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June 7, 2013

Widespread Home Health Probe – Face-to-Face Encounter Documentation

As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers. The topic code for this review will be 52xxT (‘xx' denotes various numbers) and the edit will select start of care home health claims equally across the provider community. Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.

In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the "face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes." (CMS FAQ #44External PDF)

The FTF documentation, which must be a separate and distinct section of or an addendum to the Start of Care Certification must include:

  • Clear title to show it is a FTF encounter
    • HHA may title
  • The patient's name
  • The date of the encounter
  • A description of the clinical findings during the encounter
  • An explanation of how the clinical findings support homebound
  • An explanation of how the clinical findings support the need for skilled home care
  • The certifying physician's dated signature
    • HHA may enter date received if not dated by the physician

The most common errors identified by the CERT contractor regarding FTF encounter documentation are insufficient documentation of clinical findings by the physician/non-physician-practitioner (NPP) to show the encounter was related to the primary reason for home care, and a description of why the patient was homebound and in need of Medicare covered home health skilled services.

In some cases, the FTF documentation only provided a diagnosis, or the frequency and duration of services to be provided. Below is a list of statements or items frequently used that, alone, would be considered insufficient for documentation of the homebound status and need for skilled services:

Homebound Status Need for Skilled Services
"Functional decline" "Family is asking for help"
"Dementia" or "confusion" "Continues to have problems"
"Difficult to travel to doctor's office" List of tasks for nurse to do
"Unable to leave home" "Patient unable to do wound care"
"Weak" "Diabetes"
"Unable to drive"  

As a reminder, the FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or qualified NPP working in conjunction with the certifying physician. An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility. That physician can then report the FTF encounter to the certifying physician. The certifying physician must document the encounter either on the certification, or a signed addendum to the certification. Only the certifying physician may sign the FTF encounter document.

Finally, please remember that as the billing entity, it is your responsibility to:

  • Facilitate and coordinate between patient and physician to ensure the FTF occurs timely,
  • Ensure all FTF requirements are met,
  • Ensure the physician's documentation is complete, and
  • Delay submission of the final claim until all FTF requirements and documentation is met.

For more information on FTF requirements please refer to the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (Pub. 100-02), Chapter 7, Section 30.5.1.1External PDFand the CMS home health FTF FAQsExternal PDF.

Provider Action Needed to Prepare for the Edit

HHAs should take action now to ensure that they have procedures and processes in place to appropriately identify and respond to claims that are selected for Medical Review by this edit, including:

  • Checking for claims in the Additional Development Request (ADR) status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
  • Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
  • Mailing your documentation for claims selected to CGS by day 30.

More information regarding Additional Development Request (ADR) process is available at http://www.cgsmedicare.com/hhh/medreview/adr_process.html


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