Ftag of the Week – F712 Physician Visits–Frequency/Timeliness/Alternate NPPs

Next up on the CMSCG BlogFtag of the Week,” we’re reviewing F712 Physician Visits – Frequency/ Timeliness/ Alternate NPPs. F712 is part of the Physician Services regulatory group, and this regulation specifies the requirements for physician visits to residents. Visit timing is based on a resident’s admission date.

Physician Visits Requirements – Skilled Nursing Facility

Each resident of a SNF must be seen by a physician within the first 30 days of admission and:

  • At least once every 30 days for the first 90 days after admission AND
  • At least once every 60 days thereafter

The initial comprehensive visit for a resident in a SNF may not be delegated by the physician to a non-physician practitioner (NPP). The NPP may make other medically necessary visits before and after the physician’s initial visit, if allowed by State law. States that allow the use of NPPs may also allow the NPP to make every other required visit after the initial physician visit, which is addressed under F714.

F712 allows for ten days “slippage” for a visit. Surveyors are instructed not to look at the timelines for visits unless there is a concern with a resident’s medical care.

Physician Visit Requirements – Nursing Facility

Residents of a nursing facility must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, like a SNF. However, there are nuances between the two, in accordance with State laws:

  • Visits in a nursing facility may be conducted by an NPP who is not an employee of the facility, but who is working in collaboration with a physician who is licensed by the State and performing within the State’s scope of practice. These visits can satisfy the physician visit requirements.
  • NPPs who are employees of the nursing facility may make medically necessary visits, but these visits do not take the place of required physician visits, and do not count towards the required physician visit schedule.

Recertification Survey Citation – F712 S/S: D

A facility did not ensure that a resident (reviewed for Nutrition) was seen by a Physician at least once every 30 days for the first 90 days after being admitted. There was no documented evidence in the EMR that the resident was seen by his/her Physician at least once every 30 days for the first 90 days after admission. A Medical Progress Note, written more than two months after the admission date, stated that the resident had been seen the day after he/she was admitted. There were multiple late notes stating the resident had been seen at appropriate frequencies. The Medical Director, on interview, stated that the Physician was in the facility regularly, but had fallen behind on documentation and the Physician didn’t know his notes were late. The Physician was interviewed and stated that he sometimes does not have time to write notes after seeing a resident, and that he prioritizes patient care over writing notes.

What Else to Know About Physician Visits

SOM Appendix PP includes a table of NPP authorities that should be reviewed if a provider is using NPPs in accordance with State law. The table, “Authority for Non-Physician Practitioners to Perform Visits, Sign Orders and Sign Medicare Part A Certifications/Re-certifications when Permitted by the State,” as its name implies, spells out exactly what the NPPs are allowed to do and what they are not.

For providers where beds are dually certified, the determination of how an individual resident’s stay is being paid is the key to determining if physician delegation of tasks is permissible, and if an NPP is allowed to perform a particular task.

The regulation clearly states that regardless of certification type, a facility policy that allows NPPs to conduct required visits and/or allows a 10-day slippage time for visits does not relieve a physician of his/her duty to personally visit a resident when the resident is experiencing a medical condition that makes the visit necessary.

F712 also points out that CMS expects that physician visits will occur at the facility rather than at a physician’s office unless there is equipment needs that is not available in-house or if the resident requests to go to the doctor’s office.

On Survey

As mentioned above, a surveyor may look into physician services if there is a potential issue that has been identified with a resident’s medical care. The surveyor will investigate if the frequency/ scheduling of physician visits could have contributed to an identified problem, including timeliness of the initial comprehensive visit.

Recertification Survey Citation F712 S/S: D

A facility was cited for failing to ensure physicians responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days. For one resident (reviewed for Physician Services), the medical record included an incomplete H&P after a resident was readmitted from the hospital after being sent out for osteomyelitis and returned on IV antibiotics. There was no record of the Physician visiting the resident for a month. On interview with the Regional Nurse, it was confirmed that the resident was not seen upon readmission from the hospital and should have been visited by the doctor.

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