It’s no secret that face-to-face documentation is one of the top reasons Medicare denies home health claims. The rules and regulations around F2F are often perceived as inconsistent, and even those of us who deal with it day in and day out can find it challenging to help an agency operationalize the F2F requirements in a way that assures they are compliant with Medicare guidelines.

Knowing what is required for a F2F will help agencies develop a step-by-step internal process to secure a patient’s certification of eligibility for Medicare home health benefits.   It is important to note that if F2F documentation does not sufficiently demonstrate that the patient is eligible for Medicare home health benefits, the claim will be denied and payment will not be rendered for home health services provided.

This article breaks down Chapter 7 of the Medicare Benefit Policy Manual to provide:

  1. When a F2F is required
  2. Who can complete a F2F
  3. How to create a Focus of Care based on the F2F

Learn about items to consider when developing a home health face-to-face checklist and process. Agencies can arm themselves adequately to fight back against claim denials.

Why Does Medicare require a Face-to-Face (F2F)?

Medicare began requiring a home health F2F in 2011 as the result of the Affordable Care Act (ACA). The intent of the F2F was to reduce fraud, waste, and abuse by making it a Medicare condition of payment that a physician, or other health care provider, physically meet with patients to assess their specific care needs in person prior to ordering home health services.  

When the F2F was first initiated in 2011, agencies were required to document the F2F encounter on a specific form. Many agencies and clinicians remain unaware that that requirement was eliminated by CMS in 2015 and they continue to submit F2F encounter forms as documentation. The form alone is not sufficient documentation. This oversight can be very costly for many agencies due to unnecessary claim denial.

There’s not a specific program that monitors the F2F compliance. CMS reviews records for fraud as well as home health eligibility. Although a F2F form is no longer required for billing, agencies need to always be prepared to provide supporting documentation to CMS upon request.

When Does Medicare require a F2F encounter?

F2F at SOC: A F2F encounter is ONLY required for the initial home health episode. Any time a Start of Care (SOC) OASIS (Outcome and Assessment Information Set) is completed by an agency to initiate services for a Medicare beneficiary a F2F is required. This includes if a patient is discharged from home care at their request, or due to goals met, with no expectation of returning to home care. Any future admission would require a new SOC and therefore will need a new F2F encounter.

F2F at Recert: Recertifications, performed every 60 days, do not require documentation of a new F2F encounter. Remember that all subsequent recertification periods will not be paid unless the F2F requirements for the initial episode are met. With F2F only being required with the initial admission, the F2F is good until the patient is discharged from home health services. 

F2F at Resumption of Care: Resumption of care (ROC) is performed when a patient is discharged back to the care of an agency following an inpatient stay. Many times, this can involve a change or exacerbation of condition, but a new F2F is not required for ROCs. The only exception would be if a patient were to transfer to an inpatient facility, remain under the care of that facility until the 60-day episode ends, and then return to the agency. In this case, the patient would be discharged from prior services and a new SOC would be required, along with a new F2F encounter. 

No F2F or unrelated F2F Encounter: If a patient did not have a F2F encounter at all prior to home care admission, or they had a F2F visit with their MD that was unrelated to the main reason that the patient requires home health services, a new/qualifying F2F encounter would need to take place during the 30 days after SOC.

Who must perform a F2F?

This is something our team takes very seriously. We did an entire podcast episode on the subject. Per Medicare guidance, the F2F may be performed by the certifying physician, facility/hospitalist physician, or an allowed non-physician practitioner (NPP) as defined below:

  • Certifying physician is the physician/MD that refers the patient to home health services and will review and sign the POC. Note that MD=Doctor of Medicine, Osteopathy, or Podiatry acting within the scope of his/her state license.
  •   Facility/Hospitalist physician is a physician who cares for the patient in an acute or post-acute facility (PAF) directly prior to the home health admission, and who has privileges at the facility. Although the facility/hospitalist physician may initiate home health care orders/POC and certify the patient’s eligibility, they are expected to collaborate with the patient’s community physician so that they can assume primary care responsibility for the patient upon discharge. 
  •   Non-physician practitioner (NPP) practices under the supervision of the certifying or facility/hospitalist physician. Allowed NPPs include: Nurse Practitioners, Clinical Nurse Specialist, Certified Nurse-Midwife, and Physician Assistant.

 

The F2F encounter cannot be performed by any physician or allowed NPP who has a financial relationship with the home health agency that will be providing care to the patient.

What is the F2F time frame required by CMS?

No more than 90 days prior to the SOC date, or within 30 days after the SOC date.

This allows for the patient to have a qualifying F2F with the certifying physician sometime within the 30 days after admission to home health services if the patient did not have a F2F prior to admission.  

Can a F2F be a Telehealth Visit? 

