Are you you wondering how you made it to Friday? Let’s see how many brain cells survived with this down and dirty OASIS quiz with only 5 (easy) questions.
Are you you wondering how you made it to Friday? Let’s see how many brain cells survived with this down and dirty OASIS quiz with only 5 (easy) questions.
It should be simple, right? Choose from a list of codes that describe why your patient is receiving services and go on about your business….. Piece of cake, right?
Somehow, that isn’t how it goes these days.
The first challenge is to determine what should be put in the diagnosis list. The answer is quite simple at first glance. Code every diagnosis that is related to the terminal condition of the patient. At second glance, how does a diagnosis make the list? Medicare says that pretty much any diagnosis in the zip code of the patient makes the list. Old school providers say that only the terminal diagnosis makes the grade. The real answer is somewhere in between. Some questions to ask when determining which diagnoses makes the elite list:
Is the diagnosis the reason the patient is terminal?
Is the diagnosis one of the risk factors or underlying causes of the terminal diagnosis?
Is the diagnosis a direct result of the terminal diagnosis?
What happens if you don’t treat the diagnosis?
Does the diagnosis affect the way that a patient responds to or participates in their plan of care?
Obviously, the terminal diagnosis will be included but on occasion, the terminal diagnosis is not clear. A patient with end stage Alzheimer’s disease and NY Class IV heart failure doesn’t have a long future but it may be difficult to tell which of the diagnoses is terminal. Use your judgment and if you are compliant in the rest of the coding process, neither the patient nor the hospice will suffer.
A patient who is terminal due to a stroke caused by long-standing hypertension would have Hypertension in the list. The same patient may be confined to the bed in the final days of life and some skin breakdown towards the end of life is not unusual. In these examples, the hypertension is an underlying cause of the stroke and the skin breakdown is a result of the stroke. Both would be coded.
If pain, confusion or other discomfort is a result of not treating the diagnosis, it should be included. Extremes in blood sugars may be encountered by a patient with a pre-existing diagnosis of diabetes. Include it.
We see patients taking Statin medications which are generally used to lower cholesterol to prevent heart attacks in the future. When the future is limited to a few weeks or so, it may not be important to treat the hypercholesteremia because nothing happens if it isn’t treated.
Patients with dementia are unable to respond to the plan of care as well as their clear headed counterparts. Even when Alzheimer’s disease or other dementias are not the terminal diagnosis, they should be coded.
In the past, there have been hospice providers who have chosen the primary diagnosis based on the perceived cost of treating the diagnosis. This has never been the correct approach to hospice care. The hospice is tasked with covering essentially all care related to the terminal condition of the patient. That does not mean that curative care should be offered for secondary and contributing diagnoses or even that the treatment prior to hospice admission must be followed.
Consider the following examples:
1. A patient with a diagnosis of diabetes is admitted for services but her terminal diagnosis is heart failure. Prior treatment was Lantus insulin. In the interest of comfort, it may be reasonable to check blood sugars much less frequently and treat with a short acting insulin only when the patient is uncomfortable due to symptoms. Because appetites and medications can interfere with blood sugar levels, longer acting insulins may not be appropriate. Tight control of blood sugar is not going to help the patient in the long run.
2. A patient with Alzheimer’s disease becomes severely agitated when his Namenda is withheld. In order to provide the patient with the greatest level of comfort, the Namenda would continue.
Should a patient be reluctant to discontinue a medication, the family is free to purchase the medications. However, it most likely will not be covered under the hospice benefit. If the family has some of the medication from prior to admission, it can be continued while they are approached gently over time about the need for the medication vs the need to reduce the pill burden and potential for side effects.
Keeping these principles in mind, hospice patients can be accurately depicted in the diagnosis list and a care plan addressing the individual patient needs can be created. It is not difficult but it will never be a reflexive and automatic process, either. Until patients standardize dying, there will be no standard care plan.
Needless to say, we highly recommend certified ICD-10 coders to ensure that accurate coding is included on claims, changes in the patient condition are reflected in the coding list and you and your staff have time to spend with patients.
Every so often, Palmetto posts a list of the claims that will be of interest to them on their website. This is the list that was published on August 4.
