New CMS Interpretation on Face-to-Face Encounters Creates Challenges for Providers

Healthcare providers have been facing significant challenges with PCR (Pre-Claim Review) requests in recent months, following a new directive from CMS (Centers for Medicare & Medicaid Services) to Palmetto GBA. The change in interpretation, which began impacting providers in late November, requires a face-to-face encounter performed by the certifying physician or nurse practitioner (NP) for community admissions, such as patients admitted from home. This development has led to widespread non-affirmations for PCR requests that lack the required documentation, creating frustration and operational strain for providers.

Background on the Issue

During a recent CMS audit of Palmetto GBA, auditors informed Palmetto that they had been misinterpreting the rule regarding face-to-face encounters for years. In response, Palmetto changed its stance and now requires documentation of a face-to-face encounter from the certifying physician or NP for PCR requests. While this change aligns with CMS’s interpretation of the rule, many providers argue that it is inconsistent with existing regulations and statutes.

This issue primarily impacts community admissions where the patient is admitted from home. Institutional admissions, such as those involving transfers from hospitals or skilled nursing facilities, are not yet fully clarified under this interpretation. However, providers who are experiencing non-affirmations related to institutional admissions are encouraged to report their cases immediately.

What Providers Need to Know

Until CMS provides further clarification or updates its guidance, providers are advised to include face-to-face documentation with all PCR submissions for community admissions. Here are some key points to consider:

1. Documenting the Encounter: Providers should reach out to certifying physicians or NPs to obtain documentation of the initial face-to-face encounter. These notes are often part of the patient’s medical record, as physicians typically document initial visits when they sign off on the plan of care.
2. Timing Requirements: The face-to-face encounter note must be dated within 90 days prior to the start of care or up to 30 days after the start of care. Ensuring the timing meets these parameters is critical for getting submissions affirmed.
3. Proactive Steps for Future Submissions: For any PCR submissions moving forward, providers should include a face-to-face encounter note from the certifying physician or NP as a standard part of their documentation process.

Advocacy Efforts and Next Steps

The Texas Association for Home Care & Hospice, alongside other advocacy organizations such as The Alliance (formerly NAHC), is actively engaging with Palmetto and CMS to address these challenges. Discussions are ongoing, and no official guidance has been released yet. Providers are encouraged to monitor updates through industry forums and advocacy organizations, as changes could be forthcoming.

In the meantime, providers are urged to adjust their internal processes to align with CMS’s current interpretation to avoid delays in PCR affirmations. Additionally, sharing specific cases of non-affirmations with institutional admissions can help advocacy groups gather evidence to present to CMS and Palmetto during their discussions.

Closing Thoughts

This unexpected interpretation change by CMS has placed a significant burden on providers, who are now scrambling to ensure compliance. While advocacy efforts continue, it is vital for providers to remain vigilant in their documentation practices and communicate with certifying physicians to secure the necessary face-to-face encounter notes. By taking proactive measures, providers can minimize disruptions to their operations and ensure timely care for their patients.

Stay tuned for further updates as advocacy organizations work to resolve this issue with CMS and Palmetto.

Source: Texas Association for Home Care & Hospice