  The F2F encounter can occur via telehealth, but it must be evident in the documentation that there was real-time interactive communication between the patient and the physician or practitioner using audio equipment. The practitioner can state that he/she observed, thus showing through use of video equipment that the patient was visualized and examined. Documentation stating “telephone only” or “audio only” or that the patient was “not physically examined” will result in an insufficient F2F encounter.

What if any agency is unable to obtain qualifying F2F?

  An agency may choose to terminate a patient’s services if they fail to meet F2F encounter requirements. In this case, the agency would need to issue the patient a Home Health Change of Care notice (HHCCN) in advance so that the patient can attempt to meet F2F requirements.

What if the patient dies prior to qualifying F2F?

If an admitted patient dies prior to a F2F encounter occurring, the F2F certification will be considered completed if all other certification requirements were met and the agency can provide documentation that good faith effort existed to facilitate/coordinate the encounter within 30 days of admission.

 

F2F encounter must be related to the reason home care is needed

To be F2F compliant, the medical record must contain the actual clinical note for the F2F encounter. A well-documented clinical note will typically include medical history, physical assessment findings, outline of the medical decision-making process, and documentation of active diagnoses, including the diagnosis that makes home health necessary. The note must be signed and dated by the certifying physician/NPP that performed the F2F, as evidence that the encounter occurred within the required time period.   

What counts as supported documentation? 

Examples (not a complete list) of supported documentation: Clinical/Progress Note or Discharge Summary.  

Guidance allows for information from the home health agency to be incorporated into the certifying physician’s medical record to help support missing elements of the F2F encounter related to skilled need and homebound status. Information provided by the home health agency cannot contradict the physician or facility’s documentation regarding the patient’s diagnoses and condition and cannot be used as the only documentation to support the need for home health. Information provided by the agency must be reviewed, signed, and dated by the certifying physician before it will be considered part of the medical record. Combined with the MD documentation, additional information provided by the agency can significantly help create a much more comprehensive clinical picture. 

What can be used for corroboration documentation? 

Examples (not a complete list) of information the agency may provide to corroborate:  Information from the Comprehensive Assessment and the Plan of Care.

Extracting information from the F2F encounter to establish a Focus of Care for the home health episode

Intake plays a major role for agencies regarding F2F. It is important to understand how F2F documentation comes full circle and impacts all aspects of documentation.It is vital that agencies ensure that if an unacceptable PDGM diagnosis (such as “impaired gait” or “frequent falls”) is provided in the F2F encounter as the reason for home health when a referral is received, that the physician is queried to confirm the underlying cause.   Often it is the underlying cause that results in an acceptable PDGM primary diagnosis.  

Equally important is that agencies are aware that Coding guidelines from the ICD-10-CM Official Guidelines for Coding and Reporting should always be followed when reporting diagnoses on a claim. Sequencing and selection of primary and secondary codes is a complex process! Clinical judgment as well as etiology and causative conditions must be taken into consideration when confirming that there is sufficient information to support the reason for a home health referral. The result is that often a diagnosis which is documented as the primary reason for home health F2F could actually be in sequenced in the first secondary diagnosis position on the Plan of Care, rather than the primary position due to specific rules related to manifestation/etiology or “code first” coding instructions. If there is supportive documentation to confirm both diagnoses, this will not result in denial of a claim.

Example of manifestation/etiology coding guidance related to F2F:

Referral documents state the patient is being referred to home health for Dementia.   Dementia is clearly addressed on the F2F, along with additional comorbidities including Parkinson’s Disease. Coding guidance indicates that certain conditions should be coded as related even in the absence of documentation explicitly linking them. Conditions with an assumed relationship are linked with specific terms in the Alphabetic Index of the coding guidance. Coding guidance requires that Parkinson’s Disease and Dementia have a causal relationship and that Parkinson’s Disease must be coded prior to Dementia, meaning Dementia will not be the first diagnosis listed on the claim. There are many causal relationships among the almost 73,000 ICD-10 codes to choose from.   Including, but not limited to Hypertension and CHF, as well as Osteoporosis and a current fracture.

F2F Checklist for home health

In conclusion, obtaining adequate F2F and additional documentation in conjunction with the timing of the patient’s referral is best practice. Once received consider implementing an internal process to confirm that the information obtained will support your claim prior to billing by remembering implementing the following F2F checklist:

  1. Determine if a F2F is required for the assessment being completed.
  2. Confirm that the F2F encounter was performed by a certifying physician, facility/hospitalist physician, or allowed non-physician practitioner.
  3. Confirm that the F2F encounter occurred within the F2F time frame required by CMS.
  4. Confirm there is documentation present to substantiate the patient’s need for skilled services and homebound status. 
  5. Confirm that the F2F encounter is signed, dated, related to the main reason the patient needs home health services, and that the focus is PDGM appropriate.

 

For additional information: 30.5.1.1 – Face-to-Face Encounter (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21); Medicare Benefit Policy Manual Chapter 7 – Home Health Services 

Written by Anna Powers RN, BSN, BCHH-C