Templates Include “Why” and “Because”
The Centers for Medicare and Medicaid Services (CMS) recently explored dropping a form for Certification of Medical Necessity (CMS) as a required element to determine medical necessity for claims involving Home Health Services. Although suppliers would no longer be required to collect the information on the CMS developed forms, CMS still would require the necessary data elements to determine medical necessity to be submitted on the 837 claim form. Evidently, CMS found that records reviews often “conflicted” with information found in the forms, and reviewers are instructed to ultimately rely on the medical record, regardless of the information on CMNs.
The proposed change was offered for comment between June 5 and June 12, 2015, a grand total of seven days.
One More Reason to Circle October 1st on Your Calendar
The change is now evidently in effect, and CMS has announced that Probe and Educate Reviews, pre-payment reviews of home health claims, for episodes beginning on or after August 1, 2015, will begin sending out documentation requests on or about October 1, 2015.
The CY 2015 Home Health Prospective Payment System (HH PPS) Final Rule, CMS-1611-F, was published November 6, 2014 and corrected/updated December 2, 2014. MLN Matters® article number SE1405 was published January 13, 2014 for guidance, and included a description of the required narrative for documenting Home Health face-to-face encounters. The required elements include the “why” of the need for the services, using the short phrase”…because of” as a lead-in to further explanation.
Templates Offer Specificity On Specificity
To aid providers in understanding the new patient certification requirements, two types of templates have been created by CMS, with the latest updates (as of May 8, 2015) now available, including a paper version and an electronic version.
The templates themselves are very insistent if not exactly clear about the need for specificity, with almost all narrative sections in the paper version including what not to say:
“Please be specific. Do NOT simply state: ‘considerable and taxing effort, gait abnormality, weakness, etc.'”.
The electronic version goes even further:
Please be specific. Do NOT simply state: “considerable and taxing effort,” “gait abnormality,” “weakness,” or “unable to drive car”, etc. Include functional limitations resulting from recent surgical procedures and/or any medical restrictions. Include if the patient is homebound because their immune status is compromised due to chemotherapy. Describe any other clinical issues that are impeding the patient’s ability to leave home unassisted by another individual. Identify any structural barriers, such as stairs required to enter or exit the home. Include any psychological/cognitive issues that prevent the patient from leaving home with the assistance of another individual.
A View of What’s to Come?
Short-term acute care hospitals may wonder if these two developments portend the future for more of CMS’ revenue integrity programs:
- an expansion of the Probe and Education process, which CMS evidently considers a resounding success in the campaign to pay less for medically necessary inpatient care protect the burden on beneficiaries reduce the use of Observation services for hospital stays longer than 1 day; and
- construction of voluntary paper/electronic templates for providers to copy and paste clone just read and wish they could really use show Congress how providers are the real problem, not CMS’ policies and procedures.
No “final” version the paper version is available, as yet, since it must undergo the required Paperwork Reduction Act (PRA) approval process.
Paper work to approve less paperwork. That’s an oxymoron if I’ve ever seen one.