Note the last letter of the HIPPS code. The letter ‘L’ indicates 16 – 17 therapy visits and the dreaded ‘K’ means that 20 or more therapy visits are scheduled. Only one of the edits is for therapy below 14 visits. In that edit, Palmetto GBA is looking for the lowest clinical and functional scores together with therapy.
Palmetto is asking why a patient who appears to be clinically stable and can walk, talk, bathe, transfer and dress themselves needs any therapy. It’s a good question. There could be a perfectly legitimate explanation but if it is not documented well, you are looking at a denial.
Pretty much all episodes with 20 or more therapy visits are being scrutinized. These are the expensive claims and people who are ‘gaming’ the system will often use high utilization as a method to do so. This does NOT mean that a patient should not receive 20 therapy visits if needed. For most agencies, these episodes will be few and far between.
16 and 17 visits are very profitable as well even if the dollar amount is not the same. The profit starts to drop off at 18 and 19 visits until 20 visits are made.
All clinical documentation should support the services billed but in an agency where staff is limited or compromised at time of billing, claims with these HIPPS codes might be prioritized for review prior to dropping claims.
|1BGP*||0 – 13 Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain|
|2BGL*||16-17 Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain|
|2CGL*||16-17 Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain|
|2CHL*||16-17 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain|
|5AFK*||20 or More Therapy Visits, Low Score on the Clinical Domain and Low Score on the Functional Domain|
|5AGK*||20 or More Therapy Visits, Low Score on the Clinical Domain and Moderate Score on the Functional Domain|
|5AHK*||20 or More Therapy Visits, Low Score on the Clinical Domain and High Score on the Functional Domain|
|5BFK*||20 or More Therapy Visits, Moderate Score on the Clinical Domain and Low Score on the Functional Domain|
|5BGK*||20 or More Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain|
|5CGK*||20 or More Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain|
|5CHK*||20 or More Therapy Visits, High Score on the Clinical Domain and High Score on the Functional Domain|
|All||Aggregate Length of Stay and Disbursement/Beneficiary|
|All||Home Health Services|
The Office of the Inspector General recently issued a fraud alert regarding physician relationships with providers. In case you don’t know any criminals, the Office of the Inspector General (OIG) is that government agency which prosecutes Medicare fraud and abuse and a lot of other things. They are the ones who dispatch the FBI and other investigative agencies to catch bad guys. It is never a good idea to get on the bad side of the OIG.
Now that everyone understands that it is foolhardy and dangerous to mess with the OIG, perhaps the recent warning regarding physician relationships, found here, will be of interest to you.
The essence of the alert is that you can only pay medical directors ‘fair market value’ for work they actually do for your agency. You cannot simply agree to pay a doctor a flat sum each month to be your medical director. The physician must work for the money and payment must be reasonable for the work done. Fair market value differs for each community and a healthcare accountant might be a good place to start when determining the fair market value for your area. Hint: Most doctors do not make $1,250.00 per hour and two hours of work over lunch does not satisfy a Medical Director’s contractual responsibilities towards the agency.
The alert goes on to say that an agreement may violate the anti-kickback statute if ‘even one purpose of the arrangement is to compensate a physician for his or her past or future referrals’. That’s right, folks. You heard it here, first. Any and all medical director agreements are to be entered into regardless of where the physician sends his patients. It does not prohibit a physician from sending patients to an agency where he or she serves as a Medical Director but no part of the agreement should be contingent upon referrals.
There’s more! The OIG is very clear that they have recently reached settlements with 12 physicians who entered into questionable agreements. This works for me. We have had over a million phone calls from clients and other agencies complaining because their physicians just don’t get why they have to do things as medical directors. These phone calls usually are an attempt to get us to contradict what their lawyers have told them about entrance fees for golf tournaments or the new hunting rifle given as a Christmas present. We never do.
There have been recent cases where jury convictions have been based upon ‘sham’ agreements where the list of services listed in a contract for a Medical Director were never really performed nor did the provider expect them to be performed. Employees have been placed on the stand and asked about the frequency in which the medical directors were seen at a nursing home.
