We just passed the tenth anniversary of the implementation of the physician face-to-face encounter—issued as Medicare Benefit Policy Manual, IOM Pub. 100-02, Chapter 7, Section 30.5.1.1 – Face-to-Face Encounter (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11).
This was amended significantly in 2015 with the elimination of the physician narrative requirement and implementation of the need for home health agencies to obtain the actual encounter note when requested by CMS or its contractors:
30.5.1.1 – Face-to-Face Encounter
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15) and
30.5.1.2 – Supporting Documentation Requirements
(Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)
One might think that after ten years of practice to get it right that home health agencies would have this requirement down pat and it would not cause any issues during CMS’s medical review. However, it has sadly maintained its status as a top reason for claim denials despite any and all efforts of home health agencies. This is from all Medicare Administrative Contractors in all jurisdictions. PGBA Denials and CGS Denials
Even Medicare Advantage reviews commonly cite deficiencies with the physician face-to-face as a top denial reason.
Common issues causing the denials include the encounter not being obtained, the date of the encounter not identified by the certifying physician, the encounter not being related to the reason for home health service, the encounter not performed by an allowed provider, the encounter not being performed by a certifying physician, or the encounter does not support homebound status.
From this impressive list of possible problems many agencies struggle to obtain, review, and follow-up to ensure a valid physician face-to-face encounter is placed in the record timely. Even if not under the Review Choice Demonstration (that specifically checks this as part of the review options), the encounter should be included in the record prior to physician certification of home health service. This is a key quality assurance/chart audit function.
Adding to this the problem that even obtaining the actual encounter note from the allowed practitioner who completed it can pose a challenge. And when notes are received, they often show few issues with the patient or are not related to the primary reason for home health service. Even visiting physician groups, who presumably understand the home health requirements better than most physicians, often generate notes with few or no problems in the History of Present Illness or Review of Systems. And a quick path to a denial is the Chief Complaint for the encounter being a “Well-Visit” followed by no problems identified.
So, what is the home health agency to do to address this persistent and pervasive issue? Here are a few pointers to get started:
Designate an office staff to verify that the physician face-to-face encounter documents are received.
Designate an office staffer to actually read the encounter notes for content: relation to home health need, date of encounter, and allowed provider completing it.
Integrate the encounter into the coding and Plan of Care generation process. The findings from the encounter, the Plan of Care, and the OASIS Comprehensive Assessment diagnoses/coding should align and corroborate each other.
Perform these checks as part of the admission process and plan of care generation process—NOT LATER.
Then, prior to final billing check these items are present and suffice to meet the specific certification requirements. This will give one last chance to obtain clarifying content prior to the claim being submitted—when CMS clearly expects a valid timely correct physician encounter to be part of the record.
Use MAC provided resources to educate staff and physicians on the immense importance of the encounter (Such as CGS FTF). Understand that every home health agency wants to get the same compliant documentation from the physician, so it should not be a new concept to them.
Persistence and giving review of the encounter its due importance are the baseline requirements to seek compliance with this issue. There is no excuse why, ten years from now, that we should be having the same outcomes.
Joe Osentoski BAS, RN-BC
ADR and Appeals Specialist
Gateway Home Health Coding & Consulting