The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

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• The face-to-face encounter must occur within the 90 days prior to the start of home health care, orwithin the 30 days after the start of care.• In situations when a physician orders home health care for the patient based on a new condition thatwas not evident during a visit within the 90 days prior to start of care, the certifying physician orNPP must see the patient within 30 days after admission. Specifically:• If the certifying physician or NPP had not seen the patient in the 90 days prior to the start of care, avisit within 30 days of start of care would be required.• If a patient saw the certifying physician or NPP within the 90 days prior to start of care, anotherencounter would be needed if the patient’s condition had changed to the extent that acceptedstandards of practice would preclude the physician from ordering services without the physician oran NPP first examining the patient.The Affordable Care Act and the final rule include several features to accommodate physician practice:• In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allows a physician whoattended to the patient in an acute or post-acute setting, but does not follow patient in the community(such as a hospitalist) to certify the need for home health care based on their contact with the patient,and establish and sign the plan of care. The acute/post-acute physician would then “hand off” thepatient’s care to his or her community-based physician.• Medicare will also allow physicians who attended to the patient in an acute or post-acute setting tocertify the need for home health care based on their contact with the patient, initiate the orders forhome health services, and “hand off” the patient to his or her community-based physician to reviewand sign off on the plan of care.• The law allows the face-to-face encounter to occur via telehealth, in rural areas, in an approvedoriginating site.Plan of Care (POC) and Certification ClarificationsLong-standing regulations have described the distinct content requirements for the POC and certification.The Affordable Care Act requires the face-to-face encounter and corresponding documentation as acertification requirement. Providers have the flexibility to implement the content requirements for boththe POC and certification in a manner that best makes sense for them.Prior to CY 2011, CMS manual guidance required the same physician to sign the certification and thePOC. Beginning in CY 2011, CMS will allow additional flexibility associated with the POC when a patientis admitted to home health from an acute or post-acute setting. For such patients, CMS will allowphysicians who attend to the patient in acute and post-acute settings to certify the need for home healthcare based on their face to face contact with the patient (which includes documentation of the face-to-faceencounter), initiate the orders (POC) for home health services, and “hand off” the patient to his or hercommunity-based physician to review and sign off on the plan of care. As described in the final HHPPSregulation, CMS continues to expect that, in most cases, the same physician will certify and establish andsign the POC. But the flexibility exists for HH post-acute patients if needed.Certain non-physician practitioners can play an important role in the face to face encounter. For example,an allowed non-physician practitioner who attends to a patient in an acute setting or emergency room canCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 78 MMR 2011-01, January 2011
collaborate with and inform the community certifying physician regarding his/her contact with thepatient. The community physician could document the encounter and certify based on this information.Additional InformationMedicare home health plays a vital role in allowing patients to receive care at home as an alternative toextended hospital or nursing home care. Questions and answers regarding this requirement will beavailable the via Medicare’s home health agency website, http://www.cms.gov/center/hha.asp on theCMS Web site.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenzavaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part Dcovered drug. For information about Medicare’s coverage of the influenza vaccine and its administration,as well as related educational resources for health care professionals and their staff, please visithttp://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services (CMS) Website.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Announcement of Medicare Rural Health Clinics (RHCs) and FederallyQualified Health Centers (FQHCs) Payment Rate IncreasesMLN Matters® Number: MM7101Related Change Request (CR) #: 7101Related CR Release Date: October 8, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2063CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers submitting claims to Medicare contractors (FiscalIntermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for RHC and FQHCservices provided to Medicare beneficiaries.What You Need to KnowThis article is based on Change Request (CR) 7101 which provides instructions for the calendar year (CY)2011 Payment Rate Increases for Rural Health Clinic (RHC) and Federally Qualified Health Center(FQHC) services.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 79 MMR 2011-01, January 2011
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Centers for Medicare & Medicaid Ser
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National Government Services Articl
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R4 (effective 12/16/2010): Due to a
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Article for Cardiovascular Nuclear
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For dates of service prior to 01/01
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Article for Magnetic Resonance Imag
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LCD for Scanning Computerized Ophth
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Article for Determination of Cardia
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• CMS Internet-Only Manual (IOM),
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to the third party but no notificat
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Provider Types AffectedThis article
Page 27 and 28: • HCPCS codes Q2026, Q2027, and G
Page 29 and 30: Calendar Year 2011 Annual Update fo
Page 31 and 32: Mapping Information• New code 829
Page 33 and 34: Waiver of Coinsurance and Deductibl
Page 35 and 36: Ambulance Inflation Factor for CY 2
Page 37 and 38: Key Points of CR 7049CMS is adding
Page 39 and 40: Medicare-covered preventive service
Page 41 and 42: staff, please visit http://www.cms.
Page 43 and 44: CMS has decided to follow the same
Page 45 and 46: 2011. This amendment’s expanded c
Page 47 and 48: • Rural Health Clinics (TOB 71X)
Page 49 and 50: Note: CMS requests provider, physic
Page 51 and 52: If you have any questions, please c
Page 53 and 54: Quarterly Update to Correct Coding
Page 55 and 56: • Peak oxygen consumption.Note: V
Page 57 and 58: more than 12 months after a person
Page 59 and 60: last year, increased by 1.1 percent
Page 61 and 62: CodePayment LimitQ4027 $17.23Q4028
Page 63 and 64: BillingIn general, it is inappropri
Page 65 and 66: Provider Action NeededImpact to You
Page 67 and 68: IntroductionAnnual outbreaks of sea
Page 69 and 70: • CMS Frequently Asked Questions
Page 71 and 72: Primary Care ServicesThe Affordable
Page 73 and 74: The Affordable Care Act authorizes
Page 75 and 76: Implementation of Changes in End-St
Page 77: Home Health Face-to-Face Encounter
Page 81 and 82: News Flash - A revised Medicare Lea
Page 83 and 84: DisclaimerThis article was prepared
Page 85 and 86: Provider Types AffectedThis program
Page 87 and 88: News Flash - Each Office Visit is a
Page 89 and 90: Provider Types AffectedPhysicians,
Page 91 and 92: On January 28, 2010, CMS made avail
Page 93 and 94: spelling the Ordering/Referring Pro
Page 95 and 96: • Doctor of podiatric medicine;
Page 97: ased on the CPT code descriptor, re
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The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

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