Tag Archives: medicare

Medicare Contractor Discretion to Deny Physician and Other “Related” Claims when Hospital Claims are Denied

New instructions from CMS have opened the door for denials of physician claims, including those for professional services, when they are “RELATED” to hospital claims that are denied during prepayment or post-payment review.

Effective March 6, 2014, A/B and DME Medicare Administrative Contractors, Recovery Audit Contractors, and Zone Program Integrity Audits will have the discretion to deny those claims without requesting or considering any additional documentation on the related claims or using any additional clinical review judgment. However, they are authorized to collect medical documentation to support services billed on a Medicare claim. This documentation includes such records as clinical evaluations, consultations, progress notes, physician office and hospital records, certificates of medical necessity, and other information. Continue reading

CMS home health guidelines

Medicare (CMS) Face to Face requirement are mandated by the Affordable Care Act (ACA)

Patient’s must be certified by their physician that they meet criteria for home health. This is a requirement by CMS that it is documented that the prescribing physician actually had a face to face encounter with the patient.

Some notable points are:

  • This is a condition for payment
  • Prior to certifying a patient’s eligibility for the home health benefit, the certifying physician must document that he or she, or an allowed non- physician practitioner (NPP) has had a face-to-face encounter with the patient
  • Documentation regarding these encounters must be present on certifications
  • A physician must order Medicare home health services and must certify a patient’s eligibility for the benefit
  • The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services

Why is this necessary?

  • The face-to-face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Anything else?

  • The certifying physician must document the encounter either on the certification which the physician signs, or a signed addendum to the certification. It may be written or typed.
  • It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
  • It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.