CMS Publishes Physician Voluntary Face-to-Face Encounter Progress Note Templates

Andrew B. Wachler, Esq.
Jessica C. Forster, Esq.

In January 2015, the revisions to the home health face-to-face encounter documentation rules were implemented. A notable revision to the documentation requirements was the elimination of the brief narrative requirement for almost all home health face-to-face encounter documentation. Although the home health industry accepted the substantial revision to the documentation requirements, in the Final Rule published on November 6, 2015, the Centers for Medicare & Medicaid Services (“CMS”) announced new documentation requirements for home health certification. Upon initial review, the new documentation requirements do not appear to be as burdensome as the previous brief narrative requirement. However, contradictory information from CMS and the general nature of the description of the new requirements could lead to a high rate of claim denials, similar to the rate of denials home health agencies experience from the previous brief narrative requirement.

The Final Rule requires that effective January 1, 2015, a physician that certifies home health services must have documentation in his/her medical record to support the home health certification. The specific requirements were published in Change Request 9119 that revises Chapter 7 of the Medicare Benefit Policy Manual to reflect the new physician certification requirements. Revised Section 30.5.1.2 of Chapter 7 of the Medicare Benefit Policy Manual affirms that documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records will be used to determine the patient eligibility for Medicare home health services and to support the physician’s certification of home health eligibility. The section states, “…an HHA must be able to provide, upon request, the supporting documentation that substantiates the eligibility for the Medicare home health benefit to review entities and/or CMS.” Although this language was in the November 2014 Final Rule, the specific inclusion in the Medicare Benefit Policy Manual confirms that home health agencies should clearly communicate with their referring physicians the new requirement that home health agencies should receive the physician’s medical record that documents the home health certification requirements.

In order to assist physicians and home health agencies with the new documentation requirement, in March 2015 CMS announced that it was considering developing voluntary paper and electronic clinical progress note templates that could be completed by a certifying physician during a face-to-face encounter with a Medicare patient. CMS’ goal with the proposed templates was to create a document that could be used as the physician’s progress note to support the evaluation and management (“E/M”) code that the physician would bill for the service and to support the face-to-face encounter documentation requirement. CMS held a series of special Open Door Forums (“ODF”) that included an opportunity for callers to ask questions regarding the new face-to-face encounter documentation requirements and the proposed templates. The ODFs included a discussion and overview of the proposed clinical templates and a Question and Answer opportunity for participants. Many of the questions from participants revolved around “work flow” issues, such as who can complete the progress notes. In the finalized electronic clinical template, CMS provided a list of individuals that are allowed to complete the template. Expressly not included in that list is the home health agency.

During an ODF held on March 11, 2015, CMS’ responses to questions from participants contradicted previous CMS guidance regarding the new face-to-face encounter documentation requirements. Specifically, CMS stated on March 11 that home health agencies could not provide documentation to the certifying physician for the physician to incorporate into his/her medical records to support the home health certification. Previously, and in the text of the Final Rule, CMS had stated that home health agencies could provide this information if the physician signed and dated the information and the physician’s own information corroborated the information from the home health agency. On March 23, 2015, after consistent follow-up from industry leaders, CMS retracted its statement made during the March 11, 2015 ODF and confirmed the direction in the Final Rule that a physician could accept information from a home health agency and that the information will be considered by Medicare medical reviewers as support for the home health certification.

The elimination of the brief narrative is a welcome change to home health certification requirements. However, based upon the directions provided up to now regarding the information that must be in a physician’s medical record to support the home health certification, concerns exist whether Medicare review contractors will have appropriate guidance for reviewing claims. The home health industry experienced a deluge of claim denials based on the brief narrative requirement. The new rule that the physician’s medical record include the required home health certification requirements is rather general and could be open to interpretation by Medicare contractors. Therefore, home health agencies should proactively educate their referral sources regarding the new documentation requirements. Home health agencies may choose to use the proposed paper and electronic clinical templates as training tools to guide physicians regarding the information that will be required in the physician’s medical record.

Link to Voluntary Paper Clinical Template: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/HomeHealthPaperClinicalTemplatev22.pdf

Link to Voluntary Electronic Clinical Template: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Electronic-Clinical-Templates/Downloads/eclinicaltemplatev44.pdf