Updated on: November 10, 2016

Home Health Certification: CMS Provides Clarification (RACmonitor Was Right in 2014)

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Original story posted on: November 9, 2016

Most people recall the home care face-to-face requirement that the Centers for Medicare & Medicaid Services (CMS) established several years ago. That rule required that an actual document be created by the physician to certify that each patient met qualifications to receive covered home care services.

The requirement wasn’t well received, creating mass confusion and mass denials of home care claims. CMS then modified the regulations and attempted to ease the burden by eliminating the need for a specific form, but continuing to require that a physician certify that the qualifications were met.

In my RACmonitor article published Dec. 17, 2014, I analyzed that new regulation and explained how simple it was for physicians and home health agencies (HHAs) to meet the certification requirements. But the conclusions of the article were not universally accepted, and confusion and denials continued unabated.

CMS also implemented the Pre-Claim Review Demonstration for Home Health Services on Aug. 1, 2016 to require that home care agencies submit their certification documentation to the appropriate Medicare Administrative Contractor for review prior to submitting the actual claim to ensure that all elements of certification are present. This Demonstration did not start smoothly, with reported confusion and a large number of inappropriate non-affirmations of coverage. Because of that confusion, CMS put the planned expansion of the program on hold and released a frequently asked questions document to try to smooth things over.

But on Oct. 27, 2016, CMS published an update to its frequently asked questions, which perfectly matches the guidance I outlined in my 2014 article. The answer to question No. 65 supports my recommendations (emphasis added in bold):

There is no requirement for a “face-face form,” nor is there a requirement for the certifying physician to write a narrative about the face-to-face encounter. The requirements for the certifying physician are simple in that the certifying physician must attest to five elements for home health certification:

  1. The patient is homebound;
  2. The patient is in need of skilled services on an intermittent basis;
  3. A plan of care has been established and is periodically reviewed by a physician;
  4. The patient is under the care of a physician; and
  5. A face-to-face encounter occurred within 90 prior or 30 days after the start of care, was conducted by an allowed provider type, was for the primary reason the patient is in need of home health services, and the date of the encounter is listed.

These elements listed above can be included on the old CMS form 485 (the home health plan of care), which many HHAs continue to use, though it is not a Medicare requirement. HHAs have the discretion to provide the certification in any manner they so choose as long as all of the elements are included. In the downloads section is an example of how one HHA incorporated all five elements of the plan of care, and even though the certifying physician did not conduct the face-to-face encounter, he attests that one occurred and documents the date of the encounter (see field No. 26 on the plan of care). This example is a valid certification for home health eligibility. If the certifying physician did not conduct the actual face-to-face encounter, he does not have to write a face-to-face narrative and he is not required to co-sign the actual face-to-face encounter note. He only must attest to the five elements above as part of the home health certification. He is, however, required to sign the certification and the home health plan of care. If he does not sign the certification or plan of care, the HHA cannot bill for any services rendered, as the eligibility requirements have not been met.

In simple terms, that means the HHA can include all the details of how the patient is considered homebound and all the details of the need for skilled services in the narrative section of the plan of care, then use the wording that CMS has noted is compliant, as indicated below, in the physician certification section to meet the requirements.

I certify this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy, and/or speech therapy, or continues to need occupational therapy. This patient is under my care, and I have authorized the services on this plan of care, and will periodically review the plan. I further certify this patient had a face-to-face encounter that was performed on (date) by a physician or Medicare-allowed non-physician practitioner that was related to the primary reason the patient requires home health services.

The HHA then should insert the date of the patient’s face-to-face visit with the hospital physician, and the certifying physician need only sign and date that plan of care and keep a copy of it in the patient’s chart; that way, all the requirements are met. It should be emphasized that every single patient who is in the hospital and then subsequently referred for home care also has a face-to-face visit with one or several physicians in the hospital, and that one of those physicians ordered home care services on one of those hospital days. That physician visit meets the face-to-face requirement, and the date of the visit should be placed on the plan of care. The HHA should request a copy of that progress note in its records to support its claim.

It is interesting that CMS has come close to endorsing the continued use of form CMS-485. The requirement to use CMS-485 was rescinded over a decade ago, but it continues to be used by the majority of HHAs. It therefore is a welcome surprise to see CMS use the CMS-485 form as its example of a plan of care that meets the requirements of certification.

In my prior RACmonitor article, I noted that “as with the elimination of the inpatient admission certification requirement, CMS has handed hospitals a gift for the New Year (2015). They had good intentions; home care fraud is rampant, with criminals setting up sham agencies and recruiting patients, but the old face-to-face requirement was a hindrance to getting home care to patients who needed it. As outlined above, the new rule is clear and the guidance provided is easy to understand.”

While that statement was correct, I probably should have known that implementation of a new regulation is never as easy as it should be. But once again, I am willing to state that if HHAs only accept patients who are homebound, have skilled needs, and have seen a physician, and then follow my simple guidance. Their claims will be approved and paid, and more importantly, patients will get the care they need. 

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 Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

Contact the Author

RHirsch@accretivehealth.com

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