CMS answers flexibilities questions


MACs are using Medicare manual, not Covid-19 waivers, to determine compliance

Covid-19 walloped home health agencies with staffing issues, personal protective equipment shortages, patients too scared to allow home visits and scores of other hardships. But chief among the problems caused by the pandemic has been confusion about compliance with basic Medicare requirements: Who can perform the face-to-face encounter and sign the plan of care? Public health emergency waivers granted by Centers for Medicare and Medicaid Services (CMS) say one thing -- but the Medicare Benefit Policy Manual, traditionally the compliance "Bible" of the industry, says something different. The Benefit Policy Manual has not been changed to reflect the flexibilities granted last year under the Coronavirus Aid and Relief Security (CARES) Act. "The difference in wording used in the Benefit Policy Manual and the public health emergency waivers has created plenty of confusion this year," said J'non Griffin, President of Home Health Solutions, a Simone Coding Company. Additionally, there is conflicting wording between Chapter 7 of the Benefit Policy Manual and Chapter 4 of the Medicare General Information, Eligibility and Entitlement Manual about who can order the patient’s plan of care during certification or recertification. NAHC asked for clarification The National Association for Home Care and Hospice (NAHC) recently asked CMS to clarify who can perform the F2F – and to address the conflicting information about who can sign the patient’s plan of care. CMS acknowledged that there are confusing language discrepancies. “CMS said it plans to update the language as soon as possible,” Griffin said. “But no timeframe was provided.” In the meantime, NAHC asked all three of the Medicare administrator contractors how reviewers are handling the discrepancies, and all three MACs said the same thing; reviewers follow the Benefit Manual when determining F2F compliance. “So, until the Benefit Manual is updated, NAHC is recommending that agencies follow what the manual now states at Chapter 7, Section 30.5.1.1 for compliance,” Griffin said. Who can conduct the F2F? Here is what the Benefit Policy Manual says in Chapter 7, Section 30 about allowed provider types for the F2F encounter, and what NAHC recommends agencies follow for now: As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner (NPP).

NPPs who are allowed to perform the encounter are:

A nurse practitioner or a clinical nurse specialist working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician, with privileges, who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health;

A certified nurse midwife, as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health;

A physician assistant under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

Who can sign the POC? Unless the patient is being admitted directly to home health from an acute or post-acute care setting where the F2F was performed by an allowed providers, CMS confirms that the POC will need to be signed by the same allowed provider who performed the F2F. CMS acknowledged that it needs to correct its own conflicting information on signing the POC. Here is what CMS said about the discrepancy: "We note that Chapter 7 of the Benefit Policy Manual does include erroneous language regarding who may sign the POC. We do plan on correcting this language as soon as possible, as well as updating the language in Chapter 4 of the Medicare General Information, Eligibility, and Entitlement manual. "In the meantime you can refer providers to the FAQs found in the program guidance and information on the CMS.gov website about our response to COVID-19. We state that the home health conditions of participation do not prohibit home health agencies (HHAs) from accepting orders from multiple physicians, and now with the recent statutory change, nurse practitioners, physician assistants, and clinical nurse specialists (i.e., allowed practitioners). The HHA is ultimately responsible for the plan of care, which includes assuring communication with all physicians and allowed practitioners involved in the plan of care and integrating orders from all physicians/allowed non-physician practitioners involved in the plan to assure the coordination of all services and interventions provided to the patient. This responsibility extends to a physician or other allowed non-physician practitioner, other than the certifying physician or allowed non-physician practitioner who established the home health plan of care, who signs the plan of care or the recertification statement in the absence of the certifying physician or allowed non-physician practitioner. This is only permitted when such physician or non-physician practitioner has been authorized to care for his/her patients in his/her absence. The HHA is responsible for ensuring that the physician or allowed non-physician practitioner who signs the plan of care and recertification statement was authorized by the physician or allowed non-physician practitioner who established the plan of care and completed the certification for his/her patient in his/her absence. Our regulations at 42 CFR 424.22(a)(1)(v)(A) require that the physician or allowed practitioner that performed the required face-to-face encounter also sign the certification of eligibility unless the patient is directly admitted to home health care from an acute or post-acute care facility and the encounter was performed by a physician or allowed practitioner in such setting."

NPPs can’t order private duty nursing In addition, NAHC asked whether NPPs may order private duty nursing under Medicaid. CMS clarified that the statutory changes only addressed the home health benefit under Medicaid and not the private duty nursing benefit. Editor's note: This article originally appeared in the e-newsletter sent out by Home Health Solutions - A Simione Coding Company - each Monday. To subscribe to the free e-newsletter, sign up here.

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