Coding for home health agencies has moved to the forefront of quality review and agency scrutiny with the implementation of the Patient Driven Groupings Model (PDGM) and the most recent clarifications of the involvement of the primary diagnosis coding with the Face-to-Face Encounter. Medical Review and the Review Choice Demonstration (RCD) have forced agencies to have heightened awareness of the coding aspect of documentation. In addition to the review aspect, coding has a significant impact on the calculation of reimbursement under the PDGM model. The primary diagnosis on the claim drives the Clinical Grouping portion of the PDGM case-mix grouping, while the secondary diagnoses are used in determining the comorbidity status. Therefore, inaccurate coding leads to inaccurate payment!
Ensuring that your principal/primary diagnosis on the plan of care aligns with the Face-to-Face encounter is crucial to the documentation health of your charts and can impact your bottom line! The principal/primary diagnosis on the plan of care must have been treated during the Face-to-Face encounter and that treatment documented on the encounter note.
This is a continuation of the discussion on Face-to-Face Encounters that started in September in the Monday Minute with Melinda: Face-to-Face by addressing Face-to-Face issues home health care agencies often encounter.
One of the most common questions that HPS is asked by clients and HPS Alliance members about the Face-to-Face encounter is, “Do we HAVE TO get a new Face-to-Face encounter….”
WHEN THE CLINICIAN FINDS A WOUND THAT ISN’T MENTIONED IN THE ENCOUNTER THAT WE HAVE?
Yes! If the wound is determined to be the primary reason for home health services and will be the principal/primary diagnosis on the plan of care, the physician must address/treat the wound in the Face-to-Face encounter and document that treatment in the encounter note.
You will need to get a new encounter note if you don’t want to see this denial reason in an audit:
The required face-to-face encounter is not related to the primary reason for home health services.
Home Health Services
- Your home care agency is in control of financial outcomes when outsourcing billing & collections to HPS. Click here to learn more about Home Health Billing services.
- Outsource home health coding to HPS to boost your agency’s clinical compliance. Click here to learn more about Home Health Coding services.
- Home care agencies are subject to multiple layers of review by government contractors. This is an ongoing process, and a critical need, where your agency may need guidance to prevent inaccurate results and a negative effect on your agency’s operations. Click here to learn more about Medical Review Consulting.
WON’T AN ADDENDUM OR DIAGNOSIS QUERY AND CONFIRMATION WORK?
No. If the wound is the primary reason for home health services and will be coded as the principal/primary diagnosis, the wound had to be addressed/treated during the encounter.
A physician cannot write an addendum on a wound that was not actively treated during the encounter.
A diagnosis query and confirmation will not meet the Face-to Face requirements for a condition that was not actively treated during the Face-to-Face encounter.
Tell me more about this active treatment you speak of…
Glad you asked!
Auditors look for a diagnosis that is actively treated during the Face-to-Face encounter. Unfortunately, there is no clear definition of active treatment.
What is clear? Home health principal diagnoses listed under the treatment plan with continue meds, stable, or continue to monitor and those listed without active treatment cause auditing issues.
Good news. You might not need another Face-to-Face encounter, in every case.
If the patient had active treatment during the Face-to-Face encounter and the physician inadvertently omitted clear documentation of the active treatment, a physician addendum to the Face-to-Face encounter note can be used. Keep in mind that this is a physician addendum to the specific encounter note, of treatment that took place on the encounter date.
Addendum documentation written by the home health agency and signed by the physician is not allowable.
If there was no active treatment during the encounter, then the agency will definitely need a new Face-to-Face encounter.
In what other instances might a new Face-to-Face encounter be needed?
- When the allowed practitioner documents that the actively treated condition is resolved.
- When the actively treated condition is a diagnosis that is not a PDGM acceptable primary diagnosis.
- When the Face-to-Face encounter is solely a pre-op note and home health will focus on skilled post-op care.
- When the Face-to-Face encounter is a note from an in-patient stay and the patient was not directly admitted to home health services following that stay.
- When the Face-to-Face encounter is a note from a community physician (urgent care, specialist) that will not be the certifying physician or a non-physician practitioner working under the certifying physician. Also note: when the certifying allowed practitioner is a non-physician practitioner, the community Face-to-Face encounter is required to be done by the same non-physician practitioner.
With all these things that can render the encounter note non-allowable, it seems like many of the Face-to-Face encounters that agencies receive may not meet criteria.
SINCE THE ENCOUNTER CAN BE COMPLETED WITHIN THIRTY DAYS OF THE START OF CARE DATE, AGENCIES CAN GO AHEAD AND CODE THE CHART NOW AND GET A VALID FACE-TO-FACE ENCOUNTER LATER, RIGHT?
Wrong! Coding prior to obtaining a Face-to-Face encounter note will likely result in auditing issues and increased administrative burden due to the need for recoding the chart.
Some agencies that participate in this practice are finalizing the plan of care and sending to certifying allowed practitioner for signature before the Face-to-Face encounter visit is even completed. This is completely unacceptable, because the certification MUST include certifying the date of the Face-to-Face Encounter and that cannot happen until the encounter has taken place.
It is highly recommended that agencies NEVER code a new Start of Care Plan of Care without an adequate Face-to-Face encounter note.
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If you should need any assistance from HPS regarding Coding and the Face-to-Face encounter, please do not hesitate to let us know.