home health certification/recertification michigan home ......statement i certify this patient is...
TRANSCRIPT
Home Health
Home Health Certification/Recertification
Michigan Home Care & Hospice Association
May 3, 2017
Home Health
Disclaimer
National Government Services, Inc. has produced this material as an
informational reference for providers furnishing services in our contract
jurisdiction. National Government Services employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of
Medicare information is error-free and will bear no responsibility or
liability for the results or consequences of the use of this material.
Although every reasonable effort has been made to assure the accuracy
of the information within these pages at the time of publication, the
Medicare Program is constantly changing, and it is the responsibility of
each provider to remain abreast of the Medicare Program requirements.
Any regulations, policies and/or guidelines cited in this publication are
subject to change without further notice. Current Medicare regulations
can be found on the CMS website at https://www.cms.gov.
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Home Health
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Attendees/providers are never permitted to
record (tape record or any other method) our
educational events
This applies to our webinars, teleconferences, live events
and any other type of National Government Services
educational events
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Home Health
Acronyms
Acronyms used in this presentation can be
viewed on the NGSMedicare.com website. On
the Welcome page, click on Provider
Resources > Acronyms.
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Home Health
JK/J6 Territories
Jurisdiction K Jurisdiction 6
Maine
New Hampshire
Vermont
Rhode Island
Massachusetts
Connecticut
New York
New Jersey
Michigan
Wisconsin
Minnesota
Idaho
Nevada
Washington
Oregon
California
Arizona
Alaska
Hawaii
Puerto Rico
Mariana Islands
American Samoa
Virgin Islands
Guam
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Home Health
Objectives
To further the understanding of the
documentation that supports home health
certification and recertification
To learn how to avoid errors from the top denials
from the first round of the Probe & Educate
Endeavor
To provide the latest information about the Pre-
Claim Review Demonstration
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Home Health
Agenda
Overview of the Medicare FFS HH Benefit
Five elements of certifying/recertifying HH
Probe & Educate Endeavor and the Top
Reasons for Denial
Pre-Claim Review Demonstration Update
References & Resources, and CERT
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Home Health
Medicare HH Benefit
Services that the Medicare beneficiary may
receive at home include:
Skilled nursing services
Home health aide services
Physical therapy
Speech-language pathology services
Occupational therapy services
Medical social services
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Home Health
Patient/Beneficiary Eligibility
CMS regulations state that when the physician
refers a patient to home health, the patient must:
Be confined to the home
Need skilled services
Be under the care of a physician
Receive services under POC established and reviewed by
a physician
Have a FTF encounter for their current diagnosis with a
physician or allowed NPP
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Home Health
Medicare HH Benefit
For purposes of benefit eligibility, “intermittent”
means:
Skilled nursing care that is either provided or needed on
fewer than 7 days each week or less than 8 hours of each
day for periods of 21 days or less (with extensions in
exceptional circumstances when the need for additional
care is finite and predictable)
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Home Health
Homebound Status
Criteria One
One Standard Must Be Met
Because of Illness or injury, need the
aid of supportive devices such as
crutches, canes, wheelchairs and
walkers; the use of special
transportation; or the assistance of
another person to leave their place of
residence.
OR
Have a condition such that leaving his
or her is medically contraindicated.
Criteria Two
Both Standards Must Be Met
There must exist a normal inability to
leave home.
AND
Leaving home must require a
considerable and taxing effort.
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Home Health
Homebound Status
Declaring any portion of the regulation as a blanket statement copied from the CMS manual is vague (“It’s a taxing effort for the patient to leave home”). Documentation must:
Include information about the injury/illness & the type of support and/or supportive device/assistance required for illness/injury to assist the patient in leaving home
Or explain in detail how the patient’s current condition makes leaving home medically contraindicated
Clarify exactly the distinct difference in the patients normal ability versus their normal inability
Describe exactly what effects are causing the considerable and taxing effort for this patients when leaving home
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Home Health
Homebound Status
If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.
For religious services
For other unique or infrequent events
• Funeral, graduation, hair care
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Home Health
Need for Skilled Services
Documenting the need for all skilled services
requested (including SN, PT/OT/SLP, SW):
Distinguish exactly what services are going to be provided
by the skilled professional in the patients home
Explain why a skilled professional is required to provide
the HH care services requested
Disclose clinical information (beyond a list of recent
diagnoses, injury, or procedure) that is individual and
specific to the patient
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Home Health
Plan of Care
A plan of care has been established and is
periodically reviewed by a physician. As per CR
9189:
The referring/certifying physician’s initial order for home health
services initiates the establishment of a POC (for example:
discharge plan) as part of the certification of patient
eligibility
The physician’s initial order must specify the medical treatments
to be furnished and does not eliminate the need for the POC
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Home Health
Plan of Care
CMS Form 485 is no longer an up-to-date or CMS
endorsed document because the certification
statement does not encompass all five
requirements of certification. It doesn’t reference
the fact that a F2F encounter was performed:
I certify/recertify that this patient is confined to his/her home and
needs intermittent skilled nursing care, physical therapy and/or
speech therapy or continues to need occupational therapy. The
patient is under my care, and I have authorized the services on
this plan of care and will periodically review the plan.
