Seeking to eliminate what it considers an unnecessary burden, CMS plans to remove its requirement that certifying physicians must estimate in home health recertifications how much longer skilled services will be necessary.
The change would take effect Jan. 1, 2019, CMS notes in the 2019 proposed PPS rule.
Removing the requirement would be great news for home health agencies, industry experts say.
Many denials in CMS’ targeted probe-and-educate review occur because such an estimate has not been included, says Diane Link, director of clinical services for Conshohocken, Pa.-based BlackTree Healthcare Consulting.
“I think it will be a huge burden off of providers, as getting the physicians’ compliance on this has been very difficult,” adds Kristi Bajer, vice president of clinical operations for OperaCare in Socorro, N.M.
For now, at least, agencies still must work to avoid denials involving physician estimates. Nurses should talk with doctors and explain language on recertification statements should outline that the patient is projected to need home health care for a certain number of days, weeks or months.
CMS took rule’s comments into account
In last year’s proposed PPS rule, CMS invited public comments about any improvements it could make to reduce unnecessary burdens for hospitals, physicians and patients that would improve care quality, decrease costs, and ensure patients and physicians make the best possible health care choices.
Within their suggestions, several commenters asked CMS to eliminate the requirement involving certifying physicians estimating how much longer skilled services will be required at each home health recertification, as set forth at §424.22(b)(2) and in subregulatory guidance in the Medicare Benefit Policy Manual (Chapter 7, Section 30.5.2).
The revised Home Health Conditions of Participation (CoPs) outline 17 requirements for the content of the home health plan of care, including frequency and duration of visits to be made [§484.60(a)(2); G574].
As a result, some comments about last year’s rule stated that the plan of care already provides “an estimate of how much longer home health services are expected to be required,” CMS notes in the 2019 proposed PPS rule. Commenters considered the physician estimate in the recertification statement “duplicative and unnecessary.”
Commenters added that because certifying physicians must review, sign and date the patient’s plan of care at least every 60 days, that serves as an attestation that the patient still requires care.
In addition, commenters contended that while the estimate has no apparent value to CMS, agencies, patients or physicians, failure to include it within documentation leads to claim denials.
CMS: removal saves doctors millions
CMS contends that eliminating the recertification requirement would save doctors $14.2 million per year.
That figure comes from CMS’ estimate that certifying physicians completed 2.1 million recertifications in 2017. Doctors earn $203.26 per hour including fringe benefits and overhead, CMS says, and removing the requirement would save them two minutes per recertification.
But CMS’ estimate that doctors spend two minutes per recertification detailing how much longer skilled services will be necessary is far too high, Link contends. She says doctors probably only spend seconds considering this.
Keys to successful recert documentation
Despite potential elimination of the requirement, reviewers still will scrutinize other elements of documentation involving home health recertifications. To withstand scrutiny, agencies should do the following:
  • Make clear why the patient requires more services. For example, documentation in a coordination note or communication note with the physician might state that two weeks prior to the end of the episode, the patient, who has CHF, gained weight and needed a change in medication, Link says. The note would state the patient requires recertification due to a need for continual skilled assessment and medication monitoring.
  • Explain how patients will reach their goals. For example, you might have a therapy patient who hasn’t met a long-term goal for distance. The note might explain that the patient has a comorbidity impacting the ability to fully participate in therapy and that in the next episode, therapy will focus on lower extremity strengthening and endurance, Link says.
  • Ensure therapy documentation is in order. On reassessments, reviewers want to see a comparison from therapists of how the patient is doing now and how the patient was previously doing. According to Chapter 7 of the Medicare Benefit Policy Manual, reassessments must occur at least every 30 days performed in conjunction with an ordered therapy service. “At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient and compare the resultant measurement to prior assessment measurements,” the manual states. “The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.”