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There have been many concerns and questions surrounding the 2015 Home Care Face to Face (F2F) documentation requirements since the release of the proposed regulation. Now that the regulation is final and the Centers for Medicare & Medicaid (CMS) has conducted a webinar and issued some clarifications it is more clear as to what to expect moving forward.

In regard to what is required in the actual documentation, that the agency must obtain, the following is an excerpt from the transcript of the CMS call:

The certifying physicians and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit. And the actual clinical note must demonstrate that the encounter (1) occurred within the required timeframe, (2) was related to the primary reason the patient requires home care services, and was (3) performed by an allowed provider type. This information can be found most often, but is not limited to, clinical and progress notes and discharge summaries.

The other 2 items required to complete the F2F requirement is narrative documentation to support that the patient needs skilled home care services and that the patient is homebound. If the narratives to support the need for skilled services and homebound status are not present in the visit note/discharge summary, then the agency is able to provide this information, following the comprehensive assessment of the patient. CMS has provided examples of visit notes and discharge summaries that are complete and has also provided examples that lack the adequate narratives. In the case of the inadequate visit notes and discharge summaries, CMS has provided agency documentation examples that should be sufficient to provide the additional narratives. Please see those examples at the link below:

Make sure that you are clear……IF the agency supplements the visit note or discharge summary with additional information from the comprehensive assessment to support homebound status and the need for skilled services, this must be sent to the physician to sign and date, making it a part of the medical record of the patient.

Lastly, please understand that the home care agency MUST obtain the visit note and/or discharge summary and this document MUST contain the first three criteria: 1) a visit date that falls in the required timeframe for the F2F; 2) the reason for the visit is related to the primary reason for home care; and 3) the visit was performed by an allowed provider type.