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Lessen the burdens of Medicare's home health requirements

From the February ACP Internist, copyright 2012 by the American College of Physicians

By Michelle Kline

Over the past few months, many ACP members have expressed concerns about Medicare's new home health face-to-face (FTF) encounter requirement. The Affordable Care Act (ACA) established the requirement for certification of eligibility for Medicare home health services to ensure that orders for home health care are based on current knowledge of a patient's condition.

ACP has been working with the Centers for Medicare and Medicaid Services (CMS) to clarify and address many of our members' concerns. A description of the home health FTF encounter requirement and a FAQ are available on ACP's practice management site.

Patients often leave a facility without getting th...

Patients often leave a facility without getting the proper home health face-to-face encounter documentation. This may result in delayed care or not receiving care. Photo by Photodisc



Below are common concerns and ACP's recommendations to address them and ease the burden of this new requirement.

Q: Why are there so many different home health FTF encounter forms? Is there a standard form?

A: According to CMS, as long as the FTF documentation includes the patient's name, the date of the FTF encounter, the physician's description of the patient's clinical condition, and a description of how the condition supports the need for skilled services and homebound status, the documentation would be acceptable. However, different home health service providers use different forms to meet the requirement. Our members report that trying to adhere to many different forms has put an administrative burden on their practices.

Members have reported that home health agencies all have different forms. Although they all must include the same minimum information, each home health agency develops their own forms to adhere to this new requirement. An electronic health record (EHR) would actually ease the burden, as CMS does not require a form, just the documentation of the information which could be printed out from the EHR.

Physicians trying to adhere to the different forms encounter a lack of consistency and standardization, making it more difficult to adhere to the requirement. To ease this burden and ensure that each form fits into the practice workflow, physician practices may develop their own standard form that includes the required information. ACP has created a few example forms online at its practice management website that might be used to fulfill the home health FTF encounter requirement. These forms can be attached to the certification documentation.

Q: Is CMS requiring yet another form for physicians to fill out?

A: Not necessarily. Physicians may include the required information for the home health FTF encounter on the home health care certification documentation and eliminate the need for an additional home health FTF encounter form.

Furthermore, CMS does not require the use of a form at all to fulfill the home health FTF encounter requirement. As long as the necessary information is present, CMS will accept it as the FTF encounter documentation. For example, if the required information is part of the patient's electronic health record, it can be printed and attached to the signed certification.

Q: How can we help prevent patients discharged from hospitals or acute care facilities from falling through the cracks?

A: Patients often leave the hospital or acute care facility without getting the proper home health FTF encounter documentation, and then must be seen by their community physician before receiving home health care. Often, this results in patients not receiving timely home health care or not receiving care at all.

The inpatient physician or hospitalist who cares for a patient in an acute or post-acute facility can help ensure that the patient receives the necessary home health care. The inpatient physician can inform the community certifying physician about his or her encounters with the patient and the patient's need for skilled services and homebound status, and the community physician can use this information to satisfy the FTF encounter requirement, much like a nonphysician practitioner (NPP) currently can.

Alternatively, the physician who cares for the patient in an acute or post-acute facility before the patient's home health admission can perform and document the FTF encounter and certify the patient's home health eligibility, initiate the plan of care, and hand off the plan of care to the patient's community physician.

ACP recommends that community physicians and inpatient physicians work together to develop a plan to fulfill the FTF requirement in an efficient and coordinated manner. In addition, ACP is working with the Society of Hospital Medicine to develop information to notify physicians of these options in fulfilling the home health FTF encounter requirement.

Q: Does the certifying physician have to perform the FTF encounter?

A: Not necessarily. CMS requires the certifying physician to document that he or she or an allowed NPP had a face-to-face encounter with the patient. When the patient's community physician is the certifying physician, certain NPPs or the physician who cared for the patient in an acute or post-acute facility may perform the face-to-face encounter and inform the certifying physician about the clinical findings. However, the certifying physician must document the encounter and sign the certification.

NPPs include nurse practitioners or clinical nurse specialists working in collaboration with a physician in accordance with state law, certified nurse-midwifes, or physician assistants working under the supervision of a physician.

Q: What needs to be included in the “brief narrative”? What does CMS mean by “brief”?

A: The FTF encounter certification requirement must include a brief narrative composed by the certifying physician that describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.

Many physicians find this added documentation component unnecessary, duplicative and unduly burdensome. Members are often concerned about how lengthy and descriptive this narrative must be in order to qualify. However, CMS does not require that the narrative be long and overly detailed. Here is an example from CMS of an acceptable narrative to include on the FTF documentation:”The patient is temporarily homebound secondary to status post-total knee replacement and currently walker-dependent with painful ambulation. Physical therapy is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new chronic obstructive pulmonary disease medical regimen.”

CMS does not currently accept the use of check-off boxes for this requirement, as it does for some other forms. However, following the short and straightforward example above could help minimize the additional burden of providing an acceptable “brief narrative.”

More information on the home health FTF encounter requirement can be found on CMS’ Home Health Agency Center website.

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