CMS Clarifies Home Health Face-to-face Documentation Requirements

Since Jan. 1, 2011 a certifying physician must document that he or she—or an qualified non- physician practitioner (NPP)—had a face-to-face encounter with the beneficiary prior to certifying a beneficiary’s eligibility for the home health benefit. The Centers for Medicare & Medicaid Services (CMS) has clarified this documentation requirement in a special edition of the MLN Matters newsletter. The clarification “is intended for physicians who refer patients to home health, order home health services, and/or certify patients’ eligibility for the Medicare home health benefit, home health agencies, and non-physician practitioners (NPPs).”

As a condition of payment, a face-to-face encounter must occur within 90 days prior to the start of home health care, or up to 30 days after the start of care. CMS reiterates that the encounter document must include an explanation of why the clinical findings support that the patient is homebound, and in need of either intermittent skilled nursing services or therapy services. The agency stresses that diagnoses alone do not support the need for skilled service; that standard language (e.g., “taxing effort” or a notation such as “gait abnormality”) alone do not support homebound status, and; that most insufficient documentation errors occur because “the face-to-face encounter document does not sufficiently describe how the clinical findings from the encounter support the beneficiary’s homebound status and the need for skilled services.”

Per CMS, the two elements of the required brief narrative for documenting the home health face-to-face encounter are:

1. Confined to the home – Describe why the patient is homebound. An individual shall be considered “confined to the home” (homebound) if both of the following two criteria are met:

A. The patient must either:

  • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
  • Have a condition such that leaving his or her home is medically contraindicated.

B. There must exist:

  • A normal inability to leave home; and
  • Leaving home must require a considerable and taxing effort.

2. Need for Skilled Services – To qualify for home health services, the beneficiary must need intermittent skilled nursing services, physical therapy (PT), or speech language pathology (SLP) services. Describe what the RN, PT, or SLP and other services will be doing in the home. For example, “skilled nursing required to assess and manage new COPD regimen.”

  • Skilled nursing services must be reasonable and necessary for the treatment of the patient’s illness or injury. Skilled nursing services can be, but are not limited to:
    • Teaching/training
    • Observe/assess
    • Complex care plan management
    • Administration of certain medications
    • Tube feedings
    • Wound care, catheters and ostomy care
    • NG and Tracheostomy aspiration/care
    • Psychiatric evaluation and therapy
    • Rehabilitation nursing
  • PT, OT, SLP must be reasonable and necessary for the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury within the context of his or her unique medical condition.Assuming all other eligibility and coverage requirements have been met, one of the following three conditions must be met for therapy services to be covered:

1. The skills of a qualified therapist are needed to restore patient function.

2. The skills of a qualified therapist are needed to design or establish a maintenance program.

3. The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy.

The MLN Matters article also provides examples of proper documentation, relative to the type of encounter.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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