Face-to-Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Nonphysician Practitioners

Physicians play a key role in determining and documenting the medical necessity for home health care for Medicare beneficiaries. We encourage physicians who certify the need for home health care to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters to your patients regarding home health care.

The documentation of clinical findings by the physician/nonphysician practitioner should show: 

• The encounter was related to the primary reason for home care;
• How the patient’s condition supports the patient’s homebound status; and
• How the patient’s condition supports the need for skilled services

Acceptable face-to-face documentation does not have to be lengthy or overly detailed. However, the face-to-face documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.

Below are examples of face-to-face documentation that, used alone, are considered insufficient documentation.

Examples of appropriate documentation include:

• Wound care completed to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Skilled nurse visits to perform wound care and assess wound status. Patient on bed to chair activities only.
• Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema. Short of breath with talking and ambulation of 1–2 feet. Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.

Who May Document the Face-to-Face Encounter? 
As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner (NPP).

Medicare guidelines also contain specific documentation requirements:

• The certifying physician must document that the face-to-face visit took place, regardless of who performed the encounter
• If the face-to-face was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the face-to-face must communicate clinical findings of the face-to-face encounter to the certifying physician. NPPs performing the face-to-face encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the face-to-face.
  • The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP. He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
  • The face-to-face documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare
  • The face-to-face documentation must include:
    • The date of the face-to-face encounter
    • Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services

Finally, because the face-to-face is a requirement for payment, when the face-to-face requirements as outlined above are not met, the entire claim is denied. For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but face-to-face documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

Resource: The CMS Medicare Benefit Policy Manual (Pub. 100-02, Chapter 7, §30.5.1.1 (PDF).