Avoid Denials and Protect Your Bottom Line with

Face to Face Compliance

Presented live on September 17, 2013 and by video ongoing

Presented by:

Rhonda Will RN, BS, COS-C, BCHH-C

Assistant Director Clinical Competency Institute

Fazzi Associates, Inc.

Fazzi Associates, Inc.

Continuing Education Activity

Required Disclosures to Participants

Successful Completion of this Continuing Nursing Education Activity

To receive the certificate awarding contact hours for this CNE activity, you must:

Listen to entire educational activity.

Complete the evaluation.

Conflicts of Interest

A conflict of interest occurs when an individual has an opportunity to affect educational

content about health care products or services of a commercial company with which

she/he has a financial relationship.

The planners and presenters of this CNE activity have disclosed no relevant financial

relationships with any commercial companies pertaining to this activity.

There is no commercial company support for this CNE activity.

There is no noncommercial support for this CNE activity.

Fazzi Associates, Inc.’s accredited provider status refers only to continuing nursing

education activities and does not imply that there is real or implied endorsement of any

product, service, or company referred to in this activity.

Fazzi Associates, Inc. Continuing Education Activity Session and Contact Hour Info

Objective for this session 1. Identify the needed components for Face to Face documentation to ensure comprehensive Home

Care Plan of Care and regulatory compliance.

Presenter Bio Rhonda Will RN, BS, COS-C, BCHH-C, has experience as a registered nurse since 1971 and has worked in home health care since 1979 in various clinical, administrative and management roles. Has extensive experience as a trainer. Her areas of expertise include PPS and OASIS assessment skill building, documentation, care planning and care management, regulatory compliance, and policy and procedure development.

With Fazzi Associates Rhonda has developed the OASIS audit and clinical and management training programs and basic ICD-9-CM Coding training and oversees the clinical auditors and trainers. She presents OASIS and basic coding training on site and by audio conferencing for home health agencies, state home health associations and national professional and commercial organizations. She provided clinical leadership for the 2003 3M National OASIS Integrity Project, clinical director of the National OASIS-C Best Practices Project 2009, and a facilitator at the Delta National Excellence in Therapy Forum September 2010. In January of 2008, in collaboration with a physical therapy colleague, she developed and produced a series of electronic streaming videos for home health care orientation.

Rhonda has developed a reputation in the home health industry as an OASIS Expert: reviewed the draft OASIS-C Guidance Manual for CMS 2009; reviewed Tina Marelli’s .Handbook of Home Health Standards: Quality Documentation and Reimbursement, 5th edition 2009; Editorial board member and peer reviewer for “Home Healthcare Nurse” 2012; Speaker for national and state home care associations and vendor conferences.

Rhonda’s training style ensures that participants walk away motivated and armed with simple and practical information for easy application in their day to day responsibilities.

Directions on how to Receive Contact Hours This continuing nursing education activity was approved for 1 Contact Hour. Fazzi Associates, Inc. is an approved provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. 1. If you have questions from the presenters about program content or other concerns contact via email

training@fazzi.com. 2. Each participant must complete an electronic evaluation in order to receive contact hours. 3. Click on the following link in order to access the online evaluation form:

https://www.surveymonkey.com/s/YNDB58G.

Instructions and Handouts for:

Avoid Denials and Protect Your Bottom Line with Face to Face Compliance

September 17, 2013

It is very important that you have these materials printed and ready to use prior to the

start of the training.

In order to participate in this training you will need to do the following:

1. Dial 1-877-655-0051 at least 10 minutes prior to the start of the tele-training.

2. When prompted, enter Conference ID Passcode: 889-501-758.

3. If at any time you need assistance you may press *0 for the operator.

4. There will be a Q & A period toward the end of the session. Questions will be

answered in the order in which they are received. To ask a question, press *1. You

will have the opportunity to ask your question and then be returned to “listen mode.”

Do not press *1 prior to this time.

5. To view the presentation online, you must click on the link sent to you from

GoToWebinar.

* Note: Please do not forward your own webinar login information as each one is email

specific. Once you are logged in to the webinar anyone else that tries to use your

information will not be allowed in.

1

3

2

5 6

7

8

9

11 12

10

4

1

3

2

5 6

7

8

9

11 12

10

4

1

3

2

5 6

7

8

9

11 12

10

4

1

3

2

5 6

7

8

9

11 12

10

4

Eastern Standard Time

1:00 PM to 2:30 PM

Central Standard Time

12:00 PM to 1:30 PM

Mountain Standard Time

11:00 AM to 12:30 PM

Pacific Standard Time

10:00 AM to 11:30 AM

9/12/2013

1

Presented by:Rhonda Will RN, BS, COS‐C, BCHH‐C

Assistance Director Clinical Competency InstituteFazzi Associates, Inc. 

