Medicare requires for face-to-face encounters with patients in certain health care situations. Note that the Centers for Medicare & Medicaid Services (CMS) has delayed implementing the hospice face-to-face visit rule until Jan. 9, 2012.
Hospice: A hospice physician or nurse practitioner must see a Medicare patient enrolled in hospice before the patient’s 180-day recertification and for each 60-day recertification thereafter.
Only a physician may certify the patient’s terminal illness. The certification must document the face-to-face visit, and include a signed and dated face-to-face encounter attestation. If a nurse practitioner saw the patient, he or she must attest to giving information collected during the encounter to the certifying physician. See the rule in the Federal Register (PDF) and update from CMS (PDF).
Home health service: A physician who certifies a patient as eligible for Medicare home health services — or a nonphysician practitioner (NPP) working under the physician — must see the patient within the 90 days before the start of home health care, or within the 30 days after care begins.
As part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and how the patient’s clinical condition supports a homebound status and need for skilled services. See CMS’ MLN Matters No. SE1038 (PDF) for more information.
Home dialysis for end-stage renal disease: Physicians or NPPs receiving Medicare monthly capitation payments must see home dialysis patients monthly to be paid under CPT codes 90963-66. See CMS’ MLN Matters No. MM7003 (PDF) for more information.
Note that Medicare allows waiving this requirement on a case-by-case basis. TrailBlazer, the Texas Medicare contractor, acknowledges that a monthly face-to-face visit may not always be possible, but says it “expects the absence of a monthly face-to-face visit to occur infrequently.” For example, a face-to-face visit may be unnecessary when the nephrologist’s notes indicate the physician actively and adequately managed home dialysis patient’s care throughout that month.
Use modifier 52 when billing the services for a home dialysis patient who remained on home dialysis the entire month and did NOT receive at least one face-to-face visit.
Durable medical equipment (DME): For all DME orders under Medicare, the ordering physician or NPP must have seen the patient within the last six months. This includes all initial DME orders, as well as orders for replacement parts or replacement equipment, even if the patient is stable but needs the equipment permanently. The physician must keep a copy of the order in the medical record.
Published Jan. 11, 2011
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