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Home Health
Example of a Complete Certification Statement
I certify this patient is confined to his/her home and needs
intermittent skilled nursing care, physical therapy and/or
speech therapy, or continues to need occupational therapy.
This patient is under my care, and I have authorized the
services on this plan of care, and will periodically review the
plan. I further certify this patient had a face-to-face
encounter that was performed on xx/xx/xxxx by a physician
or Medicare allowed non-physician practitioner that was
related to the primary reason the patient requires home
health services.
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Home Health
Example of a Complete Certification Statement – Ordering IS Certifying but NOT following care
I certify this patient is confined to his/her home and needs
intermittent skilled nursing care, physical therapy and/or
speech therapy, or continues to need occupational therapy. I
have authorized the services on this initial plan of care which
will be further developed by Dr. XXX who is overseeing the
home health services. I further certify this patient had a face-
to-face encounter that was performed on xx/xx/xxxx by a
physician or Medicare allowed non-physician practitioner
that was related to the primary reason the patient requires
home health services.
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Home Health
Face to Face Encounter –DOS Eff 1/1/15
Documentation from the medical record that a visit occurred to ensure that the beneficiary was seen for the reasons (diagnosis) for which home care is being ordered.
Timeframe: A face-to-face encounter can occur 90 days prior to the start of care or within 30 days after the start of home health care.
Can be performed by a MD, NP, PA, CNM, CNS The face-to-face encounter does NOT have to include
information about homebound status or the need for skilled services
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Home Health
FTF Encounter 2015 Changes
2014
FTF Encounter Form
• Narrative mandatory
regarding:
– Need for skilled services,
and
– Homebound status
2015
FTF Encounter
• Documentation from the
patient’s medical record
providing proof that a visit
occurred for same reason
(primary diagnosis) that
home care is being ordered
• Example: discharge
summary or office progress
note
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Home Health
Required Elements of the Certification
Physicians or non-physician practitioners are required to
have face-to-face encounters with beneficiaries before they
certify 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.
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Home Health
Certification
Per CR 9189:
The certifying physician must also document the date of the face-to-face encounter as part of the certification
There is no specific form or format for the certification, as long as the five certification requirements are met
The HHA’s generated medical record documentation for the patient, by itself, is not sufficient in demonstrating the patient’s eligibility for Medicare home health services.
It is the patient’s medical record held by the referring certifying physician and/or the acute/post-acute care facility that must support the patient’s eligibility for home health services.
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Home Health
Recertification
Recertification is required at least every 60 days
Medicare does not limit the number of
continuous episode recertifications for patients
who continue to be eligible for the HH benefit.
The physician recertifying the patients eligibility
is the physician that has been monitoring the
POC and providing oversight of HH Services
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Home Health
Recertification
Per CR 9189 - For all medical necessity reviews,
the Medicare review contractors shall:
Determine whether the supporting documentation
addresses each of the 5 certification criteria.
Review the certification documentation for any episode
initiated with the completion of a home health agency start
of care assessment.
• This means that if the subject claim is for a subsequent episode of
home health service, the home health agency must submit all initial
certification documentation as well as recertification documentation.
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Home Health
Recertification
Recertification must :
Be obtained at the time the plan of care is reviewed since
the same interval (at least once every 60 days) is required
for the review of the plan.
Include an estimate of how much longer the skilled
services will be required – measurable and pt specific
Be signed & dated by the physician who reviews the plan
of care
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Home Health
Collaboration of Supporting Documentation
Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.
Information from the HHA can be incorporated into the certifying referring physician’s and/or the community physician’s medical record for the patient.
The certifying physician must review and sign any documentation incorporated into the patient’s medical record that is used to support the certification.
If this documentation is to be used for verification of the eligibility criteria, it must be dated prior to submission of the claim.
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Home Health
MLN SE 1524Home Health Probe & Educate
CMS implemented a Probe and Educate
medical review strategy to assess and promote
provider understanding and compliance with the
Medicare home health eligibility requirements.
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Home Health
MLN SE 1524Home Health Probe & Educate
MLN SE 1524
First Round: Episodes beginning on or after
August 1, 2015
https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE1524.pdf
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Home Health
MLN SE 1524Home Health Probe & Educate
CMS has directed contractors to select a sample
of FIVE (5) claims for pre-payment review.
