With margins tight, staffing pressures constant, client acuity rising, and a host of other challenges for home heath agencies, they can’t afford to see their Medicare reimbursements jeopardized or delayed.
To make sure they’re getting the basics right, agencies may want to double-check their practices against the following information on face-to-face documentation and supporting homebound status, which was shared by Medicare Administrative Contractor (MAC) CGS at the National Association for Home Care & Hospice (NAHC) annual conference this week in Orlando.
“I get a lot of questions when I’m out and about, when do I have to get a new face-to-face?” said Sandy Decker, RN, senior provider education consultant at CGS. “It’s really simple. If you have the need for a new start of care OASIS, then you need a new face-to-face. If you have a readmission OASIS, anything like that, you don’t.”
The face-to-face also has to be for the main reason a patient is coming to home health, Decker noted. For instance, if a patient sees a physician numerous times in the 90 days before the start of care for COPD, but then falls and breaks an ankle and that precipitates the home health episode, that is what the face-to-face has to cover.
Also, the face-to-face should focus on the main condition rather than a side effect, Decker explained. As an example, one provider turned in a face-to-face that was all about a patient’s depression and anxiety, even though the individual just had undergone a surgery.
“I understand that having surgery can cause depression and anxiety, but it never mentioned the surgery, so we couldn’t accept the face-to-face,” she said.
Other face-to-face issues sometimes crop up when the patient is coming to home health right after a hospital or skilled nursing stay. In these cases, the face-to-face does not have to be done by the certifying physician, but the certifying physician must document the date of the face-to-face.
“There’s a real easy way to do that,” Decker said. “On your 485, [include] a sentence that says ‘The face-to-face encounter was performed on [blank date], by doctor so-and-so.’ Then the certifying physician signs the 485, and they [may] never even know the sentence was on there. But if that sentence is on there, and they sign it, it means they’ve documented the date of the face-to-face encounter, and you’re good.”
If, say, the hospitalist performed face-to-face and also signed the certification, then they have to identify who will be the community physician taking care of that patient, she added.
“This is showing continuity of care,” she said. “There are a lot of face-to-face forms out there, especially that come from hospital software, that have enough information on there to count as a certification. If it talks about homebound status or need for skilled care, then it could be considered a certification, and the person who fills it out has to identify the name of the community physician.”
Another area of focus was supplemental documentation to the face-to-face to support the need for home health. This is needed because the face-to-face encounter documentation often is not explicit about the patient’s homebound status.
“I don’t mean to be derogatory, but physicians don’t care about the patient’s homebound status,” Decker said. “They are concerned with the need for skilled care and what needs to happen to get that patient better.”
Therefore, it falls on the shoulders of the home health provider to bolster the physician’s documentation for the homebound status. This supporting documentation can be created or generated by the agency or be information that the agency has obtained, such as a discharge summary.
Once that documentation is sent to the physician’s office, the physician needs to sign and date it. A rule of thumb is that every time there is a physician’s signature, it needs to be followed by a handwritten date, Decker said. Another MAC in attendance at the conference, Palmetto, also confirmed that dates need to be handwritten as opposed to stamped.
As for whether the physician needs to sign every page, this is not necessary, as long as the pages are numbered in such a way that it is clear a signature at the end covers the entire document. For example, numbering pages “1 of 12,” 2 of 12,” and so on.
Finally, keep in mind that homebound status does not mean that the beneficiary can never leave the house, Decker said. They can leave their house if it’s infrequent, for periods of relatively short duration. Not only leaving the house to receive medical treatments, but also to attend religious services, or even attending adult day care on a daily basis, all could be allowed without compromising someone’s homebound status.
Special events such as weddings and funerals also are acceptable, as are other uncommon occasions—a home health patient leaving the house to attend the Iowa State versus University of Iowa football game was one example Decker provided.
“When you have a patient with something like that, what you’re wanting to put in your documentation is, what was the aftermath of that?” she said. “He probably had to rest up for at least a week, maybe two weeks. He may have been completely in bed for three days because he was so exhausted.”
Written by Tim Mullaney