CMS Proposes Home Health Physician Documentation Templates

In the most recent updates to the Medicare Home Health Prospective Payment System,[1] CMS made significant changes to the face-to-face encounter documentation requirements by eliminating the physician narrative requirement for most home health services for care episodes beginning on or after January 1, 2015.[2] In making this change, CMS stated that the medical records of the certifying physician or the acute/post-acute care facility (if a patient in that setting was directly admitted to home health) must contain sufficient documentation to support the physician's certification of patient eligibility for home health services.

Although the changes to the face-to-face encounter documentation were intended to eliminate the burden of the physician narrative requirement, home health providers have continued to assert that the new documentation requirements are equally burdensome and are too vague for providers to know what constitutes "sufficient" documentation to support a patient's eligibility for home health services.

Earlier this week, CMS announced that it is considering developing voluntary clinical templates to help physicians adequately document their encounters with Medicare patients.[3] CMS has proposed a sample paper template progress note as well as suggested electronic clinical template elements for a progress note. The list of suggested elements for an electronic clinical template is intended to allow electronic health record vendors to create prompts to assist physicians when documenting the home health face-to-face encounter for Medicare. Once completed, the resulting paper or electronic progress note or clinic note would be incorporated into and become part of the physician's medical record.

The sample paper and electronic templates provide some indication of what CMS may consider adequate physician documentation of a patient's eligibility for home health services. Beginning in February, CMS is planning to host a series of Special Open Door Forums to provide opportunities for physicians, home health agencies, and other interested stakeholders to provide feedback on the proposed templates. CMS is also currently accepting public comments on the voluntary clinical templates via email at HomeHealthTemplate@cms.hhs.gov. We encourage home health agencies, physicians and other stakeholders to participate in the Special Open Door Forums and to email your comments to CMS.