Part B Insider (Multispecialty) Coding Alert

Published on Thu May 17, 2012 PDF

Medicare has finally loosened up on some unnecessarily strict documentation requirements for face-to-face encounters with physicians who are certifying home health. But just how loose the rules have gotten is under debate.

In a new MLN Matters article, "A Physician's Guide to Medicare's Home Health Certification, including the Face-to-Face Encounter," CMS gives its official approval to physicians using checkboxes in their documentation of the F2F encounter. "The face-to-face documentation can include, or exist as, checkboxes so long as it comes from the certifying physician," CMS states.

This is an about-face from earlier CMS statements, which said checkboxes were not allowed and that physicians must write a narrative in their own words.

Reminder: "For initial home health certifications, the certifying physician must document that the physician himself or herself, an allowed NPP, or a physician caring for the patient in an acute or post-acute facility who has privileges at the facility had a face-to-face encounter with the patient," CMS explains in the article. The encounter must occur up to 90 days before or 30 days after the start of care.

Be careful: But CMS's communication about checkboxes isn't entirely clear, leaving some providers reluctant to encourage referral sources to use them.

The MLN Matters article still also says that "documentation includes a brief narrative which describes how the patient's clinical condition, as seen during that encounter, supports the patient's homebound status and need for skilled services."

And in a new set of questions-and-answers about F2F topics, CMS replies "it depends," when asked whether referral sources can use F2F forms that utilize checkboxes. "We would not allow a form created by the HHA, which contained only checkboxes for the certifying physician to check off, to satisfy the requirement," the agency warns.

However: "We accept documentation which was generated and/or extracted from a physician's medical record by the physician's support staff, assuming it contains all the required content, regardless of what format it is in," CMS continues. "As long as it comes from the certifying physician, checkboxes either generated from a physician's electronic health records, or more simply created and used by a physician for documentation purposes, are allowable."

In a separate Q&A, CMS says it's OK for physicians to "use their own electronic medical records with drop down menus to select from prepared descriptive language when completing the face-to-face encounter documentation."

"This allows the sort of flexibility where such documentation could be dictated by the physician to one of his support personnel, or to allow it to be generated by the physician's electronic medical record software," CMS explains. "Such is common practice for physicians to document their patient encounters."

The new MLN Matters article is online at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1219.pdf. The Q&As are at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/QandAsFull-5-4-12.pdf.