Last month, CMS published a change request effecting change for Medical Review of Medicare-covered home health services.[1] The changes in how contracted home health medical record reviewers are instructed to assess claims, according to CR 9189, go into effect August 11, 2015.
Many agencies are not familiar with this change request, and believe that home health regulations have changed, effective August 11. However, this assumption is incorrect.
Only the manner of medical necessity review of Medicare home health claims is changing on August 11. The guidelines that reviewers are instructed to consider (per this change request) went into effect on January 1, 2015, as part of the Home Health Prospective Payment System (HHPPS) Final Rule which was published on November 6, 2014.[2] The new medical necessity reviewer guidance is in regard to how physician certification, recertification, and statements of eligibility for Medicare-covered home health services are to be analyzed and interpreted.
The new reviewer directives are laid out specifically in Chapter 6 of the Medicare Program Integrity Manual (Review Guidelines), which was also updated per CR 9189.[3] This manual states that Certification of patient eligibility is a condition for Medicare payment, which means the new requirements that went into effect January 1, 2015, must be met before an agency bills Medicare for services. Medical necessity reviewers are instructed to examine requested documentation submitted to them by the home health agency to ensure that all certification documentation requirements are met.
In order to understand the new directives for reviewers, we must first understand some background information.
According to section 6407 of the Affordable Care Act, effective January 1, 2011, the physician or allowed non-physician practitioner must ensure that a face-to-face encounter with the patient occurred either 90 days prior to or within 30 days of a home health start of care. This encounter must be related to the primary reason the patient requires home health services, and the certifying physician must document in medical records the date of the face-to-face encounter, and include a narrative explanation of why the clinical findings of the encounter support that the patient is homebound.[4] This should be done prior to a physician certifying a patient’s eligibility for Medicare home health eligibility, and is a condition of payment for home health agencies. Both the face to face encounter and the certification of home health eligibility are conditions of payment for Medicare home health.[5]
Remember, a face-to-face ENCOUNTER is different that a face-to-face form. The narrative face-to-face FORM is no longer required because CMS stated that the physician’s statement of certification of eligibility for Medicare home health should contain all the pieces of information needed to establish that the patient qualifies for home health services. [6]
What are the patient eligibility requirements?
The eligibility requirements for Medicare home health are as follows:
- The patient must have Medicare Part A and/or Part B;
- The patient must be confined to the home;
- The patient must require skilled services of a SN, PT and/or SLP;
- The patient must be under the services of a physician;
- The patient must receive services under a plan of care established and reviewed by a physician AND;
- The patient must have had a face to face encounter with a physician or allowed non-physician practitioner within the correct timeframe.
As a condition of payment, a physician must certify that a patient is eligible for Medicare home health services according to the guidelines and the physician who establishes the plan of care must sign and date the certification. Note that a Plan of Care (POC) and Certification are two different things.
The statement on the once mandated CMS 485 (still commonly used as a Medicare home health Plan of Care), in locator #26, is NOT sufficient coverage of the certification statement. Why not?
1) The CMS–485 form was discontinued over a decade ago to provide HHAs with more plan of care flexibility.[7]
2) CMS does not require a specific form or format for the certification.
3) The following five requirements must be documented in the physician’s certification statement:
- Patient needs intermittent SN care, PT care, and/or SLP services
- The patient is confined to the home
- A plan of care has been established and will be periodically reviewed by a physician
- Services will be furnished while the individual is or was under the care of a physician
- A face-to-face encounter, meeting all the face-to-face requirements occurred.
So, how and where are physicians to document certification information? Per CMS, “documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health from a facility) shall be used.” Agencies should have this documentation as soon as possible after admission, and MUST have it prior to billing Medicare. Guidance to physicians can be found in the Medicare General Information, Eligibility, and Entitlement Chapter 4 — Physician Certification and Recertification of Services Manual, section 30.[8]
According to regulations at 42CFR 424.22(c), certifying physicians and acute/post acute care facilities MUST PROVIDE, UPON REQUEST, the medical record documentation that supports certification of patient eligibility for the Medicare home health benefit to the home health agency, review entities, and/or CMS. This medical record documentation must contain information that justifies the referral for Medicare covered home health services, including:
- Need for services
- Homebound status
- Clinical note for the Face to Face encounter.
This information can most often be found in, but is not limited to clinical notes, progress notes, and discharge summaries. Agencies “should obtain as much documentation from certifying physician’s medical records and/or acute/post-acute facility’s medical records as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria for certification/recertification has been met. The agency must be able to provide CMS and its review entities this documentation upon request, such as an ADR request.
So, what will reviewers start doing effective August 11?
For all medical necessity reviews, the contractors will check certification documentation for any episodes that have an admission OASIS (Start of Care episodes). For recertifications or subsequent episodes, they will look for certification documentation as well as recertification documentation. The agency must submit all certification documentation as well as recertification documentation for these episode reviews. The reviewer will look for substantiating evidence that the patient was/is eligible for the Medicare home health benefit. IF the review contractor finds the certifying documentation is not sufficient to demonstrate eligibility, the contractor will deny payment or initiate an overpayment demand letter. (Remember CMS does NOT require a specific FORM or format for the certification as long as the certifying physician documents that the five requirements for Medicare home health eligibility are met.)
For recertification, a certifying physician statement which must indicate the continuing need for services and must estimate how much longer the services will be required must be documented by the physician. This, again, should come from the physician’s medical records or be documented on an addendum and signed by the physician just below the documented statement of eligibility and length of services. Again, there is no required standard “form” that is required, and a recertification statement at indicator #26 on the 485 will NOT meet the recertification document requirement.
Because there is no standard form requirement for documenting certification or recertification of a patient’s eligibility to receive Medicare home health benefits, each agency should review and update its policies regarding required documentation. Agencies must bear in mind that they are not to supply this information for the physician, but rather this documentation is to be documented in the physician’s or facility’s records and obtained by the agency before billing Medicare for payment.
For more information on what is required in the agency records regarding certification and recertification of the patient’s eligibility to receive the Medicare home health benefit, including examples from CMS, review the following CMS published documents:
Footnotes:
[1] https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R602PI.pdf
[2] http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf
[3] https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R602PI.pdf, page 7-13
[4] http://www.hhs.gov/healthcare/rights/law/patient-protection.pdf, section 6407.
[5] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf; 30.5.1
[6] http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf; pages 66038-66051
[7] http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf; Page 66049
[8] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c04.pdf
