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June 12, 2013

Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)

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 (FTF) with your patients regarding home health care.

Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The most common error is 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
  • How the patient's condition supports the patient's homebound status; or
  • How the patient's condition supports the need for skilled services

Acceptable FTF documentation does not have to be lengthy or overly detailed. However, the FTF 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 FTF documentation that, used alone, are considered insufficient documentation.

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"  

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 FTF Encounter?

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 NPP can then report the FTF encounter to the certifying physician.

Medicare guidelines also contain specific documentation requirements:

  • The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.
  • If the FTF was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must communicate clinical findings of the FTF encounter to the certifying physician. NPPs performing the FTF 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 FTF.
  • 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 FTF documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare.
  • The FTF documentation must include:
    • The date of the FTF 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 FTF is a requirement for payment, when the FTF 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 FTF documentation is insufficient, the beneficiary's ability to receive this skilled care may be jeopardized.

References and Resources:

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