Home Health Face-to-Face Encounter

1. Home Health Face-to-Face Encounter Presented by: National Association for Home Care & Hospice William A. Dombi, Vice President for Law Mary St. Pierre, Vice President for Regulatory Affairs

2. Home Health Face-to-Face Encounter: Basis • Affordable Care Act Section 6407 • Prior to certifying Medicare eligibility • Fee-for-service Medicare home health • Physician or NPP must document face-to-face encounter • May be by telehealth in accord with 1834(m)

3. CMS Encounter Rule • Final rule: HH PPS Update 2011 • Link at CMS web site: http://www.cms.gov/center/hha.asp • Regulatory amendment • 42CFR §424.22 • CMS Manual revision underway • RAP payment process not affected

4. Encounters: Who • Who may conduct the encounter? • Certifying physician, or • NP, CNS, Nurse midwife working in collaboration with certifying physician, or • PA under supervision of certifying physician

5. Encounters: Hospitalist Role • At issue: “patient must be under the care of the physician” certifying home health • Preamble language confusing/unclear • Refers to patients who • May or may not have community physician, • Hospital physician who may or may not assume responsibility • Indicates patient “under the care of” physician who assumes responsibility post acute • Expects (not require) identification of community physician in discharge plan when hospitalists document and certify • Requires updated plan by community physician

6. Encounters: Related Reason • Related reason • Encounter must be related to primary reason for home health • Not necessarily primary reason for encounter • CMS Intention • Enable physicians to: • Understand current clinical needs • Establish effective plan of care • Ensure homebound status • Ensure skilled need

7. Encounters: When • When must the encounter occur? • No more than 90 days prior to the home health start of care date, or • Within 30 days of the start of the care • *Applies to certification “start of care” episodes only

8. Encounters: Telehealth • Telehealth Encounters • Subject to the requirements in section 1834(m) • Encounter limited to one of the specified types of originating sites

9. Encounters: Documentation • Who must document the encounter on the home health certification? • The physician who orders services and signs the plan of care • Regardless of whether conduct of encounter by physician or NPP

10. Encounters: Documentation • Non-physician practitioner performing face-to-face encounter must: • Document encounter in the medical record • Communicate findings of encounter to certifying physician

11. Encounters: Documentation • Documentation on home health certification must include • Date of the encounter • Explanation of why clinical findings of encounter support: • Homebound status • Patient need for intermittent skilled nursing or therapy

12. Encounters: Documentation • Documentation of encounter must be: • Separate and distinct section of certification or • Addendum to certification • Based on findings of the encounter • Standardized language prohibited • NOTE: CMS removed physician medical record documentation requirements

13. Encounters: Physician Payment • No separate payment for home health face-to-face encounter • Physician payment is allowed for other medically necessary services under fee schedule • No change to reimbursement for care plan certification

14. Encounters: Enforcement • Literal interpretation of “primary reason for home health” not intended • No intent to edit for relationship • Physician claim diagnosis against home health claim diagnosis • CMS Plan • Expand manual guidance on enforcement • Issue instructions to medical review contractors • Review via other program integrity efforts • Monitoring of compliance by surveyors

15. Encounters: Certification Requirements • Timing of certification • At the time the plan of care is established, or • As soon thereafter as possible • Unchanged from current policy • Signature requirements • Certification of plan of care signed and dated by physician who establishes plan of care • Issue: CMS failed to respond to questions regarding date stamping policy

16. Encounters by HHA Employees/Contractors • Certification by physician or NPP with financial relationship prohibited unless: • Stark exceptions and anti-kickback safe harbors, e.g. • Paid for and perform administrative functions • Paid fair market value • Proof of work done • Physicians and NPPs • May NOT be paid to conduct face-to-face encounters

17. Beneficiary Notification • No CMS guidance for notifying beneficiary • HHABN deemed not appropriate • No CMS guidance as to patient payment liability • ***HHAs may not provide free transportation to patients for physician visits

18. Unanswered Questions • Impact on payment (no encounter versus late encounter) • Encounters by Hospitalists, Residents, SNF and Rehab Facility physicians, • Beneficiary notification • Beneficiary liability • Others: ???????????????

19. Model:Resources and Letters • 1. Patient Letter • 2. Patient Information About Face to Face • 3. Notice of Potential Liability • 4. Notice of Nonacceptance • 5. Notice of Termination • 6. Notice of Termination Version Two • 7. General Letter Physician • 8. Referring Physician Letter • 9. Referring Source Notification • 10. Guide to Documentation

20. Work Ahead for Home Health Agencies • Seek responses to unanswered questions • Develop policies and procedures • Finalize letters and notices • Develop encounter tracking protocols • Analyze the face-to-face encounter • Regulation and preamble • CMS policy manual update when released • Educate • Agency staff and contractors • Patients • Physicians • Referral sources