Key Home Health Audit Risk Areas Providers Need to Be Prepared For
Home health providers are well advised to prepare now for RAC audit activity. While the RACs haven't taken aim at home health agencies on the approved issues list, providers can take heed of key audit risk areas identified in the audits conducted.

August 26, 2011 /24-7PressRelease/ -- Home health providers are well advised to prepare now for RAC audit activity. While the RACs haven't taken aim at home health agencies on the approved issues list, providers can take heed of key audit risk areas identified in the audits conducted by Medicare Administrative Contractors (MACs) and Program Safeguard Contractors (PSCs) / Zone Program Integrity Contractors (ZPICs). In addition to the implementation of the face-to-face encounter at the start of home health care, providers should implement compliance measures to improve documentation related to homebound status, the need for skilled services, and the patient's functional deficits, as well as the requirements for physician certification and plan of care.

A provision of the Patient Protection and Affordable Care Act (PPACA) requires physicians to perform face-to-face encounters with their home health patients as part of the home health certification requirements. The PPACA provision required implementation of face-to-face encounters by January 1, 2011, but the final rule released on November 17, 2010 indicated that CMS would not begin enforcement of this new protocol until April 1, 2011. In order to satisfy the face-to-face requirements, the encounter must take place not more than 90 days prior to, or within 30 days after, the start of the home health care. The encounter may occur up to 90 days prior to the start of home health, if this previous face-to-face encounter was related to the reason the patient requires home health services.

The encounter is required to be performed by a physician or an allowed non-physician practitioner (NPP), i.e., advanced practice nurse or physician assistant. If an NPP performs the face-to-face encounter, the practitioner must document the clinical findings and communicate those findings to the certifying physician. The documentation of the face-to-face encounter must be a separate and distinct section or an addendum to the certification, and must be signed and dated by the certifying physician. The documentation of the encounter also needs to include an explanation of why the clinical findings support that the patient is homebound and in need of either intermittent skilled therapy and/or skilled nursing services. The certification must to be signed and dated by the certifying physician who established the patient's home health plan of care. The face-to-face encounter and related documentation must now be made part of the home health certification process.

The documentation required in connection with the face-to-face encounter implicates other audit risk areas home health providers are currently seeing targeted in MAC and ZPIC audits. Homebound status is a key audit target of the Medicare contractors. In order to qualify for coverage of home health services, the patient must be confined to the home in accordance with the Medicare guidelines. In order to meet the homebound requirement for home health services, the patient does not have to be bedridden. Instead, the patient will be considered homebound if the patient's condition is such that there exists a normal inability to leave home and, as a result, leaving home would require a considerable and taxing effort.

When documenting that the patient is homebound, it is important for home health providers to note physical and psychological limitations that prevent the patient from leaving home. This documentation may take the form of the patient's limitations in performing activities of daily living, vision and hearing impairment, limited endurance or dyspnea, as well as the use of supportive devices (crutches, canes, wheelchairs and walkers), the use of special transportation, or whether they require the assistance of another person to leave the home. Home health providers should continue to document these factors throughout the certification period to provide support that the patient continued homebound status.

Contractors often point to absences from the home as evidence that the patient is not homebound. The Medicare Benefit Policy Manual specifically provides that a patient may be considered homebound if the absences from the home are infrequent or for periods of relatively short duration or are attributable to the need to receive health care treatment. Absences for the purposes of attending a religious service or an occasional absence for attendance at a family function (i.e., funeral, graduation, reunion) would not disqualify the patient from being considered homebound for purposes of home health. Documentation of the facts surrounding the patient's absence from the home, for example, in connection with a missed visit, may prove helpful in defending a future audit denial that the patient was homebound.

Another common denial rationale cited in home health audits is that the documentation did not support that the skills of a nurse and/or physical therapist were reasonable and necessary. In making this determination, the Medicare guidelines instruct contractors to consider both the inherent complexity of the services provided, as well as the condition of the patient, to determine if skilled management of the services provided is needed though many of the specific services do not require the skills of a nurse or therapist. In light of this denial, it is imperative that providers adequately document both the treatments and modalities utilized in treating the patient, as well as the patient's condition. For example, providing sufficient detail about the therapy modalities employed, such as the type of therapeutic exercises, number of repetitions, etc., as well as information regarding how these modalities may have changed due to the patient's improvement over the course of treatment, can provide strong support for the defense of a future audit denial. Further, providers are often faced with denials stating that the "documentation does not support a complex function deficit" to warrant ongoing therapy. While the Medicare Benefit Policy Manual does not expressly require documentation of a "complex functional deficit," it is often.

