Doctors win 3-month reprieve from home health documentation rule

Washington -- Advocacy efforts by the American Medical Association helped persuade the Centers for Medicare & Medicaid Services to delay enforcement of a new regulation that requires physicians to document face-to-face encounters with patients for the beneficiaries to receive covered home health services.

The regulation, required under the health system reform law, went into effect Jan. 1. However, CMS decided to delay enforcement of the regulation for the first three months of 2011.

Patients always have needed physician authorization to receive home health services. The new documentation requirement is intended to ensure that a doctor's order is based on up-to-date knowledge of the patient's condition, CMS said.

Under the rules, a doctor or authorized nonphysician practitioner whose patient needs home health services must document a face-to-face visit with the patient within 90 days before the start of services and provide a separate certification that the patient is homebound and needs the care. For patients who start home health care based on a new condition without having seen a doctor in the past 90 days, the doctor must document a face-to-face visit and certification within 30 days of the onset of care for the services to be covered by Medicare.

The AMA had argued for a six-month delay of enforcement for the rule, saying that CMS had not done enough to make physicians aware of the new documentation requirements.

"We are deeply concerned that CMS has done little outreach to physicians affected by this requirement, and unless CMS postpones enforcement of this requirement, patients and physicians could be negatively impacted," AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, wrote in a Dec. 23, 2010, letter to CMS Administrator Donald M. Berwick, MD. The Association worried that home health agencies would start rejecting patients who did not have the appropriate documentation, forcing them into hospitals or nursing homes.

Dr. Maves said the AMA is pleased that the agency already made changes to the final rule based on physician recommendations, such as extending the window of time in which the face-to-face encounters can occur. But, he added, "We know from considerable experience that at least six months is needed to conduct outreach to physicians on new policies."

Concerns about fraud, abuse

According to physicians familiar with the regulation, Congress authorized it and CMS developed it to improve access to home health services and prevent fraud and abuse.

"CMS was concerned about home care agencies serving patients who might not actually be eligible for coverage for the services," said Edward Ratner, MD, associate professor of medicine at the University of Minnesota Medical School.

He said once physicians who see patients requiring home health care know about it, the documentation requirements shouldn't prove too difficult for doctors.

"It requires some level of appropriate physician oversight, and it might be messy at first, but hopefully it won't be too onerous," Dr. Ratner said. "It's important for physicians to make sure they don't stop referring. We don't want to underserve our patients because there's a new paperwork requirement."

C. Gresham Bayne, MD, an emergency physician in the San Diego area, said physicians who already make house calls should not have a problem with the new regulation. He said such doctors already have had to document the "medical reasonableness and necessity" of home visits for years. However, he said office-based physicians may have more trouble with the new documentation requirements.

These doctors "simply have fewer options to the quandary of seeing patients who cannot be seen in the office," said Dr. Bayne, who is also the chair and founder of Call Doctor Medical Group, a San Diego-based organization that provides board-certified physicians and physician assistants to provide house calls to patients. He started the organization after seeing firsthand how costly unnecessary emergency department care can be.

Dr. Bayne added that patients of office-based physicians who may need home care services could encounter access problems if they're not made aware of the new face-to-face visit requirements. The vast majority of homebound patients do not have any contact with doctors or nonphysician practitioners who make house calls, he said.

Still pushing for more time, outreach

Some physicians who refer patients for home health services said the 90-day delay in the regulation will be advantageous.

"Pushing back the deadline is helpful, because I don't think a lot of doctors knew about this regulation," said Peter Boling, MD, professor of medicine and interim chair of the division of internal medicine at Virginia Commonwealth University School of Medicine in Richmond. "Home health agencies worry that patients will not have a timely certifying visit post-hospital that will support agency billing."

Dr. Boling said typical problems with documentation and continuity under the new rules could arise when a patient initially is treated for an illness in a hospital and is then placed on home care after discharge without a solid hand-off.

That's one of the reasons the AMA continues pushing for a full six-month delay of enforcement from CMS. In the meantime, the Association is calling on CMS to continue educating physicians about the new requirements, as well as the contractors who will need to process the related claims.