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CMS recently issued a final rule that will require a Face-to-Face (F2F) encounter for Medicaid patients receiving home health services or Durable Medical Equipment (DME) and may expand coverage of medical supplies, equipment and appliances under the home health benefit. The ruling states “The face-to-face encounter is required for initial orders for home health services and for all episodes initiated with the completion of a Start-of-Care OASIS assessment. OASIS is the “Outcome and Assessment Information Set.” The final rule revises section 6407 of the Affordable Care Act and section 504 of the Medicare Access and CHIP Reauthorization Act of 2015. The effective date of the rule is July 1, 2016 and compliance with the rule for up to one year if the state’s legislature has met in that year, otherwise 2 years. 46 state legislatures meet annually and only Montana, Nevada, North Dakota and Texas meet every other year.
In order to be eligible for home health services, medical necessity must be supported but Medicaid beneficiaries are not required to be homebound. Another important difference to note is services are not limited to the home under Medicaid. §440.70(c)(1) states “Specifically, individuals may receive home health services in any setting in which normal life activities take place, other than a hospital, nursing facility; intermediate care facility for individuals with intellectual disabilities; or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.”
Some requirements for the Medicaid F2F encounter are the same as Medicare F2F but not all. The encounter must occur within 90 days before or within 30 days after the start of services and the reason for the encounter must also be related to the primary reason for home health services. The encounter may be conducted by a qualified physician, a nurse practitioner or clinical nurse specialist, a certified nurse midwife or a physician assistant under the supervision of a physician. Medicaid requires the certifying physician to document that an allowed NP or PA completed the encounter and the physician must order home health services. A podiatrist is not permitted to complete a F2F encounter for a Medicaid beneficiary. The F2F may also be conducted in person or via telehealth but cannot be completed by phone.
If the beneficiary is admitted to service following an inpatient stay, the attending acute or post-acute physician may conduct the F2F encounter. The acute or post-acute physician must communicate the clinical findings of the encounter to the ordering physician. Documentation would be required to support this communication and the ordering physician acknowledged the facility F2F encounter. The clinical findings would then be included in the patient’s medical record.
The F2F documentation requirements described in the final rule state the ordering physician must “Document the face-to-face encounter which is related to the primary reason the patient requires home health services, occurred within the required timeframes prior to the start of home health services. Must indicate the practitioner who conducted the encounter, and the date of the encounter.”
Many agencies have patients that are dually eligible and may switch the patients from Medicare to Medicaid when skilled services are no longer required. In response to a question related to this transition, the final rule states “If a face-to-face encounter was performed at the start of home health services, or to support the order for medical equipment, a new face-to-face encounter is not required if the source of payment has changed to Medicaid.” In response to another question about dually-eligible patients, “To clarify, if a Medicare enrolled physician has completed the face-to-face requirement for a dually-eligible individual, an additional face-to-face requirement would not be needed by a Medicaid enrolled physician, should the benefit change to Medicaid services, as long as there was no new start of care. However, if a new face-to-face encounter is needed under Medicaid, the physician must be Medicaid-enrolled.” Please note the qualifier “as long as there was not new start of care”. Therefore, if a new start of care is required due to discharge, a F2F would be required and must meet all of the previously stated requirements.
Due to this new ruling, agencies must be vigilant in obtaining, tracking and reviewing F2F encounter documentation for both Medicare and Medicaid patients. The final rule reiterates the importance of the F2F by stating, “we clarify that no payment for home health services can be made for which a timely face-to-face encounter was not documented. Furthermore such services are not covered in the absence of a physician order for the services, or a written plan of care. Medicaid payment is not available if these conditions are not met.”
Medicaid Program; Face-to-Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health may be viewed at: https://www.federalregister.gov/articles/2016/02/02/2016-01585/medicaid-program-face-to-face-requirements-for-home-health-services