In the early days of CMS’ new nationwide home health “Probe and Educate” review, nearly 90% of claims have been denied – with MAC NGS denying 97% of all claims reviewed! It’s clear that issues remain with face-to-face (F2F) documentation despite recent regulatory changes.
For a few years the Affordable Care Act has required a physician or a non-physician practitioner to have a face-to-face encounter with the beneficiary before a physician certifies the beneficiary’s eligibility for the home health benefit. One aspect of the certification is for the certifying physician to certify (attest) that the face-to-face encounter occurred and document the date of the encounter. For medical review purposes, Medicare requires documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records to be used as the basis for certification of patient eligibility. This documentation must include the clinical note or discharge summary for the face-to-face encounter. To avoid home health claims payment denials or improper payment recoveries agencies and physicians must understand Medicare’s requirements.“…the industry is essentially on the cusp of all providers needing a modern and effective way to handle denied claims in lockstep with the transition to value-based care and, to a lesser extent, the upcoming Oct. 1, 2106 date after which the Centers for Medicare and Medicaid Services is poised to demand greater specificity in claims submitted using ICD-10 codes.” — from Healthcare Finance News article
Resources:
- CY 2015 Home Health Prospective Payment System Final Rule
- Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1
- National Provider Call: Certifying Patients for the Medicare Home Health Benefit
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