Currentblue cross blue shield - tennesseePolicy N/A

Home Health Face-to-Face Encounter Question & Answers

Guidance on what constitutes acceptable face-to-face encounter documentation for Medicare home health certification and who may perform or communicate the encounter, affecting home health agencies, certifying physicians, allowed non-physician practitioners, and acute/post-acute facility staff.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyHome Health Face-to-Face Encounter Question & Answers

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateMay 9, 2014

Next Review DateN/A

Key ActionObtain face-to-face documentation that is clearly titled, dated, and signed by the certifying physician before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>20Q&A entries

CMS-485Forms referenced

Certifying physicianSignature requirement

oneInitial only

30dAfter SOC window

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Coverage Criteria for Face-to-Face Encounters

inv-01: COVERAGE CRITERIA

Acceptable sources and signer requirements for face-to-face documentation:

Certifying physician must document the face-to-face encounter and sign the encounter documentation if using another practitioner's communication as their documentation.

A resident who is not enrolled in Medicare may perform the face-to-face encounter only under the supervision of a teaching physician who has admitting privileges at the acute or post-acute facility; the certifying physician must document the encounter and may sign the discharge summary or referral to indicate they are using it as their face-to-face documentation.

Documentation produced by ER, observation, or acute/post-acute physicians or allowed non-physician practitioners (NPPs) may be used as the face-to-face communication if it meets all face-to-face documentation requirements, is dated and clearly titled, and the certifying physician signs it when electing to use it as their documentation.

Allowed NPPs working in the acute or post-acute setting may perform the encounter and, through the physician who cared for the patient and has privileges, inform the certifying physician of clinical findings supporting homebound status and the need for skilled services.

CMS does not require the informing physician or NPP to sign the communication document; however, if the certifying physician relies on that document as their face-to-face documentation, the certifying physician is expected to sign, title, and date it in most cases.

Hospital discharge summaries often suffice as the informing communication when they include required content; information gaps may be resolved via communication by phone, email, or through physician support staff facilitating transfer of clinical details.

Home health agencies (HHAs) may add a title or date to face-to-face documentation if missing but may not alter clinical content; ensure documentation is complete and appropriately titled/dated before billing.

If a patient transfer to a hospital does not create a 60-day gap between episodes, a new face-to-face encounter is not required upon return to home health.

inv-02: Face-to-face encounter coverage criteria

Conditions under which a face-to-face encounter satisfies certification content requirements:

Timing: the face-to-face encounter must occur within 90 days prior to the start of home health care or within 30 days after the start of care.

Documentation source: acceptable sources include hospital/post-acute discharge summaries, physician electronic medical record entries, or a signed addendum that meet all face-to-face documentation requirements.

Signature: when the certifying physician elects to use another practitioner's communication (e.g., discharge summary, ER/observation physician note) as the face-to-face documentation, the certifying physician must sign the document to demonstrate they received and are using that information as their documentation.

Content: the documentation must include the physician's assessment linking clinical findings to the patient's homebound status and the need for skilled services; HHA-created checkbox-only forms are not acceptable unless they originate from the physician's medical record and include the required assessment.

inv-03: Face-to-face coverage criteria

Conditions under which episodes are covered and how incomplete or late face-to-face encounters are handled:

Requirement for payment: a completed face-to-face encounter is required for the initial certification and is a condition of Medicare payment; without a complete initial certification, subsequent episodes cannot be billed.

Exception for death: if the patient dies shortly after admission before a face-to-face encounter occurs, the certification may be deemed complete if the Medicare administrative contractor determines the HHA made a good faith effort to facilitate the encounter and all other certification requirements are met.

Timing windows and consequences: acceptable face-to-face documentation occurs within 90 days prior to the SOC or within 30 days after SOC; if neither window is met, the episode is not billable until eligibility is established, with the eligibility date equal to 30 days prior to the face-to-face encounter (the face-to-face date is counted as day 0).

OASIS and late encounters: when a face-to-face encounter is late, providers may use an existing OASIS to generate a new SOC OASIS with the SOC date equal to the first visit on or after Medicare eligibility; report the actual Date Assessment Completed and retain documentation explaining the non-covered period; delete or correct previously submitted OASIS as necessary in accordance with guidance.

