Face-to-Face Related to Primary Reason for Home Health Services

The face-to-face clinical note used for home health services must be related to the primary reason that the patient requires home health services as outlined in the Medicare Benefit Policy Manual, Chapter 7 — Home Health Services (PDF, 543 KB), 30.5.1.2 — Supporting Documentation Requirements.

An acceptable example would be when Diabetes Type 2 is listed as the primary reason for home health services on the plan of care. The focus of the face-to-face clinical note is for an infected foot but also references a history of Diabetes, medications for Diabetes such as Insulin, lab values such as A1C/blood glucose levels, etc. This is related to the primary reason that the patient requires home health services. The connection could be made that Diabetes predisposes the patient to progressive neuropathy and an increased likelihood of infections; this is often a problem in the feet.

An unacceptable example would be when Hypothyroidism is listed as the primary reason for home health services on the plan of care. The focus of the face-to-face clinical note is Dementia without any connection to, reference of or documentation for the Hypothyroidism. 

If you have any questions regarding face-to-face or coding requirements, please refer to the following resources:

• Medicare Benefit Policy Manual, Chapter 7 — Home Health Services, Section 30.5.1.1 — Face-to-Face Encounter (PDF)
• Medicare Administrative Contractor (MAC) Beneficiary and Provider Communications Manual, Chapter 6 — Provider Customer Service Program (PDF)