Big risk area - face to face

Certification / Plan of Care

Homebound status

PT - functional decline

Home health patients will be getting more face time with their physicians starting in early 2011. A provision of the Patient Protection and Affordable Care Act (ACA) requires physicians to perform face-to-face encounters with their home health patients as part of the home health certification requirements. The ACA provision required implementation of face-to-face encounters by January 1, 2011, but on November 17, 2010, CMS promulgated a final rule laying out the framework for the face-to-face encounter, and indicated that it would not begin enforcement of this new protocol until April 1, 2011. This delay in enforcement was in response to comments during the notice and comment period that patient care might suffer while physicians and home health agencies adapted to the new regulations in such short order. Thus, home health agencies have just a few months to comply with the new face-to-face requirements before facing claim denials.

In order to satisfy the face-to-face requirements, certain criteria must be met. First, the encounter must take place not more than 90 days prior to, or within 30 days after, the start of the home health care. The encounter may occur up to 90 days prior to the start of home health, if this previous face-to-face encounter was related to the reason the patient requires home health services. Second, this encounter must be performed by a physician or an allowed non-physician practitioner (NPP), i.e., advanced practice nurse or physician assistant. If an NPP performs the face-to-face encounter, the practitioner must document the clinical findings and communicate those findings to the certifying physician. The documentation of the face-to-face encounter must be a separate and distinct section or an addendum to the certification, and must be signed and dated by the certifying physician.

Both physicians and NPPs who have a financial relationship with a home health agency are prohibited from conducting the face-to-face encounter unless the relationship falls within a Stark or anti-kickback exception. This regulatory requirement prevents a home health agency from hiring physicians or NPPs to perform the face-to-face encounters and is an important consideration for a home health agency setting up program for compliance with the new requirements.

Documentation of the face-to-face encounter needs to include an explanation of why the clinical findings support that the patient is homebound and in need of either intermittent skilled therapy and/or skilled nursing services. The certification must to be signed and dated by the certifying physician who established the patient's home health plan of care. The face-to-face encounter and related documentation must now be made part of the home health certification process.

It is extremely important for home health providers implement compliance measures now. CMS has indicated that it will issue instructions to its contractors in connection with medical reviews and program integrity activities. These contractors will be tasked with making sure that providers are complying with the required timeframes set forth for the face-to-face encounters. CMS has also indicated that partial payments will not be made if the face-to-face encounter is performed outside the required timeframes. For example, if the patient has their face-to-face encounter with the physician on the 33rd day of care, the home health agency will not be able to bill for days 1 through 32. Home health agencies need to be aware of whether or not this condition has been met, and if not, take immediate action to remedy the situation. This can be a costly mistake and health home providers need to construct procedures for making sure these new restrictions have been met. Foresight and planning prior to the April 1st implementation deadline will go a long way to alleviate any potential pitfalls with the government enforcement of this provision begins.

Physicians and home health agencies should note that the face-to-face encounter is only required for the initial certification, and is not required for any subsequent recertification. A hospitalist could determine a patient's need for home health based on a face-to-face encounter that occurred under the physician's care during an acute hospital stay. The hospitalist should document the encounter, perform the certification and review of the initial plan of care, and then clearly communicate the name of the physician in the community (i.e., the patient's primary care physician) who will continue to follow the patient going forward. The face-to-face encounter may also be conducted via telehealth services. These telehealth encounters would need to comport to the telehealth requirements of section 1834(m) of the Social Security Act. The face-to-face requirement is only applicable to Medicare fee for service billing, so it is not a requirement of Medicare Advantage plans.

Home health agencies and physicians need to collaborate proactively to create an effective way to conduct these face-to-face encounters and patient certifications in order to ensure compliance with these new requirements. Compliance with the encounter and certification requirements and the requisite timelines is vital to avoiding unnecessary claim denials. This cooperation needs to happen quickly as the April 1, 2011 enforcement date is rapidly approaching.

Press Release Contact Information:

Cheryl Sawicki
Wachler & Associates, P.C.
Director of Operations
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Royal Oak, MI
United States 48067
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