Forms, Codes, and Visit Counting

Forms and certificationmixed

No codes listed

Physician certification billingmixed

Physician who certifies may bill Medicare for physician certification.

mixed

No codes listed

inv-07: Medicare-covered visit counting

RuleOnly Medicare-covered visits count toward assessment and therapy visit timing; therapy visits provided before a retroactive start-of-care date are non-covered and must not be counted.

Action for HHAsTrack both Medicare-covered and non-covered therapy visits when face-to-face encounters are late to maintain correct Medicare-covered visit counts for assessment timing.

Reference guidanceCY 2012 final rule: only Medicare-covered visits are to be considered and counted when determining therapy visit milestones.

inv-08: face-to-face windows

Timing windowA qualifying face-to-face encounter must occur within 90 days prior to the start of home health care (SOC) or within 30 days after SOC.

Provider Responsibilities and Operational Guidance

Documentation Required

Pre-billing documentation check — Obtain face-to-face documentation

Obtain face-to-face documentation that is clearly titled, dated, and signed by the certifying physician before billing. The certification is not complete without that documentation; the certifying physician may sign and adopt a hospital discharge summary or an encounter note from an acute/post-acute practitioner provided it meets content requirements and is signed by the certifying physician.

Documentation must be a separate and distinct section or addendum to the certification and include: patient name; encounter date; how the clinical findings support homebound status and need for skilled services; certifying physician signature (original, faxed copy, copy of original with signature, or electronic signature — not stamped); and either the signature date or the date the document was received by the HHA.

Billing Rule

Therapy visit counting when start date changes

Key Definitions

inv-18: separate and distinct

Definition'Separate and distinct' means the face-to-face documentation must be a clearly titled, dated section of the certification or an addendum so it is easily recognizable as the face-to-face documentation.

Content requirementDocumentation must be titled as the face-to-face encounter, include patient name, date of encounter, clinical findings supporting homebound status and need for skilled services, and the certifying physician's signature or accepted electronic/faxed copy.

HHA actionHHAs may add a title or date if missing but may not alter clinical content; certification is not complete until face-to-face documentation is clearly titled, dated, and signed by the certifying physician.

inv-19: allowed NPP

Allowed NPPsNurse Practitioners, Clinical Nurse Specialists, Certified Nurse-Midwives (as authorized by State law), and Physician Assistants (under physician supervision).

Policy Summary

Payerblue cross blue shield - tennessee

PolicyHome Health Face-to-Face Encounter Question & Answers

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateMay 9, 2014

Next Review DateN/A

Key ActionObtain face-to-face documentation that is clearly titled, dated, and signed by the certifying physician before billing.

SourceLink

On This Page

Billing impact and patient protections: certification is a condition of Medicare payment; HHAs must not bill the patient or abruptly discharge solely for a missing face-to-face encounter, and a narrow exception exists if the patient dies shortly after admission and a MAC determines a good faith effort was made.

Who may perform: the encounter may be performed by the certifying physician, an allowed NPP, or a physician who cared for the patient in an acute/post-acute facility with privileges; residents may perform encounters only under supervising privileged physicians.

Conflict of interest: the certifying physician may not have a disallowed financial relationship with the HHA as defined in applicable regulations when serving as the certifying physician.

Electronic documentation: submissions via electronic portals and electronic signatures are acceptable provided the face-to-face documentation is separate, titled, dated, and signed by the certifying physician when required.

Initial vs. re-certification: the face-to-face encounter requirement applies only to initial certification and not to re-certifications.

Non-covered period: services provided before the Medicare eligibility date (the period prior to the retroactive SOC when the F2F occurs late) are non-covered and not payable by Medicare.

If not metIf neither window is met, the episode is not billable as a Medicare home health episode until eligibility is established based on the face-to-face date.

Eligibility date calculationWhen F2F is late, the date when Medicare eligibility was met is 30 days prior to the F2F encounter date (F2F date = Day 0).

Therapy visits that occurred before a retroactive start-of-care date established after a late face-to-face encounter are not Medicare-covered and therefore must not be counted toward Medicare-covered therapy visit thresholds (for example, the 13th and 19th visit timing). HHAs should track both Medicare-covered and non-covered therapy visits to determine accurate Medicare-covered visit counts for assessment timing and OASIS reporting.

Only Medicare-covered visits are counted for Medicare visit-count timing.
Track non-covered visits separately to avoid miscounting therapy visit thresholds.

