CMS Releases Change Request to Update Sub-Regulatory Guidance for Physician Home Health Certification and Recertification Requirements

  On April 10, 2015, the Centers for Medicare & Medicaid Services (CMS) released Change Request 9119 that implements changes to Chapter 7 of the Medicare Benefit Policy Manual pursuant to the CY 2015 Home Health PPS Final Rule published in November 2014. 

The changes to the Medicare Benefit Policy Manual will be effective May 11, 2015. 

Change Request 9119 introduces changes to the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1 – Physician Certification.  The revisions reflect the changes finalized in the November 2014 Final Rule, but also provide clarification of requirements previously in place.  For example, under the section describing the requirements for physician home health certification, CMS included revisions that clearly state the timeframe requirements for performing a face-to-face encounter and that the certifying physician must document the date of the encounter.  Furthermore, CMS included language requiring a physician in an acute/post-acute setting that certifies home health services for a patient, but will not follow the patient after discharge from the acute/post-acute facility, to identify the community physician who will follow the patient after discharge. 

The new manual language also restates that the certification must be completed prior to the home health agency bills for Medicare reimbursement, but that the certification should be completed when the plan of care is established, or as soon as possible afterwards. However, CMS also added the following language: “[I]t is not acceptable for HHAs to wait until the end of a 60-day episode of care to obtain a completed certification/recertification.”  Due to the addition of this language in the manual, home health agencies should carefully review their systems and processes for obtaining certifications from physicians in a timely manner. 

CMS’ Change Request 9119 also introduced revisions to Sections and of Chapter 7 of the Medicare Benefit Policy Manual.  Section introduces CMS’ changes to the Manual section addressing the physician certification face-to-face encounter.  The section provides more information regarding non-physician practitioners that are allowed to perform the face-to-face encounter, including a nurse practitioner or a clinical nurse specialist, a certified nurse midwife and a physician assistant. 

Section implements important changes pursuant to the November 2014 Final Rule that eliminated the brief narrative requirement for certification periods beginning on and after January 1, 2015.  The section 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 HHAs should receive the physician’s medical record that documents the home health certification requirements. 

Finally, Section also confirmed clarification previously provided by CMS regarding the Final Rule’s provision that home health agencies could provide information for the certifying physician to incorporate into his/her medical record to support the home health certification.  CMS provides in Section

“Information from the HHA, such as the initial and/or comprehensive assessment of the patient required per 42 CFR 484.55, can be incorporated into the certifying physician’s medical record for the patient and used to support the patient’s homebound status and need for skilled care.  However, this information must be corroborated by other medical record entries in the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.”

In addition to the corroboration requirement, previous instructions from CMS and the November Final Rule requires the physician to sign and date the information from the home health agency, thus incorporating the information from the home health agency into the physician’s medical record. 

During a previous Special Open Door Forum addressing the new physician certification documentation requirements, CMS contradicted the Final Rule’s provision allowing home health agencies to provide supporting documentation to the physician.  Although CMS provided clarification in a retraction posted on the Home Health Agency Medical Review website page, the revisions to the Medicare Benefit Policy Manual confirms that home health agencies may provide information to the certifying physician to support the home health certification. 

The revisions to Chapter 7 of the Medicare Benefit Policy Manual provide additional guidance and clarification to the revisions to the new requirements for physician home health certification and recertification effective January 1, 2015.  Home health agencies should carefully review the revisions as Medicare contractors will use the guidance in the Medicare Benefit Policy Manual as standards for reviewing claims. 

About the Authors

Andrew B. Wachler is the principal of Wachler & Associates, P.C.  He graduated Cum Laude from the University of Michigan in 1974 and was the recipient of the William J. Branstom Award. He graduated Cum Laude from Wayne State University Law School in 1978. Mr. Wachler has been practicing healthcare and business law for over 25 years and has been defending Medicare and other third party payor audits since 1980.  Mr. Wachler counsels healthcare providers and organizations nationwide in a variety of legal matters.  He writes and speaks nationally to professional organizations and other entities on a variety of healthcare legal topics.

Jessica Forster is an associate at Wachler & Associates, P.C.  Ms. Forster dedicates a considerable portion of her practice to defending healthcare providers and suppliers in the defense of RAC, Medicare, Medicaid and third party payer audits.  Her practice also includes the representation of clients in Stark, anti-kickback, and fraud and abuse matters.

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