From CMS.gov - Thu 12/8/2011
It has come to our attention that some CMS contractors are denying payment for patients who use home health services following an acute or post-acute stay when:
- The HHA uses a single form (i.e., 485) for the plan of care and the certification with a single signature by the community physician who assumes oversight of the patient’s home healthcare
- The physician who cared for the patient in the acute or post-acute setting is the certifying physician and has provided and signed attached documentation of the face-to-face encounter
In the CY 2011 HH PPS final rule and in Chapter 7, Section 30.5.1.1 of the Medicare Benefit Policy Manual (BPM), CMS allowed for the following when the patient is admitted to a home health agency following an acute or post-acute stay:
- The physician who cared for the patient during the acute or post-acute stay may certify the patient’s eligibility for the Medicare home health benefit, document the encounter based on his or her experience with the patient in the acute or post-acute setting, and initiate and sign the patient’s plan of care. The community physician who assumes care for the patient after admission to the HHA would then oversee and update the plan of care as needed.
- A physician who cared for the patient during the acute or post-acute stay may certify the patient’s eligibility for the Medicare home health benefit, document the encounter based on his or her experience with the patient in the acute or post-acute setting, and initiate the patient’s plan of care. We allow the physician who assumes responsibility for the patient’s home healthcare to update the plan of care as needed, and sign the plan of care. This flexibility is allowed because often the acute or post-acute physician is hesitant to sign the home health plan of care since he or she does not follow the patient after acute discharge.
CMS does not require that a specific form be used for the certification or the plan of care. However, many providers have chosen to use the no-longer-required CMS-485 form to satisfy the plan of care and the certification. Since April, providers who use this form typically attach the face-to-face encounter documentation to the CMS-485, as an addendum. The CMS-485 contains only one physician signature line for both the plan of care and the certification of eligibility.
In the case of patients admitted to home health following an acute or post-acute stay, the BPM language allows for one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care. If the face-to-face encounter documentation and the CMS-485 form collectively satisfy all of the certification and plan of care content requirements as defined in Chapter 7 Section 30 of the BPM, Medicare contractors shall accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements. In this scenario, the certifying physician is the acute or post-acute physician, has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation. The physician who signs the CMS-485 assumes care for the patient’s home healthcare.
Additionally, it has come to our attention that some contractors are denying claims for failure of the acute or post-acute physician to identify the community physician who will assume care for the patient. CMS has not mandated the acute or post-acute physician to follow a specific documentation protocol to hand-off a patient to the community physician.
For claims that have been previously denied for not having met face-to-face requirements in the scenarios described above, upon receiving a request from the home health agency for reopening of the claim, CMS contractors have been instructed to reopen and determine if face-to-face requirements have been met, due to their meeting the criteria described in the instruction described above. However, a determination that face-to-face requirements have been met would not result in an automatic pay of the claim. Contractors must subsequently perform a complete and full review to determine if payment should be made.
In summary, assuming all content requirements of the certification and the face-to-face documentation are otherwise met, in the case of patients admitted to home health following an acute or post-acute stay, Medicare contractors have been instructed to accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the requirement of the certification, (which now includes the face-to-face encounter).
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