New Medicare Rule: Physician Face to Face Encounter

PPS Refinement 2011: “Physician Face to Face Encounter”

As part of the Affordable Care Act that was signed into legislation on March 23, 2010, several refinements to the Perspective Payment System (PPS) were enacted. One of these refinements which will have an immediate impact on reimbursement and compliance is the Physician Face-to-Face Encounter. Effective January 1, 2011, The Center for Medicare and Medicaid Services (CMS) will require that all Medicare patients have a face-to-face encounter with a physician or certain non-physician practitioners within 90 days prior to or within 30 days of the initial start of home healthcare for a patient. Preparation for compliance with this newly released rule is imperative and should be reviewed and implemented by the January 1, 2011 effective date.

Rule Overview

As a condition for payment, the Physician Face-to-Face Encounter mandates that, prior to certifying a patient’s eligibility for the home health benefit, the physician must document that the physician or a permitted non-physician practitioner (NPP) has had a face-to-face encounter with the patient. Physician’s or non-physicians encounters with a patient must be conducted within 90 days prior to or within 30 days of the initial start of care date for home healthcare patients. The goal for the implementation of this rule as noted in the final rule published on November 17, 2010 in the Federal Registry is an effort by the federal government to have greater physician accountability in certifying a patient’s eligibility and establishing a patient’s plan of care.

Who Can Perform the Face-to-Face Encounter?

The rule clearly identifies which healthcare practitioners are qualified to certify a patient’s eligibility for the home health benefit. The most obvious of these practitioners is the patient’s primary care physician, however the indicated primary physician cannot be employed or have a financial relationship with the home care agency. A second group of providers that are qualified to perform the face-to-face encounters are described as non-physician practitioners (NPP’s). Qualified non-physician practitioners include nurse practitioner, clinical nurse specialist, certified nurse-midwives and physician assistants who are working in collaboration or under the supervision of the physician. As in the case with physicians, non-physician practitioners cannot be employed or have a financial relationship with the home care agency.

Documentation of the Encounter

Documentation of the encounter is the most significant point of this new rule. As many clinicians are familiar with the saying “if you did not document it, you did not do it” this holds especially true in the case of the face-to-face encounter. Although non-physician practitioners are able to certify patients eligibility for the home health benefit the physician must document the encounter. The rule explicitly states that “the certifying physician must document the face-to-face encounter regardless of whether the physician himself or herself or one of the permitted NPPs perform the face-to-face encounter.”

Details of the Encounter

In addition the rule outlines very specific documentation requirements and related rationale for supporting the reason for the visit. In order for a patients visit to a practitioner to be considered a viable face-to-face visit the reason for the encounter must be related to primary reason for home health. Non-physician practitioners performing face-to-face encounters are required to communicate their findings to the certifying physician and document findings in the medical record. With regards to detailed information required for the home health certification, documentation must be present of date of the encounter, explanation of why clinical findings of encounter support the patient’s homebound status and need for intermittent skilled nursing or therapy services. The rule goes further to state that the physician must document this information on the certification document or addendum.

Tele-Health

The Affordable Care Act also allows the encounter to be satisfied through the use of tele-health services. Tele-health encounters are subject to the requirements in section 1834(m) of the rule, which limits encounters to one of the specified types of originating sites.

Tips for Compliance

It is important to understand that the Face-to-Face Encounter is a legislative mandate and condition for payment. With the January 1st deadline quickly approaching planning and implementation of a compliance plan for this new rule is key for preventing any reimbursement issues in the near future. Here are a few tips to assist your agency with complying with the new rule:

• Educate All Staff on New Rule (example: Conduct in-services)
• Educate Patients (example: send informational letter to all new and current patients about physician encounter requirements & timeframe)
• Educate Physicians & Staff (example: Develop information letter, conduct in-service for office staff)
• Educate Referral Sources
• Prior to/At time of admission request supporting documentation (example: most recent history & physical, date(s) of last office visit from qualifying physician)
• Assist patient with scheduling appointment with certifying physician prior to expiration of 30-day window
• Coordinate appropriate referrals (example: MSW-for transportation assistance, referral for visiting/in-home physician visit for patients who unable to leave their homes)
• Develop evaluation and tracking process to ensure all new patients are compliant (example: as part of the admission process request H&P and recent physician office visit dates; for patients who have not been seen develop process to assist patients with scheduling appointment with certifying physician)

The National Association for Home Care (NAHC) has created a series of beneficiary and physician educational letters and notices of non-coverage to share with the home health community. We have provided links to the letters below that agencies can customize to meet their needs.

• Patient Letter: Informs home health patients that there are new face-to-face encounter requirements.
• Patient Information about Face-to-Face: Provides home health patients detailed information on face-to-face encounter requirements.
• Notice Potential Discontinuation of Care: Notice of possible discharge for failure to have a Physician Encounter
• Notice of Non-Acceptance: Advises patients why they have not been accepted by a home health agency that decides to only accept patients who have had physician face-to-face encounter prior to admission.
• Notice of Termination: Advises patients of termination by the home health agency because they failed to comply with encounter requirements.
• General Letter to Physicians: Generic letter informs/educates all physicians of face-to-face encounter requirements.
• Referring Physician Letter: Informs/educates physicians who have referred a patient for home health services about face-to-face requirements.
• Referring Source Notification: Generic letter informs/educates all referring sources about face-to-face encounter requirements.
• Model Physician Referring Overview Face-to-Face: Requirement for A Face-to-Face Encounter between the Patient and the Patient’s Physician or Non-Physician Practitioner
• Guide to Documentation: Template identifies specific information that physicians must provide as derived from their encounter with patients.

Click here to view these letters on the NAHC website.