To:       NHPCO Members
From:   NHPCO Regulatory Team
Re:       March 28, 2011

Updates from CMS on the Hospice Face-to-Face Encounter

1. Same Physician

   NHPCO has clarified the “same physician” requirement with CMS.  CMS intended to release a separate written clarification on the preamble language that suggested that the same physician was required to do all components of the recertification process.  However, in our discussions with CMS around implementation issues, CMS stated that the manual updates, released as CR7337 on March 2, 2011, were the only clarification they intended to issue on the “same physician” issue.  
   Therefore, one physician may be employed or contracted to conduct Face-to-Face encounters and sign the Face-to-Face attestation.   A different physician, either an employee of the hospice or under contract to the hospice, may complete the recertification process.  If physicians are involved in the recertification process, the physician conducting the Face-to-Face encounter and attestation should communicate the clinical findings to the physician who will be completing the recertification.
    

2. Discharge when the Face-to-Face encounter is not completed before the beginning of the benefit period.

    If a hospice does not meet the Face-to-Face encounter time frames, including those when there are exceptional circumstances, the hospice has failed to meet the threshold requirements for recertifying the patient’s terminal illness.  Therefore, the patient would cease to be eligible for the Medicare Hospice Benefit (MHB).  The hospice may continue to serve the patient under hospice care, but assumes all financial responsibility for the care until the Face-to-Face encounter is completed.  When the Face-to-Face encounter is complete and if the patient continues to be eligible, the patient can be re-admitted to the MHB.
    

3. Exceptional circumstances are described by CMS in the Q&A.

   In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period. For example, if the patient is an emergency weekend admission, it may be impossible for a hospice physician or NP to see the patient prior to admission. Or, if CMS data systems are unavailable, the hospice may be unaware that the patient is in the third benefit period. In such documented cases, a Face-to-Face encounter which occurs within 2 days after admission will be considered to be timely. Additionally, for such documented exceptional cases, if the patient dies within 2 days of admission without a Face-to-Face encounter, a Face-to-Face encounter can be deemed as complete.
    

4. New admission in 2nd or later benefit period – one signature or two?

   NHPCO has had questions from providers who discover, after checking the Common Working File, that the patient is in the 2nd or later benefit period. The question is “Should both the attending and the hospice physician sign the recertification form when the patient is new to our hospice, but has received hospice services from another hospice provider previously?”  The Medicare Hospice Regulations at 418.22(c)(1) require both the attending physician and the hospice physician to sign the certification of terminal illness forms ONLY for the initial certification.  Therefore, if the patient is in the second or later benefit period, only the signature of the hospice physician is required.
    

5. Billing Occurrence Code 77

   There have been questions from providers about the use of occurrence code 77 when the Face-to-Face encounter timeframes are not met.  CMS states that occurrence code 77 may not be used when the Face-to-Face encounter is not complete.  The law requires the encounter to be completed prior to the start of the benefit period for eligibility to continue.  
    

6. Timing of Attestation for Face-to-Face

   CMS states that if the Face-to-Face encounter was conducted within the required timeframe, the attestation may be signed at any time before billing. 
   

Members will find a range of tools and resources regarding the Face-to-Face rule on a special page in the Regulatory and Compliance section online -- visit nhpco.org/facetoface.

Members may send inquiries to regulatory@nhpco.org.

[1] Centers for Medicare and Medicaid Services, CR7337, Issued March 2, 2011.
[2] Centers for Medicare and Medicaid Services, Hospice Face to Face FAQs.
[3] Centers for Medicare and Medicaid Services, Original Medicare Hospice Conditions of Participation, December 16, 1983, 418.22, Certification of Terminal Illness.
[4] Centers for Medicare and Medicaid Services, Hospice Face to Face FAQs.
[5] Centers for Medicare and Medicaid Services, Hospice Face to Face FAQs.