face to face documentation

Face-to-Face Documentation Requirements

Documentation must be clearly titled, dated, and signed by the certifying physician, whether as part of the certification form itself, or as an addendum. It must also include the date the face-to-face encounter was performed. Face-to-Face Documentation Requirements

Documentation includes a brief narrative which describes how the patient’s clinical condition, as seen during that encounter, supports the patient’s home bound status and need for skilled services.

The face-to-face documentation must be that of the certifying physician, and cannot be altered/changed in any way by the home health agency.

The face-to-face documentation is part of the certification, and the certification is required at the time the home health agency bills Medicare.  

The face-to-face documentation can include, or exist as, check boxes so long as it comes from the certifying physician.

If the physician who cared for the patient in the acute or post-acute facility chooses to use documentation that is compiled from the patient’s medical record (e.g. a discharge summary) to inform the certifying physician of how the clinical findings of the face-to-face encounter support Medicare home health eligibility for that patient, the compiled documentation must be reflective of the clinical findings of that face-to-face encounter as observed by that physician caring for the patient in the acute or post-acute facility, thus serving as that physician’s communication to the certifying physician.  Further, if the certifying physician chooses to use the encounter documentation from the informing physician as his or her documentation of the face-to-face encounter, the certifying physician must sign and date the documentation, demonstrating that the certifying physician received that information from the physician who performed the face-to-face encounter, and that the certifying physician is using that discharge summary or documentation as his or her documentation of the face-to-face encounter.One physician signature, from the certifying physician, suffices if the face-to-face encounter documentation is co-located with the physician’s certification of eligibility.  Otherwise, if the face-to-face documentation is attached as an addendum to the certification (a separate document), the face-to-face documentation and certification each require a signature from the certifying physician.  

Electronic signatures are also acceptable.

Who Can Perform the Face-to-Face Encounter?

Medicare-enrolled physicians who are also the certifying physician;

The following physicians are allowed to perform the face-to-face encounter and inform the certifying physician:

  • Physicians (Medicare-enrolled or otherwise) who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and have privileges at the facility; 
  • Because residents (Medicare-enrolled or otherwise) do not have privileges at acute or post-acute facilities, if they are performing the encounter and informing the certifying physician, they must inform the certifying physician under the supervision of their teaching physician who must have such privileges.

NPPs allowed to perform the face-to-face encounter include: 

  • A nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law;  
  • A certified nurse-midwife under the supervision of the certifying physician, as authorized by State law; and  
  • A physician assistant under the supervision of the certifying physician. 

NPPs are subject to the same financial restrictions with the home health agency as the certifying physician.

Does Face to Face encounter required for Recertification?

Face-to-face encounter documentation is only required for the initial certification. At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for a subsequent 60-day episode.  

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