Note

Exception for death before encounter

If a patient dies shortly after admission before a face-to-face encounter occurs, the certifying physician documentation requirement may be deemed satisfied when the Medicare Administrative Contractor determines the HHA made a good faith effort to facilitate the encounter and all other certification requirements are met.

This is a limited exception applicable when death occurs before the encounter and the MAC finds a good faith effort by the HHA to coordinate the encounter.

Documentation Required

OASIS and late face-to-face handling

When a face-to-face encounter occurs after the allowable window (not within 90 days prior to SOC or 30 days after SOC), the episode is not Medicare billable until Medicare eligibility is established. In these cases an HHA may generate a new SOC OASIS with an SOC date equal to the first visit on or after the date eligibility was met (the date 30 days prior to the F2F encounter, counting the encounter date as day 0). The (M0090) Date Assessment Completed must reflect the actual date the new OASIS is generated. If an original OASIS was already submitted, it should be deleted and replaced by the regenerated SOC OASIS; document and retain all assessments and an explanation in the clinical record. Timing warnings from the OASIS system may occur and can be disregarded where justified.

Date when Medicare eligibility is established = 30 days prior to the F2F encounter (encounter = day 0).
Non-covered visit period example: first visit Jan 1, F2F Feb 5 (day 35) → eligibility established Jan 6 (Jan 1–5 non-covered).
Use the assessment closest to the date of Medicare eligibility (SOC, ROC, or Follow-up) when regenerating OASIS.
Update M0030/M0090, M0110 (Episode Timing), and M2200 (Therapy Need) as needed to exclude non-covered visits.

Certain NPP encounters performed in acute or post-acute settings may satisfy the face-to-face requirement when collaborating with the certifying physician.

CommunicationAn allowed NPP may inform the certifying physician of clinical findings; the certifying physician must sign if using that documentation as the face-to-face record.

inv-20: physician support staff

Who they arePhysician support staff are individuals who regularly work with or for the physician and who routinely perform documentation, take dictation, or extract material from the physician's medical records to support the physician.

Permitted useSupport staff may compile or extract documentation (e.g., discharge summaries) for physician review and signature to meet face-to-face documentation requirements.

Electronic documentationPhysicians may use EMR-generated narrative or checkbox text; support staff may extract this content for physician signature, provided required assessment content is present.

inv-21: Certifying physician

RoleThe certifying physician is the statutorily required clinician to document the face-to-face encounter and must sign the encounter documentation when using another physician's or NPP's communication as their documentation.

Possible identitiesMay be the acute/post-acute physician who cared for the patient and has facility privileges, or a community physician who receives a signed encounter addendum and assumes oversight.

RestrictionsPhysicians with disallowed financial relationships per 411.351 may not serve as certifying physicians; residents may perform encounters only under a supervising privileged physician.

inv-22: Allowed documentation formats

Acceptable formatsDischarge summaries, physician EMR entries, signed addenda, or EMR-generated checkbox text are acceptable if they contain the physician's assessment linking clinical findings to homebound status and need for skilled services.

HHA-created formsHHA-created checkbox-only forms are not acceptable unless the documentation originates from the physician's medical record and contains the required assessment content.

Electronic signaturesElectronic signatures, faxed copies, or copies of original signed documents are acceptable (stamped signatures are not).

inv-23: face-to-face encounter documentation

Required elementsFace-to-face encounter documentation must be titled as the face-to-face encounter, include patient name, date of encounter, assessment of how clinical condition supports homebound status and need for skilled services, and the certifying physician's signature or accepted equivalent.

Signature typesAcceptable signature formats include original signature, faxed copy, copy of original document with signature, or electronic signature; stamped signatures are not acceptable.

Completion requirementThe certification is not complete until the face-to-face documentation is complete and meets all content and signature requirements.

inv-24: HHABN Option 2

What it isHHABN Option 2 is a change-of-care notice used to discontinue services for administrative reasons, such as failure to meet the face-to-face encounter requirement, and does not shift financial liability to the beneficiary.

Usage requirementWhen used to terminate services for lack of face-to-face, the HHABN must state that reason and should be provided in advance if possible to allow beneficiary and physician to address the deficiency.

No expedited notice before terminationHHAs do not issue the Notice of Medicare Provider Non-coverage (CMS 10123) before care is terminated under these circumstances.