Avoid Denials and Protect Your Bottom Line 

with Face to Face ComplianceSeptember 2013

Successful Completion of Education Activity • Listen to entire program • Complete evaluation 

Disclosures• No conflict of interest for presenters & planners• No commercial company support• No noncommercial company support• No endorsement of any products, services, or company

DISCLOSURES

1. Identify the needed components for Face to Face documentation to ensure comprehensive Home Care Plan of Care and regulatory compliance.

OBJECTIVE

9/12/2013

2

Presented by:Rhonda Will RN, BS, COS‐C, BCHH‐C

Assistance Director Clinical Competency InstituteFazzi Associates, Inc. 

Avoid Denials and Protect Your Bottom Line 

with Face to Face ComplianceSeptember 2013

FACE TO FACE DENIALS

• Contractor analysis of Comprehensive Error Rate Testing (CERT) Reviews

• Continuing increase in denials related to F2F documentation

• Palmetto and CGS conducting widespread audits

• Has one contractor really denied 399 claims out of 801 within an 11 day period?

DENIAL REASONS

• No F2F encounter documentation

• Insufficient F2F encounter documentation

• F2F encounter not obtained within the required time frame

• Issues related to the physician signature– No signature– Missing co‐signature from the certifying physician

9/12/2013

3

INSUFFICIENT DOCUMENTATION

• Brief narrative describing how the patient’s clinical condition, as seen during that encounter, supports the patient’s homebound status and need for skilled services. 

• Encounter is related to the primary reason for home care

PHYSICIAN CERTIFICATION

• 42 CFR 424.22 Requirements for home health services; conditions for Medicare payment

• Requires physician certification/recertification and a plan for care established and periodically reviewed by a doctor of medicine, osteopathy or podiatric medicine

HOME HEALTH CERTIFICATION

• The home health services are because the individual is confined to his/her home and

• needs intermittent skilled nursing care, physical therapy and/or speech‐language pathology services, or continues to need occupational therapy; and

9/12/2013

4

HOME HEALTH CERTIFICATION

• A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and

• The services are or were furnished while the individual was under the care of a physician. 

• Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible

…CONTINUED

HOSPICE CERTIFICATION

• Written certification of terminal illness for each period of hospice care

• Specifies: prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course

• Brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less

FACE TO FACE ENCOUNTER

• Added January 1, 2011

• Purpose: Ensure the appropriate use of the Medicare home health and hospice benefits

• Places the patient in the presence of the physician to set the plan for care in motion and to determine/certify that the patient meets the eligibility criteria for home health services and continued eligibility for hospice care

9/12/2013

5

485/PLAN OF CARE

• A plan for care: initial physician orders– Modified orders

• Certification document 

• Requires a physician signature prior to billing for home health services

ELIGIBILITY CRITERIA

A Physician’s Guide to Medicare’s Home Health Certification, including the Face‐to‐Face Encounter, CMS MLN Matters, Article Number SE1219,

DO YOUR PHYSICIANS KNOW?

http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/ downloads/SE1219.pdf

QUALIFYING CRITERIA

• In need of skilled nursing care on an intermittent basis OR physical therapy OR speech language pathology; have a continuing need for occupational therapy.

• Confined to the home.

• Under the care of a physician.

• Receiving services under a plan of care established and periodically reviewed by a physician.

• Once the qualifying criteria are met, the patient may also receive the dependent services of an occupational therapist, medical social worker, registered dietician and/or home health aide.

MEDICARE BENEFIT POLICY MANUAL CH. 7, 30.5.1

9/12/2013

6

HOMEBOUND CLARIFIED

One of these:The individual has a condition due to an illness or injury that restricts his or her ability to leave their place of residence except with: 

• the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; OR

• if leaving home is medically contraindicated. 

And BOTH of these:The individual does not have to be bedridden to be considered “confined to the home.” However, the condition of the patient should be such that: 

• There exists a normal inability to leave home and, consequently; AND

• Leaving home would require a considerable and taxing effort. 

PPS FR 2012

HOME HEALTH F2F CONTENT

• State what how and why the clinical findings at the time of the encounter support the patient’s primary need for home health care and the specific skilled services ordered

• State what clinical findings at the time of the encounter support the patient’s homebound status

NEED FOR SKILLED SERVICES

• Family is asking for help

• Continues to have problems

• List of tasks for nurse to do

• Patient unable to do wound care

• Diabetes

NOT THIS!

9/12/2013

7

CONTRACTOR EXAMPLES

• “Wound care completed per POC to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.”

