Part B Insider (Multispecialty) Coding Alert

Face-To-Face:

MACs Deny Staggering 92 Percent of Claims Under F2F Audits

Published on Mon Apr 11, 2016

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One MAC maintains nearly a 100 percent denial rate.

The face-to-face physician encounter rules that took effect last year are plaguing both physicians and home health agencies, and a recent audit reveals that most practitioners aren’t up to speed with the requirements just yet.

The proof: In the Probe & Educate medical review initiative Medicare launched at the end of last year, two Medicare Administrative Contractors have denied more than 90 percent of claims reviewed so far. National Government Services recently said it has denied 300 of 309 claims reviewed under the probe and educate (P&E) audits — 97 percent. And CGS says that it has denied 808 of 904 claims reviewed — 85 percent. Combined, the NGS and CGS reviewers have denied 92 percent of the claims they’ve reviewed thus far. (That includes partial denials, CGS points out.)

Palmetto GBA says it is not releasing P&E denial stats yet due to the small sample size that the MAC reviewed, a Palmetto spokesperson says. Also, results wouldn’t include appeals, the MAC points out in a statement. Palmetto will issue results on its website later, it adds.

In a quick breakdown, CGS ranks its P&E denial reasons:

# 1 denial reason: Certification issues — 57 percent (breakdown below)
# 2 denial reason: No response to ADR — 30 percent
# 3 denial reason: Medical Necessity of therapy services — 7 percent.

Of the 57 percent of claims CGS denied due to certification issues, the reasons were:

F2F missing/incomplete/invalid (91 percent)
Untimely POC/certification (2 percent)
POC/Certification not signed (2 percent)
Missing certification/POC (2 percent)
Recertification estimate missing (1 percent)
Initial cert missing/invalid (1 percent).

Reminder: CMS implemented new F2F documentation rules in January 2015. Under the new requirements, physicians no longer have to furnish a narrative, but they now must proffer their own clinical records to substantiate a patient’s home care stay. Last summer, CMS announced its P&E medical review push focused on face-to-face physician encounter compliance, and in November, the agency said that the reviews would “assess and promote provider understanding and compliance with the Medicare home health eligibility requirements.” Specifically, CMS highlighted the requirement that took effect in 2015: “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) is to be used as the basis for certification of home health eligibility,” the article notes.

The certifying physician “can incorporate information obtained from or generated by the HHA into his or her medical record, to support the patient’s homebound status and need for skilled care, by including it in his or her documentation and signing and dating to demonstrate review and concurrence,” CMS told practices last fall.