The Executive Director of a home health agency in Lexington, KY agreed to pay $1,000,000.00 back to Medicare for an ongoing fraud case involving kickbacks. Note that the Executive Director is paying back the money – the case against the agency is ongoing.
The kickbacks in the Kentucky case are not what you might imagine. The agency was a corporate sponsor of Kentucky football and physicians were given tickets to Kentucky football games. Some were given bottles of tequila, as well, and tickets to see Journey play in concert. This is not the type of financial exchange that many of us associate with ‘bribes’ and ‘kickbacks’. In the South, football tickets tend to be a currency of their own.
Now would be a good time to have all of your contracts reviewed by a healthcare lawyer. We can certainly recite the contents of the OIG fraud alert and news articles but we are not qualified to answer questions regarding nuances of the law and your specific contracts. There are varying degrees of cost in these gifts and the specific conditions upon which a gift was given matters.
If you are too cheap to get your contracts reviewed by a qualified lawyer who specializes in healthcare, a good rule of thumb is to give nothing at all. We cannot support any exchange of cash or kind without a healthcare lawyer blessing your contracts. We have worked with several and will be glad to give you a name upon request.
Please remember that your cash will be cut off before you actually go to jail or write 7 figure checks. As such, your coders and consultants will not be paid. That’s completely unacceptable.
I had the privilege of attending an educational session with Jamie Boudreaux with the Louisiana-Mississippi Hospice and Palliative Care Organization this week. I highly recommend taking advantage of any opportunity that comes your way to attend any LMHPCO events.
During Jamie’s talk, he referenced numerous changes that were proposed for 2016 in Hospice. After hearing so much about this exciting document, I couldn’t wait to read it. You should read it, too and send your comments should you have any.
The highlights – or at least those points that we find interesting as coders and clinicians, are found below. This is not an all inclusive account of the regulations and I strongly encourage you to read them for yourself.
You are getting a raise. It is projected that hospice payments will rise almost 2 percent. But that’s not all. Remember that talk about a U Shaped curve? It isn’t exactly a ‘U’ but you now have a change in how you will be paid.
There are two factors that will increase your payment. In the current system, due to the increased expenses in admitting a patient and establishing a care plan, a patient will be on service for approximately 21 days until the hospice breaks even. As time goes by, the payment stays the same and hospice providers are collecting the same payment for long stretches of time when the patient has minimal needs. This is traditionally when the hospice made money. As death approaches, the costs usually increase again.
As such, two new provisions have been added.
During the first 60 days of hospice, payment will be at a rate (adjusted for your area) of $187.63
After day 60, per diem payment will fall to $145.21
Important: An episode of hospice care is considered to be all episodes that are separated by no more than 60 days. You cannot discharge and readmit a patient prior to 60 days and expect the higher rate. Hospice providers who pick up patients from other hospices as in a transfer will be similarly unable to claim the higher rate.
But there’s more!
During the last seven days of care, hospices will be able to bill a Severity Intensity Add-on or SIA. In addition to the hospice per diem rate, for Registered Nurse and Social Work visits during those last 7 days, an additional rate equivalent to the continuous care rate may be billed up to 4 hours. That means that in addition to the daily rate, a hospice can receive almost $160.00 more.
There are conditions:
The reported reason for this change is to encourage providers to provide additional care when it is needed the most. A full 20 percent of patients did not receive a visit on the day of death.
So that’s the good news. Hospice providers will be receiving additional cash when expenses are the highest. Back to the beginning of the document where the news isn’t quite so exciting.
Normally, we would not bore you with the background of any proposed regulations but in this case, the continual references to the 1983 hospice benefit rules probably indicate that some of the recent changes and proposed changes are an indication that hospices haven’t gotten it right, yet.
The tone of this document is well worth your time to read so you can heed the inherent warnings.
The rule is one per patient. The fact that over one third of patients have multiple physicians submitting claims indicating they are the attending physician results in Medicare paying the physicians when in fact, the hospice is the correct payor source. Don’t get caught doing this.
A signed document is required when a patient chooses to change physicians.
Medicare is not mandating surveys to be conducted at least every three years as opposed to the every 6 year rule now. Select hospices who have long lengths of stay can expect to find themselves on a private list where all claims for services past 180 days of admission are routinely reviewed. Do not get on this naughty list.