Review will focus on HHA compliance with CMS
1611-F and the new regulations highlighted in
CR 9119 and 9189
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Home Health
MLN SE 1524Home Health Probe & Educate
Contractors have been advised by CMS to
repeat the probe & educate process for
providers found to have moderate to major
concerns with claim/medical record review.
ADRs began to be sent January 2017
If the HHA fails to submit five claims, the
provider will be considered moderate concern
(unless four claims were reviewed and the
contractor approved all four).
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Home Health
MLN SE 1524Home Health Probe & Educate
Top Reasons for Denial:
The actual clinical note for the face-to-face encounter visit (physician’s progress note or the facility’s discharge summary) is not being submitted by the HHA when responding to the ADR.
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2 indicates that documentation from the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records are to be used to determine eligibility for the Medicare home health benefit. It further states that this medical record must contain the actual clinical note for the face-to-face encounter visit.
Make sure to submit the actual medical record of the face-to-face encounter with your records for NGS to review. This information can be found most often in clinical and progress notes and discharge summaries.
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Home Health
MLN SE 1524Home Health Probe & Educate
Top Reasons for Denial: The eligibility requirements to substantiate that the patient has the need for
skilled home health services and is homebound must be justified by the documentation in the certifying physician’s and/or the acute/post-acute care facility records.
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2, “The certifying physician and/or the acute/post-acute care facility medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s need for the skilled services and homebound status.”
Examples of documentation to support the need for skilled services and homebound status may include: facility therapy notes, social work or discharge planning records, history and physicals, and other clinical progress notes.
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Home Health
MLN SE 1524Home Health Probe & Educate
Top Reasons for Denial: When the physician from the acute/post-acute care setting is certifying the
patient’s eligibility for home health services but will not be following the patient after discharge, there is no documentation of the community physician who will be following the patient after discharge.
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.2, “One of the criteria that must be met for a patient to be considered eligible for the home health benefit is that the patient must be under the care of a physician. Otherwise, the certification is not valid.”
This requirement only applies when the facility/referring physician is the certifying physician. If the facility physician or a hospitalist is providing the certification of the five required elements, confirm that the community physician is identified by the certifying physician.
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Home Health
MLN SE 1524Home Health Probe & Educate
Top Reasons for Denial: CMS has instructed that the MACs assure that the beneficiary meet all
certification requirements at the start of care. The HHA is not providing the certification and face-to-face encounter documentation from the start of care (SOC) episode when the claim under review is a recertification claim.
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.2, “ The reviewer will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid.
Supply all of the documentation relating to the certification requirements and the face-to-face encounter for the SOC episode even on claims that apply to a recertification period. It is helpful to include the SOC POC with the recertification document, a physician’s certification form if used, any of which can help support the physician certification for the initial episode.
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Home Health
MLN SE 1524Home Health Probe & Educate
Top Reasons for Denial:
The recertification does not include an estimate by the physician of how
much longer the skilled services will be required.
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7,
Section 30.5.2, “The physician must include an estimate of how much
longer the skilled services will be required.”
The HHA should review all recertification forms for the estimate of how much
longer the skilled services will be required; if missing, obtain documented
clarification from the physician before the services are billed to Medicare.
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Home Health
The Centers for Medicare & Medicaid Services
(CMS) plans to implement a three-year
Medicare pre-claim review demonstration for
home health services in the states of Illinois,
Florida, Texas, Michigan, and Massachusetts.
The demonstration began in Illinois on August 3,
2016.
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Pre Claim Review Demonstration
Home Health
As of April 1, 2017, the Pre-Claim Review demonstration was paused for at least 30 days in Illinois. The demonstration will not expand to Florida on April 1, 2017.
After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre-Claim Review requests. During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance via an update to this website of further developments related to the demonstration.
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Pre Claim Review Demonstration
Home Health
CMS is testing whether pre-claim review
improves methods for the identification,
investigation, and prosecution of Medicare fraud
occurring among Home Health Agencies (HHAs)
providing services to people with Medicare
benefits. Additionally, CMS is also testing
whether the demonstration helps reduce
expenditures while maintaining or improving
quality of care.
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Pre Claim Review Demonstration
Home Health
This demonstration could also:
Reduce home health expenditures by avoiding
the delivery of services that are not medically
necessary or otherwise do not meet Medicare
coverage requirements.
Reduce burden on Home Health Agency
providers by allowing them assurance that a
claim is likely to be paid.
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Pre Claim Demonstration
Home Health
The pre-claim review demonstration does not
create new clinical documentation requirements.
HHAs will submit the same information they
currently submit for payment, but will do so
earlier in the process.
