essentially ensuring that unskilled care is achieving its purpose, CMS believes that it is still appropriate for the physician to include a brief narrative describing the clinical justification for this need as part of the certification/re-certification of home health eligibility. CMS believes such instances should be infrequent, meaning that, most of the time, physicians will not need to provide a narrative.

    CMS reminds certifying physicians that they are responsible for providing the medical documentation necessary to support that the patient is eligible for the home health benefit. Indeed, Medicare plans to review only the certifying physician’s medical record for the patient to determine eligibility at the start of care. If the patient’s medical record is not sufficient, Medicare will not pay for home health services. Further, if the home health agency’s claim is not covered because of insufficient documentation, Medicare also will not cover or pay the physician’s claims for certification/recertification of eligibility for home health services.

    Certifying physicians who show patterns of non-compliance with this requirement, including providing inadequate or incomplete documents, may be subject to increased reviews, including services unrelated to the home health claim being reviewed or the Medicare patient who was referred for home health services.

    – Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

    Posted on Jan 27, 2015 by David Twiddy

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.