Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).
Background: Qualifying Criteria for the Medicare Home Health Benefit
To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements:
• Be confined to the home;
• Under the care of a physician;
• Receiving services under a plan of care established and periodically reviewed by a physician;
• Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
• Have a continuing need for occupational therapy.
The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).
Major Documentation Errors
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF. The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:
• The encounter was related to the primary reason for home care
• How the patient’s condition supports the patient’s homebound status; or
• How the patient’s condition supports the need for skilled services
Acceptable FTF documentation does not have to be lengthy or overly detailed. However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.
Following are examples of FTF documentation that, used alone, are considered insufficient documentation.
|Homebound Status||Need for Skilled Services|
|“Functional decline”||“Family is asking for help”|
|“Dementia” or “confusion”||“Continues to have problems”|
|“Difficult to travel to doctor’s office”||List of tasks for nurse to do|
|“Unable to leave home”/ “Unable to drive||“Patient unable to do wound care”|
|“Status post total hip”|
Examples of appropriate documentation include:
• “Wound care to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Skilled nurse visits to perform wound care and assess wound status. Patient on bed to chair activities only.”
• “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema. Short of breath with talking and ambulation of 1-2 feet. Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.”
• “CHF, CLL, weakness, 3+ edema in R & L legs; needs cardiac assessment, monitoring of signs & symptoms of disease, and patient education; homebound due to shortness of breath with minimal exertion, e.g., walking 5 feet.”
• “Status post right total hip replacement. Needs physical therapy to restore ability to walk without assistance. Homebound temporarily due to requiring a walker, inability to negotiate uneven surfaces and stairs, inability to walk greater than 5 - 10 feet before needing to rest. ”
In all cases, your documentation must be specific to that patient’s condition at the time of your encounter with him or her.
Who May Document the FTF Encounter?
The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or a qualified nonphysician practitioner (NPP) working in conjunction with the certifying physician. An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility. That NPP can then report the FTF encounter to the certifying physician.
Medicare guidelines also contain specific documentation requirements:
The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.
If the FTF encounter was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must provide the face-to-face record of the FTF encounter to the certifying physician. NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF.
The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP. He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
The FTF encounter documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare and must include:
The date of the FTF encounter, and
Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services.
Finally, because the FTF encounter is a requirement for payment, when the FTF encounter requirements as outlined above are not met, the home health agency’s entire claim is denied. For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF encounter documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.
Home health agencies may ask you to provide supporting documentation from your medical records to ensure that Medicare will cover home health services. You are permitted, and strongly encouraged, to provide this documentation, the disclosure of which is permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). No specific authorization is required from your patients in order to do this. Also, please note that you may not charge the home health agency for providing this information. We ask you to work in partnership with these agencies so they can provide appropriate and medically necessary care for your homebound patients.