Documenting Face-to-Face

admin Referring to Home Health Comments Off on Documenting Face-to-Face

Medicare Patient Physician face-to-face DocumentationTips to help make it easy to document face-to-face encounters with your patient referrals

Documentation of a face-to-face encounter between you and the patients you refer to home health is required by CMS as of April 1, 2011.

Streamline the process with these quick and easy tips:

*If you certify a patient is eligible for Medicare home health services, you must see that patient within 90 days prior or 30 days after the start of home health care and provide documentation of the visit.

Required in the Documentation

  • The patient’s name
  • The date of the face-to-face encounter with the patient
  • Reason for homebound status
  • Why the need for skilled home health services
  • Your signature and the date


What to Include in the Narrative Content

Describe the patient’s clinical condition and how the patient’s condition supports homebound status and the need for skilled services.

Here is an example, courtesy of CMS:

“The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen.”

Make it Easy:

  • You do not need a separate form to record this data. Simply include the information on a patient transfer form or plan of care.
  • You can dictate the content of your face-to-face encounter for a staff member to document. It is also acceptable for the documentation to be generated from an electronic health record.
  • A member of your staff can compile the required information from the patient’s chart and attach to the plan of care for you to sign.
  • Create copy templates for commonly written notes, such as documenting need for home health services for CHF patients, and edit the template for each patient.

Other Tips:

  • The certification is only required at the actual start of care – not, for example, when a patient switches payment source from Medicaid to Medicare, or upon recertification.
  • The face-to-face encounter can be done by a non-physician, but a physician must sign the certificate.
  • Homebound status: Patients are considered homebound if leaving the home requires tremendous effort and assistance from another person or device. Homebound does not mean bedbound.
  • Remember to bill for home health care plan oversight.

What is Unacceptable?

The physician cannot verbally communicate the encounter to the home health agency, where the home health agency would then document the encounter as part of the certification for the physician to sign.