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Home Health (HH) Electronic Clinical Template

Updated 5/08/15

The Home Health Electronic and Paper Clinical Template Open Door Forum call scheduled for Tuesday, April 28, 2015, was cancelled. The next and final call has been rescheduled for May 20, 2015 at 2:30pm EST. Please continue to submit your comments/suggestions regarding this draft template via e-mail to HomeHealthTemplate@cms.hhs.gov. We value all of the comments submitted and consider each one, but we cannot guarantee all questions will be addressed during the Open Door Forum call. We will try to address the most common issues/concerns received. CMS will continue to accept comments sent to the e-mail address even after the call.  Stakeholders are encouraged to submit questions or comments as quickly as possible. Once a draft of the template is completed, the template will undergo the required Paperwork Reduction Act (PRA) approval process. A release date for the template cannot be determined until the PRA process is complete. Once released in its final approved format, the use of this documentation tool will be voluntary.

Background

In fiscal year (FY) 2014, the Comprehensive Error Rate Testing (CERT) program found that more than half (51.4 percent) of the home health claims were paid improperly. Of the 1308 CERT-reviewed claim lines in error, approximately 90 percent were found to have insufficient documentation errors. The Majority of these errors were due to inadequate documentation supporting the face-to-face requirement.

CMS is developing a list of clinical elements within a suggested electronic clinical template that would allow electronic health record vendors to create prompts to assist physicians when documenting the home health (HH) face-to-face encounter for Medicare purposes. Once completed by the physician, the resulting progress note or clinic note would be part of the medical record.   

The current draft of the electronic clinical template is available in the Downloads section below. Comments can be sent to HomeHealthTemplate@cms.hhs.gov.

In addition to developing an electronic clinical template for documenting a home health face-to-face examination, CMS is developing a paper clinical template. To see information about the home health paper clinical template, see home heath (HH) paper clinical template.

CMS has received numerous comments on the length of the template and how that makes it difficult for physicians/practitioners to complete the template.  CMS reminds commenters about three things:

1. The use of a template is voluntary.  Physicians/practitioners will not be required to use it. 

2. Once a physician/practitioner completes the template, the resulting document is a progress note or office note that is part of the medical record for that patient.  The note must contain all relevant information sufficient for patient care and sufficient for the physician/practitioner to bill for the appropriate level Evaluation and Management service.

3. The template is intended to be a “skip-template” where not all sections are relevant for all patients and therefore can be skipped.

CMS looks forward to receiving specific comments on how to improve the template to increase physicians/practitioners compliance with documenting the necessary clinical elements and possibly decrease the length of the template.     

CMS will be hosting a series of Special Open Door Forum (SODF) calls beginning in February 2015 to provide an opportunity for physicians, home health agencies and/or all other interested parties to provide feedback on the suggested electronic clinical template. The first call was held on February 11, 2015. The second call is scheduled for Wednesday, March 11, 2015 from 1pm - 2pm ET. Dial-in information and slides are in the Downloads section, below. 

To bring the suggested clinical elements to the provider community, CMS is currently collaborating with the Office of the National Coordinator for Health IT (ONC) and the electronic Determination of Coverage (eDoC) workgroup to develop the interoperability standards necessary for an electronic clinical template.  More information about the eDoC workgroup can be found on the left.  

To learn more about the conditions for payment for home health agency (HHA) services, see the CMS HHA Center  page.

Additionally, in April 2014, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report entitled “Limited Compliance with Medicare’s Home Health Face-To-Face Documentation Requirements.”  See below for a link to the report.