Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 06, 2015 PDF

Your best bet is to fill out the eligibility record at the time of hospital discharge

If your patient qualifies for home health coverage, it’s up to the physician to confirm the patient’s eligibility—and any delays in your documentation could create logjams for patients and the home health agencies planning to care for them.

To ensure that patients are able to smoothly move from the hospital or rehab facility to home health care, follow these steps that will keep the paperwork—and the reimbursement—flowing.

Background: Starting for episodes in 2015, medical reviewers will look to certifying physicians’ records to prove a patient’s eligibility for the Medicare home care benefit, CMS reviewed in a December National Provider Call, “Certifying Patients for the Medicare Home Health Benefit.” Physicians must show that the visit met these three elements for the face-to-face (F2F) encounter without any help from the home health agency:

1. Occurred within the required timeframe,
2. Was related to the primary reason the patient requires home health services; and
3. Was performed by an allowed provider.

The physician record must also show these two elements, but the physician can merely sign off on a home health agency (HHA) summary substantiating these items:

4. Need for skilled services, and
5. Homebound status.

Don’t Dilly-Dally

Industry veterans and even CMS itself all agree on the best strategy to ensure compliance with the new F2F rules—and it involves the physician giving the appropriate paperwork to the HHA from the get-go.

Here’s why: Under the new rules, HHAs must submit the physician’s substantiating documentation to the Medicare contractor reviewing the claim, said CMS’s Jill Nicolaisen during the call. But “the home health agency is not required to have a copy of the physician’s documentation prior to submitting a claim for reimbursement,” Nicolaisen acknowledged.

However: “Because eligibility for home health services is established by the physicians in the patient’s medical record, the home health agency may want to consider obtaining this documentation as early in the home health episode as possible to assure themselves that the Medicare home health patient eligibility criteria has been met,” Nicolaisen said. “While not a Medicare requirement, the home health agency may implement such a procedure as a sound business practice.”

The Illinois Homecare & Hospice Council recommends that “the agency ask for the physician’s note on the face-to-face encounter or the hospital/nursing home’s discharge summary at referral so that they get this documentation on every patient as early as possible,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. “In this way, they will be able to assess their liability.”

Take the Next Step

Just providing the visit note isn’t enough to ward off F2F denials. You need to check it for the required five elements before you share it with the HHA. If the note is missing the three elements required to be furnished by the physician, the HHA will send it back for correction.

If your physician certifies a significant number of patients as eligible for home health, you should set up a procedure so it’s easy for the providers to include documentation of the necessary visit, homebound and skilled need information in every home health patient’s record.