Remember, the data exists for Medicare to look at the average length of stay in addition to the percentage of patients on service greater than 180 days. That’s a really good number to keep handy, by the way. You can have a lot of patients on service for a year or more offset by some short lived admissions so your average length of stay may be okay but you might still have far too many patients on service longer than would be considered reasonable and necessary.
Obviously this is not a regulation but it is an indication of the overall ‘tone’ being set by document.
The number of Medicare beneficiaries receiving hospice services has grown from 513,000 in FY 2000 to over 1.3 million in FY 2013. Similarly, Medicare hospice expenditures have risen from $2.8 billion in FY 2000 to an estimated $15.3 billion in FY 2013
…..this increased spending is partly due to an increased average lifetime length of stay for beneficiaries, from 54 days in 2000 to 98.5 days in FY 2013, an increase of 82 percent.
This chart shows how many dollars per day were spent on patients in the 180 days prior to hospice admission and how many days spent in the care of a hospice. As it turns out, both of these numbers are critical for determining potential savings to the Medicare trusts.
On the vertical column, you can see the grand total of days a patient spent in hospice. The horizontal line shows what the average daily cost of the patient was prior to admission.
This is Medicare’s work. We do not agree with this method of cost analysis. However, any differences of opinions regarding the formulas used do not account for $158,000 per patient with a diagnosis of Alzheimer’s Dementia which is about what it works out to be over 120 days.
The Medicare Hospice Benefit is not reducing healthcare costs in terminally ill patients. This is a problem folks.
The proposed regulations are very clear that nobody expects the live discharge rate to be zero. Patients have the right at any time to revoke their election at any time. Some patients start to get better especially after they have been taken off 25 medications designed to prolong their life. They move and sometimes they just hate your hospice and revoke.
Based on the data within the proposed regulations, there can be no doubt that an above average live discharge rate strongly correlates with other undesirable characteristics of hospice provider. The patients discharged alive are from providers that also have more long term, low maintenance patients. Additionally, patients in these hospices cost Medicare more in terms of money spent for nonhospice care.
The proposed regulations reiterated the limited number of reasons that a provider can discharge a patient. They are as follows:
When discharging for cause, ensure that all reasons are documented especially if a patient has been on service for a while. When more than one neighborhood becomes unsafe on day 181 of a hospice episode of care, it makes for a pattern.
There are very few legitimate causes for discharge in hospice. and the regulations are clear that discharging patients due to cost is not approved by Medicare.
The data in the proposed regulations is stunning but the real damage comes from various and sundry anecdotes. It is important for providers to understand what those who right the rules are thinking and how they are thinking. Copied directly from the regs:
We have received anecdotal reports from non-hospice providers who have rendered care and services to hospice beneficiaries in which the non-hospice provider states that the care given was related to the terminal prognosis of the individual. These reports go on to say that they have contacted hospices to coordinate the care of the hospice beneficiary only to be told by those hospices that they disagreed with the non-hospice providers’ clinical judgment that the care was related to the terminal prognosis.
We have been told that hospices are refusing to reimburse the non-hospice provider for care related to the terminal prognosis.
non-hospice providers also informed us that the hospices told them to code the claim with a different diagnosis or to code condition code 07 (treatment of Non-terminal Condition for Hospice) or the modifier “GW” (service not related to the hospice patient’s terminal condition) on their claims to ensure that the non-hospice provider would consequently get paid through Medicare.
We have also received anecdotal reports from hospice beneficiaries and their families that they have been told by the hospice to revoke their hospice election to receive high-cost services that should be covered by the hospice, such as palliative chemotherapy and radiation.
In addition to publishing these comments, staff memos to employees of specific large hospices were included stating that their providers should go after the long term patients.
This is the last time that you should ever consider the words ‘terminal’ and ‘diagnosis’ together. People do not have terminal conditions in isolation. They have terminal prognoses.
All of the research and numbers that Medicare has presented all go to support their belief that hospices are not living up to their provider agreement which includes care for the diagnoses that is most likely to cause death and any and all other diagnoses that affect the patient’s comfort, are a result of the terminal prognosis or contribute to the severity of the prognosis.
