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MD to document meeting regarding home care
Another task to the discharge process
A new regulation from the Centers for Medicare & Medicaid Services (CMS) will have a far-reaching impact on Medicare patients and their providers, including hospital-based case managers, says Jackie Birmingham, RN, BSN, MS, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
The new regulation, part of the Patient Protection and Affordable Act, specifies that a physician or a qualified non-physician practitioner must certify that he or she has had a face-to-face encounter with Medicare patients when home care is ordered.
Home care agencies must receive the certification in order to be reimbursed for the home care visits, according to CMS-1510-F, which took effect Jan. 1, 2011, and will be fully implemented by the second quarter of 2011.
The new requirement means that case managers must start considering changes to their workflow to assure that the documentation is complete, Birmingham says.
"For starters, they will have to determine, who, as part of the discharge process, will perform the face-to-face encounter and what documentation certifying that encounter will be transmitted to home health agencies," she points out.
The new requirement increases the burden on case managers who have to make sure that the documentation is complete, along with other discharge requirements such as giving patients the Important Notice from Medicare and making sure they have a choice of post-acute providers, Birmingham says.
The regulation requires that the face-to-face encounter be conducted by a physician, a qualified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist who works with physician support. It must occur within 90 days before the start of care or 30 days afterwards.
CMS says that home health agency personnel, including liaisons, cannot perform the certification because of potential financial conflicts of interest.
The documentation of the face-to-face patient encounter should be either a separate and distinct area on the certification or a separate and distinct and clearly titled addendum to the certification.
The certification must document that the physician saw the patient at a certain date and time, the clinical findings of the encounter, and how the findings support medical necessity for home health services. It must state that the physician or appropriate non-physician talked with the patient and explained exactly what home health means.
Home care providers still will be responsible for ensuring that there is a physician-signed plan of care, physician-signed order, and physician-signed certification in addition to the certification for the face-to-face encounter, Birmingham says.
This means that physicians or the appropriate non-physicians have to have a conversation that goes beyond the typical conversation about home care, she adds.
"Many already are having this kind of detailed conversation about home health with their patients, but documenting what they discussed with the patient and including the date and time is something new," she says.
During the CMS Open Door Forums on the subject, hospital representatives reported that it is likely to be a struggle to educate physicians to complete the kind of documentation they need to make, Birmingham says.
The intention of the requirement is to increase physician involvement in patient care and improve outcomes, according to CMS.
But the unintended consequences could be longer lengths of stay, more referrals to skilled nursing facilities, or an increase in readmissions, particularly early this year as the requirements for the face-to-face encounters take place, Birmingham says.
"What seems to be a small change is going to interfere with case management workflow that is so tight already," Birmingham says.
The home care agencies will be looking for the documentation before they accept patients, Birmingham says.
"Otherwise, they may not take patients. Patients may linger in the hospital causing throughput problems, or patients may be sent to less appropriate alternatives such as a skilled nursing facility, or sent home without services, only to be readmitted," she says.
Discharges may also be impacted when patients learn that home health means intermittent visits, and does not mean that the nurse or therapist will be in the home all day, or every day, Birmingham says.
"Patients may say they aren't ready to be home with periodic visits from a home care nurse. They may want to either stay in the hospital or go to a skilled nursing facility," she says.
This makes tracking your readmissions and the reasons for them more important than ever, she adds.
"Look at readmissions and drill down to determine if they were readmitted from a skilled nursing facility, from home care, or from home without services," she says
Analyze the pattern of referrals to the skilled nursing facilities to determine if there's an uptick when patients refuse to go home when they find out what home health really means, or when home care agencies refuse to accept patients without the documentation, she says.
Monitor your length of stay. Typically, for some diagnoses, the length of stay for patients going home with home health may be shorter than the average length of stay for other patients because they will be receiving more services from another provider.
If there is an increase in length of stay, it may be because the patient had to stay another day until the physician completed the documentation, she says.
[For more information, contact: Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Health Group, e-mail: firstname.lastname@example.org.]