Eligibility Criteria for Face-to-Face Encounters

National Government Services is reminding home health providers that a face-to-face encounter form is not adequate documentation to support that a face-to-face encounter occurred. In CR 9119, CMS eliminated the narrative requirement (regarding the patient’s homebound status and need for skilled services in the face-to-face encounter documentation). CR 9119 also states that documentation from the certifying physician’s medical records and/or the acute/post-acute care facilities medical records (when the patient is directly admitted to home health services) are to be used as the basis for certification of patient eligibility. Therefore, home health agencies must submit the actual clinical notes from the physician and/or the acute/post-acute care facility medical record, indicating that the patient had a one-on-one visit with a physician or nonphysician practitioner when responding to an NGS ADR.

As per federal Medicare regulation, the home health agency generated medical record documentation for the patient, by itself, is not sufficient in demonstrating eligibility for Medicare home health services. The face-to-face encounter is part of the certification of patient eligibility and must be performed by the certifying referring physician or nonphysician practitioner him/herself, or another physician or nonphysician practitioner that cared for the patient in the acute or post-acute care facility. Also, a co-signature is not required when an allowed nonphysician practitioner completes and documents the face-to-face encounter or certification of eligibility.

There is no mandatory form for the face-to-face encounter. The face-to-face encounter may now be supported within documentation from the patients’ medical record, providing written documentation that a one-on-one visit occurred between the patient and the physician or nonphysician practitioner. Documentation of the encounter must include clinical information regarding the patient’s current diagnosis for which they are being referred for home health services. Documentation of the encounter may be that of a discharge summary from an acute or post-acute care facility or the progress note from a physician or nonphysician practitioner office visit. It should include the patient name, as well as the dated signature of the provider completing and documenting the actual encounter. The only mandatory narrative required in the face-to-face encounter documentation is when skilled oversight of unskilled care is ordered during the visit/encounter.

The face-to-face encounter is one of five eligibility criteria certified by the physician or nonphysician practitioner. Home health agencies are required to ensure that all Medicare beneficiaries are eligible for home health services by ensuring all five eligibility criteria have been met and are certified, including the face-to-face encounter. All five eligibility criteria will be verified during review of the acute, post-acute care facility and/or referring/certifying physician or nonphysician practitioner’s medical records shared with the home health agency. The CMS form 485 is no longer a CMS endorsed mandatory document and agencies may develop a certification statement to encompass all eligibility criteria, including the face-to-face encounter. Form 485 has been updated and is available on the CMS website. If there are two separate certification statements encompassing all eligibility criteria, they must be signed by the same Medicare enrolled physician or allowed nonphysician practitioner.

Eligibility Criteria for Face-to-Face Encounters

Related Content