Consider a patient who needs bypass surgery but because of diabetes, long term use of steroids for arthritis and a longstanding history of noncompliance due to a psychiatric illness, she is not a surgical candidate. There is no one diagnosis that is terminal. All of them play a role in his terminal prognosis and all must be addressed by the hospice.
You are making progress! In the 2015 regulations it was noted that 72 percent of hospice claims had only a single diagnosis. This year, for the 2016 update, the percentage of claims with only diagnosis is down to 49 percent.
In addition, because there has been confusion and discussion about the nature of the ‘terminal prognosis’, providers have been omitting diagnoses that are significant to the patient’s overall condition.
Since the inception of hospice, adherence to the International Classification of Diseases (ICD) has been mandated. This means that the primary diagnosis and all diagnoses that affect the patient’s ability to respond to or participate in the plan of care are to be included.
Therefore, we are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.
I have heard of denials because patients were admitted to psychiatric facilities that billed Medicare because the patient’s ‘terminal diagnosis’ was not psychiatric in nature. I suspect this has happened numerous times because psychiatric conditions are mentioned more than once in this document.
We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.
Let the last sentence of the section on coding resonate loudly on your priority list. We can and will code for you. You can learn ICD-10 coding or you can outsource to another company. Alternatively, we can help with appeals, Focused Medical Review, or ZPIC audits. The choice is yours but if you’ve ever been through that kind of regulatory scrutiny before, you would not choose non-compliance.
There is more – so much more but try digesting this first and we’ll keep an eye on the final release and do our best to summarize it for you.
More than half of the dollar amount of claims reviewed by one intermediary were denied in the last quarter of 2014. Multiple results were published this past week. Most were for smaller amounts but the denial rates were similar. The results posted below are the results for an edit of claims with a HIPPS code of 1BGP*. These are patients who were in an early episode, a clinical severity of 2 and a functional level of two, and a service level of 5. This represents a very high paying patient who is receiving therapy but otherwise isn’t all that sick.
Over half of the dollars that were billed for these claims were taken back or not paid because of a focused medical review.
For now, this is where we stand. As unfair as it may seem, there is no other option than to address these numbers until your claims make their way through the appeals process. Please do not think you are being told to grin and bear it because we are angry, too.
|Total dollars reviewed||6,074,393.71||5,588,813.76|
|Total Dollars denied||3,498,994.66||3,285,618.64|
The good news is that most of the claims were denied for Face-to-Face encounter documentation and we can obviously expect fewer denials in the future but not for several months. The claims that will be scrutinized for the next several months will all have required Face-to-Face documentation.
The bad news is that many of these claims were denied for multiple reasons. For instance, in the Southeast Region, there were a total of 1817 claims reviewed producing 1562 denials. There were 865 claims that were denied because ‘MR HIPPS Code Change – Documentation Contradicts OASIS MO Item(s)’ Look for this denial related to diagnosis coding and therapy. The functional and clinical domain (except for diagnosis) can change but the diagnosis coding should be fairly static throughout an episode unless there has been change.
Agencies need to fight fire with fire. If it’s details they want, give them every detail you have. Deprive them of the opportunity to take your money back.
The best solutions will come from within your agency. Take advantage of each individuals talents and get everyone involved. Post excellent notes where everyone can see them.
If you think you cannot afford this level of attention to detail, you might rethink that position if you are hit with an edit.
We can help prevent that with our fabulous coders who will ensure proper coding so the careplan can be written within a couple of days and followed to a T. Call us or connect by email.
We have looked and have been unable to find specific guidance on the new CoPs. There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA. Help us out if you know anything.
Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means. Look for it below in larger bold text.
Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.
(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.
(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.
(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.
(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)
(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.
(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.
(A) The face-to-face encounter must be performed by one of the following:
(1) The certifying physician himself or herself.
(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.
(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.
(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.
(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—
(i) Beneficiary elected transfer; or
(ii) Discharge with goals met and/or no expectation of a return to home health care.
(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.
(c) Determining patient eligibility for Medicare home health services. Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.
(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.
(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.
(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.
[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]