Have you heard the latest?  Are you in the “know” regarding medical review documentation requirements of your Medicare Home Health Charts?

Many of you know that the Pre-Claim Review Demonstration began in the state of Illinois and was set to begin in four other states, but has now been postponed until further notice.  During a recent workshop by Palmetto GBA and CGS, when discussing the documentation requirements for home health to be submitted under Pre-Claim Review, they referenced and used examples from a YouTube video that was done by Dr. Feliciano, Senior Medical Director of PGBA . This video was created to help educate physicians on the requirements of home health documentation.  He is providing 4 questions that physicians should be answering in the clinical documentation of their visit notes for patients that will be referred to home health.  The educators at the workshop made the statement that we should follow these guidelines in documenting the additional clinical narratives to support why the patient is homebound and why the patient needs home health.  Medical review is looking for this type of documentation.

The Face to Face Requirement includes that agencies must obtain the Face to Face Encounter visit note or discharge summary. One of those two documents must provide documentation to support:

1.    The patient was treated by the physician for the primary reason that they are being referred to home health
2.    The encounter occurred within the 90 prior to or within the 30 days after the SOC  AND
3.    The encounter must have been conducted by a valid practitioner who has signed and dated the encounter document

Once the agency has confirmed the above content on the encounter document, the agency is then going to document clinical narratives to support why the patient needs home health care and why the patient is homebound.  These clinical narratives must be signed and dated by the certifying physician.  Most agencies are including these clinical narratives on the POC.

The PGBA/CGS Educators, referenced above, are suggesting that if you utilize the four questions from Dr. Feliciano’s video, in documenting those additional clinical narratives, that you will be documenting the required elements.


1. Is there a structural impairment?

  • Structures of the nervous system
  • Eye, ear and related structures
  • Structures involved in voice and speech
  • Structures of the cardiovascular system
  • Structures of the immunological system
  • Structures of the respiratory system
  • Structures related to the digestive system
  • Structures related to the metabolic and endocrine systems
  • Structures related to the genitourinary system
  • Structures related to movement
  • Skin and related structures

2.    Is there a functional impairment? 

  • Mental functions
  • Sensory functions and pain
  • Voice and speech functions
  • Functions of the cardiovascular system
  • Functions of the hematological and immunological systems
  • Functions of the respiratory system
  • Functions of the digestive system
  • Functions of the metabolic and endocrine systems
  • Genitourinary functions
  • Neuromusculoskeletal and movement-related functions
  • Functions of the skin and related structures

3.    Are there activity limitations?

  • Communication
  • Mobility
  • Self-care
  • Domestic life
  • Interpersonal interactions and relationships

4.    How do the skills of a nurse or therapist address the specific functional and structural impairments and the activity limitations?

  • Example:  The skills of a nurse are needed to monitor the healing process of the surgical wound and educate the patient or caregiver on the dressing changes and monitoring signs and symptoms of infection.
  • Example:  Physical and Occupational therapy is necessary to evaluate the patient’s functional status, capacity for improved mobility and self care or to implement a personalized patient centered plan of care to address activity limitations.

The educators also reference MLN SE1436. This article was the result of a CMS Webinar dating back to when the newest Face to Face changes were made and has been used as a guide since then.

Using these guidelines above can only help with understanding what they are looking for in documentation content.