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Pre Claim Review Demonstration
Home Health
More information:
www.cms.gov
www.ngsmedicare.com
From the home page, Medical Policy & Review,
then Medical Review. Click on the blue box:
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Pre Claim Review Demonstration
Home Health
Educational Opportunities
Educational Opportunities Go to www.ngsmedicare.com,
click on the Education Tab, then hit the green “Register” button for
any available events
Bi-monthly webinar, “Ordering & Certifying Medicare HH
Services”
Bi-monthly on Tuesday 30 min webinars which focus on
one or two pieces of HH eligibility
YouTube Channel
CBTs at Medicare University
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Home Health
Computer Based Training Sessions
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Clinical Education:
Home Health CBTs at Medicare UniversityTo register and complete CBT courses you must log into Medicare University. If you do not have
a Medicare University account, you can create one on the MU login page for free.
Home Health Qualifying Criteria
Home Health Face-to-Face Encounters & the Plan of Care
Home Health Homebound Status & the Need for Skilled Services
Home Health Certification & Recertification
Home Health Documentation & the Additional Development Request (ADR)
Home Health
2017 J6 Dates: 2/23/17 and 8/24/17
CMS Updates (CRs, MLM Articles, regulatory
changes)
NGS Updates (Articles, Educational Sessions)
Questions Answered Live
Generate Dialogue with Home Health Peers
Minutes published on ngsmedicare.com
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Ask the Contractor TeleconferencesJK/J6 2017 Home Health ACTs
“Look and Feel” Upgrade
When is this happening?
Estimated launch: 1st quarter 2017
What isn't changing?
Functionality
What will you see?
Refreshed visual design
Simplified, intuitive and consistent navigation
Revised logout process
Multifactor Authentication
What is MFA?
Who is impacted? All providers who utilize NGSConnex
When is this happening?
Launch: 1st quarter 2017
What do you need to do now?
Verify User Profile email address
Email address must be unique to you
If applicable, update email address
My User Profile tab
Home Health
References & Resources
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Home Health
2015 Federal Register Reference
Federal Register Vol. 79, No. 215
Released: Thursday, November 6, 2014
Page 66117
http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-
26057.pdf
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Home Health
Clinical Resources
CMS Medicare Learning Network Article
SE 9119
“Manual Updates to Clarify Requirements for
Physician Certification and Recertification of Patient
Eligibility for Home Health Services”
http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/MM9119.
In accordance with its references to Transmittal 92 & 208
in the CMS IOM Publications Manual 100-01 and 100-02
Home Health
Clinical Resources
CMS Change Request 9189
• The purpose of this Change Request (CR) is to
manualize policies in the calendar year 2015
Home Health Prospective Payment System Final
Rule published on November 6, 2014, in which the
CMS finalized clarifications and revisions to
policies regarding physician certification and
recertification of patient eligibility for Medicare
home health services.
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads
/R602PI.pdf
Home Health
Clinical Resources
CMS Medicare Learning Network Article
SE 1524
• Selecting Home Health Claims for Probe & Educate
Review: Episodes that Begin on or After August 1,
2015
• https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE152
4.pdf
Home Health
Clinical Resources
CMS Medicare Learning Network Article
SE 1436
• Certifying Patients for the Medicare Home Health
Benefit
• https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE143
6.pdf
Home Health
CMS References & Resources
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6 https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/pim83c06.pdf
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c07.pdf
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10 https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c10.pdf
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Home Health
Resources – Pre-Claim Review DemoPre-Claim Review Fact Sheet
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Pre-Claim-Review-Initiatives/Downloads/Pre_Claim_Review_Fact_Sheet.pdf
Pre-Claim Review Demonstration for Home Health Services
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Pre-Claim-Review-Initiatives/Overview.html
Pre-Claim Review Demonstration for Home Health Services Operational Guide
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Pre-Claim-Review-Initiatives/Downloads/PCRD_HH_Operational_Guide.pdf
Pre-claim Review Demonstration for Home Health Services Frequently Asked Questions
https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-complianceprograms/pre-claim-review-initiatives/downloads/faq.pdf
Home Health
CERT A/B MAC Outreach & Education Task Force
The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates.
A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program.
Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions
Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate.
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Home Health
CERT A/B MAC Outreach & Education Task Force
CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT
A/B MAC Outreach & Education Task Force
• https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task-Force.html
NGS CERT Task Force Web Page Go to our website, https://www.NGSMedicare.com; in the About Me
drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page.
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Home Health
Email Updates Subscribe to receive the latest Medicare information.
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Home Health
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click on “Yes, I’ll give feedback” when you see
this pop-up so NGS can make your job easier!
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Home Health
Medicare University
Interactive online system available 24/7
Educational opportunities available
Computer-based training courses
Teleconferences, webinars, live seminars/face-to-face
training
Self-report attendance
Website
http://www.MedicareUniversity.com
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