Probe and Educate Edits for Face-to-Face Encounter Requirements.

On November 17, 2015, the Centers for Medicare and Medicaid Services (CMS) posted an updated notice on its website advising the public of instructions given to its Medicare Administrative Contractors (MAC) to conduct Probe and Educate edits of home health agencies across the country. The purpose of the Face-to-Face Medical Review edits is to determine if providers understand and are compliant with the home health certification requirements, which includes the Face-to-Face (F2F) encounter requirements that were revised in the Calendar Year 2015 Home Health PPS update and effective January 1, 2015. Under CMS direction, MACs initiated certification/F2F probe edits of the home health agencies early in December. These pre-payment reviews focus on claims for episodes that began on or after August 1, 2015.

What are the changes to F2F encounter requirements?

As a result of the amendments to the regulation, a signed physician narrative statement attesting to a F2F encounter and identifying the basis for medically necessary home health services and describing the patient’s condition supporting homebound status is no longer necessary. Therefore, although a F2F narrative is not prohibited, it will not be sufficient to meet certification and F2F encounter documentation requirements. Rather, information found in the patient’s medical record must be used as the basis for confirmation that a F2F encounter occurred in the required timeframe by an approved professional, that home health services are medical necessary, and that the patient’s condition supports homebound status.

In addition, the medical record will be used to support other certification requirements, including that the patient was under the care of a physician and a plan of care was established and reviewed by a physician. In cases where an inpatient physician conducted the F2F encounter, but a community physician signed the home health certification statement(s), the community physician must be identified in the inpatient medical record.

What Face-to-Face Medical Review problems have been found?

Although results of the probe and educate edits have not been issued, a warning was recently issued by one MAC that found, after review of claims selected for the edit, that home health providers failed to send the actual face-to-face (F2F) encounter note from the medical record in response to requests for medical documentation. The MAC reported that, most often, providers are sending a form that includes the date the F2F took place. The MAC advises that in order to avoid denial of home health services when medical documentation is requested, they must ensure the medical records submitted includes the actual clinical notes from the F2F encounter.

What is the basis for the problem?

Some agencies may be unaware that the regulatory change effective on January 1st requires the medical record, rather than a signed F2F encounter narrative obtained by the home health agency, as evidence of compliance with certification and F2F encounter requirements. Other agencies may have been misguided by information issued by CMS and its contractors identifying a single medical record document, such as a discharge summary, as sufficient evidence of eligibility for home health. This could be problematic because it fails to advise home health agencies of the need for the discharge summary to either include a visit note for a F2F encounter that occurred at the time of discharge OR if no F2F encounter at that time, a separate visit note from the medical record at another point in time must accompany the discharge summary.

What medical record documentation is required?

CMS advises home health agencies to obtain as much documentation from the certifying physician and/or the certifying acute/post-acute care facility as they deem necessary to substantiate that the home health patient eligibility criteria have been met and provide this documentation to CMS upon request. Although not required, one MAC advises that “best practice” is for home health agencies to obtain medical record evidence of eligibility at the time of referral and prior to billing.

CMS has not responded to inquiries as to whether inpatient notes, other than those notes prepared by a practitioner approved to conduct a F2F encounter, support home health qualifying criteria. However at least one MAC included in its education inpatient physical therapy notes as acceptable medical record information to help identify a patient’s eligibility. In light of that advice, and CMS’ blanket “medical record” statement, examples of records that home health agencies may consider to support certification requirements include, but are not limited to:

  • Physician/approved NPP office record, progress notes
  • Acute or post-acute care facility medical record
    • Inpatient history and physical
    • Inpatient plan of care
    • Inpatient care management notes
    • Inpatient therapy, nursing notes
  • Discharge planner notes from inpatient facilities
  • Discharge summaries from inpatient facilities

Additional information about the Face-to-Face Medical Review can be found in Centers for Medicare & Medicaid Services:

Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7 section
MLN Matters ® Number:SE1524
Program Integrity Manual, Chapter 6.2.3

About Mary St. Pierre
After retiring from the National Association for Home Care & Hospice (NAHC) in 2013, Mary St. Pierre served as a national home health and hospice consultant. At this time she is engaged in an exclusive consulting agreement with HEALTHCAREfirst, providing regulatory guidance in the design and maintenance of software and data analytics. While with NAHC, Ms. St. Pierre oversaw the operations of the Regulatory Affairs Department, tracking regulations and influencing regulatory bodies such as CMS, FDA, and OSHA.  In addition, she prepared educational programs, presented speeches and programs and kept the membership abreast of regulatory and clinical information through articles in NAHC publications.  Ms. St. Pierre had 26 years experience as a home care nurse, clinical supervisor and manager within a large metropolitan home health agency prior to joining NAHC in 1993.