• “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema.”

SKILLED SERVICES

• Why the nurse or the therapist and not the neighbor?

• What knowledge deficit?

• Self care deficits

• Disease management deficits

• Procedures, diet, meds?

• What needs to be taught?

• What procedure needs to performed and then taught?

THINK ABOUT THESE

• 3 episodes of HF in the last year…why?  

• Recent increase in confusion and more dependency on caregiver.  Assess the  environment and help caregiver find easier ways to help the patient with less strain on herself

• Therapy to increase range of motion in knee, provide pain management , prepare for transition to OP in 3 weeks.

9/12/2013

8

• Multiple medication changes.  Patient with increased confusion.  Monitor to ensure correct dosing and medications provide expected effects

• Finished course of antibiotics for bronchitis.   Has COPD and current weather is humid.  Monitor lungs.  High risk for respiratory decompensation.

• Frequent lung infections.  Still short of breath with very little movement/activity.  Monitor lungs closely for changes to reduce risk of rehospitalization

• Confusion lessening with treatment of UTI.  Ensure pt. finishes course of antibiotic therapy, symptoms resolve/return to baseline and repeat urine 10 days after last dose of antibiotic. 

• Frequent episodes of chest pain…monitor for triggers, effectiveness of med changes

• New to insulin…needs taught. Observe for effects as the patient resumes regular activity

HOMEBOUND STATUS

• Functional decline

• Dementia or confusion

• Difficult to travel to doctor’s office

• Unable to leave home

• Weak

• Unable to drive

• “Homebound”

NOT THIS!

9/12/2013

9

CONTRACTOR EXAMPLE

• “The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short‐term skilled nursing is needed to monitor for signs of decompensation or adverse events from the new COPD medical regimen.”

HOMEBOUND STATUS

• Assistive device? O2?

• What causes the taxing effort? Why is he medically restricted?

• Pain‐uncontrolled, alters mental status, 

• Dyspnea ‐ how much? Related to what activities?

• Fatigue ‐ affecting what?

• Activity intolerance of less than xxx minutes ‐ why?

• Gait?

THINK ABOUT THESE

HOMEBOUND STATUS

• Unable to tolerate more than xx minutes of activity without…resting, recovering breath, exacerbating pain, etc.

• Unable to leave home without walker, unassisted, etcdue to …weakness, activity intolerance, shuffling gait, poor safety awareness, etc

• Activities restricted to the home due to open wound and risk for infection and complications for healing

HOW ABOUT THIS?

9/12/2013

10

• Need to restrict activities to the home while adjusting insulin dosage to limit risks of hypoglycemia. At risk for sudden symptomatic changes in blood sugar

• Becomes short of breath while using O2 and walking across the room

• Unable to complete bathing without 2 rest periods

• Must sit and rest after walking 10‐15 ft.

• Significant gait impairment.  Walks with walker/cane/ rollator and another person

• Acute flair of arthritis limiting ability to function independently, dress, bathe, cook, etc.

• 3 days post op. pain medication influencing decision making and safety.

• Immunocompromised ‐ need to avoid crowds/public places

• Unable to recognize me (doctor)

• Legally blind. Needs person to ensure safe gait in the home and when outside

• 4 days post op.  Gradually increase activities within the home. Add lifting and other restrictions

HOME HEALTH CARE

• Certifying physician OR• Physician who cared for the patient in the acute or post 

acute setting OR• Non‐physician practitioner (NPP)

– Nurse practitioner or clinical nurse specialist in collaboration with the certifying physician

– Certified nurse‐midwife– PA under the supervision of the certifying physician

• No more than 90 days prior to the SOC or within 30 days after the SOC

WHO AND WHEN?

9/12/2013

11

ALERT!

• In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or NPP must see the patient within 30 days after admission

CERTIFYING PHYSICIAN

• It is the certifying physician who ultimately documents the face to face encounter and signs the document.  Will have input to the POC

• NPP can conduct the encounter and inform the certifying physician.  They or physician support staff (include hospital discharge planners) can extract/compile information for the certifying physician to use.

ALERT!

• Physician documentation of their findings or those of the qualified non physician practitioner acting on their behalf…in his/her own words 

• Agency providers may not dictate/ write or otherwise prepare the F2F text or alter/change what the physician has written 

• May provide examples and training but not directed to a specific patient

9/12/2013

12

FLEXIBILITY

• A physician (e.g. hospitalist) or an allowed NPP and who attends to a patient in an acute or post acute setting can collaborate with and inform the community certifying physician regarding his/her contact with the patient. The community physician could document the encounter and certify based on this information.

