EDITOR’S NOTE: Editorial exposure from RACmonitor contributing editors Andrew Wachler, Jessica Forster and Ronald Hirsch, MD, led CMS to release a transmittal clarifying the regulations on documentation for home care services last December. In February of this year, CMS changed its mind. This latest memo from CMS reflects the agency's original stance.
Last year, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Home Care Prospective Payment Final Rule. The landmark change was the easing of the requirement for the physician narrative on the face-to-face documentation, a task that had frustrated hospitals, home health agencies, and doctors since it was introduced.
During the December CMS Home Health Open Door Forum, several cases were presented that nicely illustrated that the physician merely had to order appropriate home care services on a homebound patient who had been seen within the last 90 days, and then review the HHA’s plan of care, sign that plan, and incorporate it into the patient’s chart in order to meet the certification requirements.
This author wrote about this on RACmonitor.com on Dec. 17, 2014, in anticipation of the effective date of Jan. 1, 2015, but the response from the home health industry was not what I expected; several agencies contacted me personally and expressed their lack of trust that CMS and the auditors would accept such a simple solution. And at the next Open Door Forum, their concerns proved true. The presenters, none of whom presented at the first Open Door Forum, indicated that all the documentation indicating the patient’s need for home care services and homebound status had to be documented by the physician and using the HHA’s documentation was not acceptable.
Several listeners took advantage of the question-and-answer session to point out the contradictory guidance provided on this call compared to the other calls, and even referred the presenters to the written case studies that were posted for the first call, but the presenters seemed to have no knowledge of that information and could not address the contradictory guidance. This left all listeners frustrated and confused, with most seemingly back to square one and continuing to require the physician to complete the face-to-face form, including the narrative description.
So it should come as a great relief that on July 10, CMS released transmittal 602, Change Request 9189, Medical Review of Home Care Services, which supports the original intent of the rule. It allows the physician to order home care services for an eligible patient and the HHA to supply the needed documentation of the details of the patient’s homebound status and exact skilled needs. This guidance states, “Per 42CFR 424.22 (a) and (c), the patient’s medical record must support the certification of eligibility. Documentation in the patient’s medical record shall be used as a basis for certification of home health eligibility. Therefore, reviewers will consider HHA documentation if it is incorporated into the patient’s medical record held by the certifying physician and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) and signed off by the certifying physician. The documentation does not need to be on a special form.” CMS instructs review contractors that “the reviewer shall consider all documentation from the HHA that has been signed off in a timely manner and incorporated into the physician/hospital record when making its coverage determination.”
It is important to note that physicians still play a crucial role in this process. They must determine that the patient requires home care services and is homebound; must provide an order for the appropriate services; and must review, sign, and incorporate into their office chart all documentation to be used to support the certification of home care services, which, in most cases, will be the HHA’s plan of care. But no longer do physicians have to be coached and cajoled into documenting the patient’s mobility limitations and skilled needs with the detail that was required by the auditors and which serve no purpose for the physician’s daily activities caring for the patient. Now this documentation can be supplied by the nurses and therapists who use such detailed assessments to provide the required care to the patient.
And as with the first Open Door forum, CMS provided case examples to illustrate the requirements. In case one, a patient with a femur fracture that was non-weight-bearing had an order from the hospital orthopedic surgeon for home physical therapy two to three times a week for six weeks, and the plan for follow-up instructions with a community physician. The HHA generated an OASIS form and a plan of care indicating the goals of therapy and the physical therapist’s notes indicated that the patient was homebound and required an assistive device. These notes were all signed by the community orthopedic physician who assumed care for the patient after discharge.
CMS noted that this satisfied all the requirements for certification as it was based on a face-to-face visit with the hospital physician within the mandated timeframe, including notes that “alluded to the fact” that the patient was homebound. The documentation also included a physician order which was obtained from the hospital physician and the therapist notes and the plan of care which specifically indicated that the patient was homebound and described the limitations of the patient, with all notes signed by the community physician and incorporated into the patient’s chart. Case two was a patient referred for homecare services by a community physician for a worsening foot ulcer after an office visit. As in case one, the majority of the certification requirements were documented by the HHA and merely signed by the physician to indicate agreement.
This CMS publication, an official revision to the Medicare Integrity Manual, now makes it clear that CMS’ intent was truly to ease the documentation burden and ensure that patients who need home care services are able to access them. It is my hope that HHAs and hospitals will review this transmittal and my previous article and make the necessary changes to their procedures.
In this age of increasing physician burden, they will welcome the retirement of the face-to-face form that most have come to loathe.
About the Author
Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.
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