Drill Down – Hospice Face-to-Face Recertification Issue

By
Original story posted on: May 6, 2013

alert-powered-by-decision-health

HDI, the Recovery Audit Contractors (RAC) for Region D, recently posted an approved issue for hospice providers. The complex audit will focus on whether a face-to-face encounter occurred when a patient was recertified for hospice. Documentation in the patient's records will be reviewed and must reflect that a face-to-face encounter took place for hospice claims on or after January 1, 2011.

Hospice recertifications on or after January 1, 2011, require that the physician or nurse practitioner must have a face-to-face encounter with a patient prior to the beginning of the patient's third benefit period and prior to each subsequent benefit period. Failure to meet the face-to-face encounter requirement results in a failure by the hospice to meet the patient's recertification of terminal illness eligibility requirement.

Per the Medicare Benefit Policy Manual, Chapter 9, Section 20.1, the face-to-face encounter requirement is satisfied when the following criteria are met:

a. Time frame of the encounter: The encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.

b. Attestation requirements: A hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter. The attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled. When a nurse practitioner performed the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course.

c. Practitioners who can perform the encounter: A hospice physician or a hospice nurse practitioner can perform the encounter. A hospice physician is a physician who is employed by the hospice or working under contract with the hospice. A hospice nurse practitioner must be employed by the hospice. A hospice employee is one who receives a W-2 from the hospice or who volunteers for the hospice.

d. Time frame exceptional circumstances for new hospice admissions in the third or later benefit period: In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period. For example, if the patient is an emergency weekend admission, it may be impossible for a hospice physician or NP to see the patient until the following Monday. Or, if CMS data systems are unavailable, the hospice may be unaware that the patient is in the third benefit period. In such documented cases, a face-to-face encounter within two days after admission will be considered timely. Additionally, for such documented exceptional cases, if the patient dies within two days of admission without a face-to-face encounter, a face-to-face encounter can be deemed complete.

Other RAC issues for the week of May 6–May 10, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner Claim Types

  • Procedures in the Post-Op Period of Other Procedures - All of Region A - Additional major and minor surgical procedures performed during the 90-day or 10-day global postoperative period of the initial procedure are considered an overpayment when billed without modifier 58, 78, or 79, or a clinically appropriate NCCI-associated anatomical modifier that justifies separate payment (i.e., indicating different body areas).

RAC Region C Connolly

Inpatient Claim Types

  • Medical Necessity: IP Psych - Medical records will undergo clinical review by a psychiatric nurse, with direct supervision from the contract medical director. The documentation will be reviewed to validate if true psychiatric conditions exist or are currently being evaluated for an acute psychiatric condition. The medical record will then be evaluated to ensure that the patient is not in an inpatient psychiatric facility to further continue treatment for urinary tract infection and pneumonia. There are clear CMS regulations that state inpatient psychiatric facilities cannot be used for respite care.
  • Medical Necessity: MAJOR MALE PELVIC PROCEDURES, MS-DRGs 707 AND 708 W CC/MCC, W/O CC/MCC - RACs will review documentation to validate the medical necessity of short-stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 707 and 708. RACs WILL ALSO review documentation for DRG Validation for MS DRGs 707 and 708, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • Medical Necessity: Diseases And Disorders of the Musculoskeletal System And Connective Tissue, MS-DRGs, 534, 535 AND 536, W/MCC, W/O MCC - RACs will review documentation to validate the medical necessity of short-stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 534, 535 and 536. RACs will also review documentation for DRG validation for MS DRGs 534, 535 and 536, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

 


 

Skilled Nursing Facility Claim Types

  • SNF Coding Validation - C000392013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical necessity will not be included in this review).
  • SNF Coding Validation - C000402013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical necessity will not be included in this review).
  • SNF Level of Care Review -C000952013 - While a three-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care and is covered under the program.
  • SNF Level of Care Review - C000962013 - While a three-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care and is covered under the program.
  • Units in Excess of PPS Assessment Maximum - Medicare assigns standard scheduled payment periods for SNF assessments. Overpayment occurs when additional units in excess of assessment maximums are billed.

RAC Region D HDI

Hospice Claim Types

  • Face-to-Face Evaluation for Recertification of Hospice Care - To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. Recertification on or after January 1, 2011, requires the hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient prior to the beginning of the patient's third benefit period. Failure to meet the face-to-face encounter requirement results in a failure by the hospice to meet the patient's recertification of terminal illness eligibility requirement. Medical documentation will be reviewed to determine timeliness of the face-to-face re-certification.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company's business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding with an emphasis on clinical and regulatory guidelines for Medicare and Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article please go to editor@racmonitor.com

Margaret Klasa, DC, APN, Bc

This email address is being protected from spambots. You need JavaScript enabled to view it.