• A face‐to‐face encounter can occur via telehealth, in rural areas, in an approved originating site.

MAY CERTIFY

• A physician who attended to the patient in an acute or post‐acute setting, but does not follow patient in the community (such as a hospitalist) may certify the need for home health care based on their contact with the patient, and establish and sign the plan of care. The acute/post‐acute physician would then “hand off” the patient’s care to his or her community‐based physician.

MAY INITIATE HOME CARE

• A physician who attended to the patient in an acute or post‐acute setting to certify the need for home health care based on their contact with the patient, initiate the orders for home health services (verbal order for home care) and “hand off” the patient to his or her community‐based physician to review and sign off on the plan of care 

9/12/2013

13

FACE‐TO‐FACE DOCUMENTATION

Includes:• Patient’s name

• Date of encounter

• How the clinical condition, as seen during the encounter, supports homebound status and the need for skilled services

• The physician’s signature (original, faxed, copy of original document with signature or electronic signature ‐ but not stamped signature)

• Date of the physician’s signature

FORM AND SIGNATURES

• A separate and distinct clearly titled section of the certification/recertification form OR

• A clearly titled addendum to the certification/ recertification form

• Above a legible dated signature 

• Electronic signatures are permissible

• Alert! If the F2F is attached as an addendum, both the certification and the F2F documentation require a signature by the certifying physician.

HOSPICE CARE

• Physician who is employed, contracted or a volunteer of the hospice

• Hospice Nurse Practitioner who is employed by the hospice

• No more than 30 calendar days prior to the 3rd

benefit period  recertification and

• No more than 30 days prior to each subsequent recertification

WHO AND WHEN?

9/12/2013

14

HOSPICE CONTENT

• State the clinical findings of the visit used to  determine whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course

ATTESTATION REQUIREMENT

• A practitioner who performs the encounter must attest in writing that he or she had a face‐to‐face encounter with the patient, including the date of the encounter

• The attestation, its accompanying signature, and the date signed, must be on a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled 

• When a NP performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course

HOSPICE NON‐RECERTIFYING PRACTITIONER

• Only the recertifying physician can sign the certification and physician narrative. 

• If a practitioner other than the recertifying physician (such as an NP) performed the encounter, a separate encounter attestation signature is required. The encounter attestation can be on the same page as the recertification and narrative, but must be a separate section above the signature of the practitioner who performed the encounter. The attestation can also be a signed addendum to the certification.

SIGNATURE REQUIREMENTS

9/12/2013

15

TAKE HOME

• Is the encounter related to the primary reason for home care?

• How does the patient’s current clinical condition support homebound status?

• How does the patient’s current clinical condition support the need for skilled services?

• Is the encounter timely?

• Is it signed and dated?

RESOURCES

• The CMS Medicare Benefit Policy Manual (Pub. 100‐02, chapter 7, §30.5.1.1, http://www.cms.gov/ Regulations‐and‐Guidance/Guidance/Manuals/ downloads/ bp102c07.pdf

• CMS MLN Matters article, SE1219, A Physician’s Guide to Medicare’s Home Health Certification, including the Face‐to‐Face Encounter, http:// www.cms.gov/Outreach‐and‐Education/ Medicare‐Learning‐Network‐MLN/MLNMattersArticles/ downloads/SE1219.pdf

RESOURCES

• Jurisdiction 11 Home Health and Hospice: Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non‐physician Practitioners (NPPs), 

www.palmettogba.com

• CGS FAQ Re: F2F requirements for home care and hospice, http://www.cgsmedicare.com/hhh/ education/faqs/FTF_FAQs.html

9/12/2013

16

RESOURCES

• Home Health Face‐to‐Face Encounter Question& Answers, http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HomeHealthPPS/ Downloads/Home‐Health‐Questions‐Answers.pdf

• Medicare Benefits Policy Manual, Chapter 7

• Revision Home Health Agency Survey Protocols; New State Operations Manual Advanced Copy, Feb. 11, 2011, Ref: S&C: 11‐11‐HHA, effective May 1, 2011.

RESOURCES

• Medicare Home Health Face to face requirement, www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HomeHealthPPS/ Downloads/face‐to‐face‐requirement‐powerpoint.pdf, Retrieved 082813

• Face to Face Requirement Affecting Hospice Recertification, http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/Hospice/Downloads/ HospiceFace‐to‐FaceGuidance.pdf, Retrieved 082813 

Fazzi Associates, Inc.243 King Street, Suite 246Northampton, MA 01060

(800) 379‐0361www.fazzi.com    ● rwill@fazzi.com

Questions:  training@fazzi.comEvaluation:  https://www.surveymonkey.com/s/YNDB58G