What is Face-to-Face Documentation?

The face-to-face encounter is a condition of payment.  This is documentation, which must be present for patients with starts of care on or after April 1, 2011. The face-to-face encounter, that results in the required documentation, must be performed by the certifying practitioner, a physician or qualified non-physician practitioner (NPP), such as a physician’s assistant, certified nurse specialist, or a nurse practitioner.  The encounter may be completed by a practitioner who cared for the patient in an acute or post-acute facility from which the patient is directly referred to home health, with the provider having had privileges at the facility. If there is no facility encounter, the face-to-face would be required to be completed by the certifying physician or a NPP working in conjunction with the certifying physician. In states that allow, if a NPP is certifying the patient for home health, the encounter MUST be performed by the same NPP.  Only the certifying practitioner can attest to the date of the encounter on either the certification/plan of care or a signed addendum to the certification.

Face-to-Face Encounter Key Details

The face-to-face encounter note/documentation often includes a brief narrative describing the nature of the visit. As such, a head-to-toe assessment, vital signs, medication listing, diagnosis code listing, treatment performed and/or a review of systems assessment is generally present within the note. Some examples of face-to-face encounter notes/documents include, but are not limited to, physician office progress visit notes, facility encounter notes, and discharge encounter summaries.

The face-to-face documentation must show that a practitioner had an encounter with the patient, and it must be related to the primary reason the patient is receiving home health services. As such, the face-to-face documentation must include several details to be considered complete. These requirements are as follows:

  • The patient’s name and date of birth (any additional identifiers that may be deemed necessary according to the physician and/or facility)
  • Date of encounter, which must be within 90 days prior to the home health start of care, or within 30 days after
  • Clear documentation that shows the patient was visually assessed by the provider (head-to-toe assessment, review of systems assessment, vital signs, etc.)
  • Documented support of the patient being homebound and the need for skilled home health services – if not enough support, the agency may create a clinical narrative, following the comprehensive assessment, regarding skilled need and homebound status and have it signed by the certifying practitioner
  • Must relate to the primary diagnosis for home health, although it is not required to be the primary focus of the patient’s visit with his/her allowed practitioner
  • Must be signed and dated by the practitioner performing the assessment and must include the practitioner’s credentials
  • If the face-to-face encounter is not performed by the certifying physician, the certifying physician must sign and date an attestation with the face-to-face encounter date

An exceptional circumstance can occur if the patient passes away shortly after admission, before the face-to-face encounter could take place. In this case, a medical reviewer would determine that a good faith effort occurred on the home health agency’s part if documentation shows that coordination of the visit took place. As such, the certification would be deemed complete under CMS requirements.

Clinical Consulting Services


Telehealth Face-to-Face Encounter Requirements

Due to the Public Health Emergency (PHE), as of March 1, 2020, CMS expanded face-to-face encounter requirements to include a telehealth option via the Section 1135 waivers. The documentation must show that both video and audio were used to conduct the visit.  Also, a part of the waivers included that the normal HIPAA approved platform requirements would be waived during the PHE.  All other face-to-face encounter requirements should be met within the documentation. If the documentation states that only audio was used, the face-to-face encounter will not be accepted under medical review.  While the PHE will end on May 11, 2023, the ability to conduct the face-to-face encounter via telehealth has been extended by CMS until December 31, 2024.  Also, the Office of Civil Rights (OCR), who is responsible for enforcing the HIPAA Privacy and Security Rules, has extended the allowance for utilizing non-HIPAA compliant platforms for 90 days.  Agencies will be required to utilize HIPAA compliant telehealth platforms effective August 10, 2023.

Home Health Primary Diagnosis and the Face-to-Face Encounter

A major point of concern and contention has been ensuring that the face-to-face encounter documentation relates to the home health primary diagnosis at the start of care. If the primary diagnosis on the home health plan of care is simply included as a diagnosis listed on the face-to-face encounter documentation, this is not sufficient and could result in a denial under medical review. The primary diagnosis should be, at a minimum, assessed by the physician and some notation regarding the diagnosis change or treatment should be made.

For example, if the primary diagnosis for home health is diabetes but this was not the primary focus of the clinical encounter note, the face-to-face encounter would be accepted if the some of the following were included in the face-to-face encounter note:

  • The diagnosis and/or acceptable ICD-10 code for diabetes
  • Inclusion of the patient’s glucose level under the vital signs
  • An assessment note specific to the patient’s diabetic status under the review of systems assessment
  • Current diabetic medication(s)
  • An implementation/summary note specific to the patient’s diabetic status
  • Ongoing plan or changes to the treatment plan based on the patient’s current clinical status

The above outline is only an example of how the face-to-face documentation can support the primary home health diagnosis with no questions about the validity of the diagnosis. This will ensure that no addendums nor a new encounter will be necessary.  This will ensure likely success for the home health agency under medical review, regarding the face-to-face component.

The face-to-face documentation requirements should be an ongoing primary focus of all home health agencies, as claims may not be billed until the documentation is complete, in the patient chart, and meets all the requirements.  Even though face-to-face encounters are only one part of the conditions of payment, failure to meet the requirements may cause a denial of the entire chart.  Visit your Medicare MAC website for additional information.

Healthcare Provider Solutions stands ready to assist in any way necessary to ensure that your documentation will pass any level of medical review. Start a conversation today!