21 May Face to Face Encounter
Face to Face (F2F) Documentation was mandated by the Affordable Care Act of 2010 and is required for Start of Care Home Health Certiﬁcations on or after January 1, 2011. F2F is a condition of payment, not a condition of participation. An agency can be denied payment even if all other conditions are met. The F2F requirement ensures that the orders and certiﬁcation for home health services are based on a physician’s current knowledge of the patient’s clinical condition.
A certifying physician must certify that Medicare Home Health eligibility has been met to include the following conditions: The patient must be confined to the home, be under the care of a physician, services are provided under a plan of care established and periodically reviewed by a physician, be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy and must have a documented F2F encounter with physician or allowed non-physician practitioner (NPP). This encounter must occur 90 Days prior to SOC or within 30 days after SOC.
A certifying physician is a Physician who cared for patient in acute/post-acute facility, a Nurse Practitioner, a Clinical Nurse Specialist, a Certified Nurse-Midwife or a Physician Assistant. Different physicians may be involved in the care of the patient, such as, the certifying physician, the MD who provided care in the acute/sub-acute facility, and possibly a specialist who prepared a pre-op history and physical. Additionally, there are Home Care Medicine practices consisting of physicians who provide home based care for homebound patients. Any one of these professionals may have prepared a document that is a valid F2F encounter.
The professional performing the F2F encounter cannot be employed by or have a financial relationship with the home health agency.
Don’t forget, only an MD (doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license) can order home health and sign the Plan of Care. The F2F encounter is to be related to the primary reason for home health.
The Face to Face Documentation has some key components. F2F should include the name of the MD or NPP who saw the patient and the date of the encounter. Include the clinical condition that supports homebound status and the need for skilled services. The F2F Documentations should support the primary reason the patient required home health, as well as, the reason for home health referral. The documentation should also include the MD name, signature and date. Items must come directly from MD. Additional items may be located throughout the medical record, but must be clearly identifiable. An easy and convenient way to identify documents in the medical record is to purchase a couple of stamps and inkpads from an office supply store. These stamps can be used to clearly mark items in the patient record as they are received. Some suggestions are: Face to Face Encounter, Home Bound Status, Need for Skilled Services. Apply the Ink Stamp beside the correct items.
Face to Face information must be based on MD medical records and/or acute/post-acute care facility’s medical records. The MD or facility medical record must include the actual clinical note for the F2F encounter visit that supports the required components. Information from the Home Health records can be incorporated into the certifying physician’s medical record and be used to support homebound status and the need for skilled care Agency records cannot be used as the sole basis to support Home Health and must corroborate other MD or facility records.
An exception to the F2F requirement might be if a home health patient dies shortly after admission before the F2F encounter occurs and it can be determined a good faith effort existed on the part of the agency to facilitate the encounter and, if all other certification requirements are met, the certification is deemed to be complete. In this situation, the agency would want to ensure accurate and complete documentation to paint a vivid picture of this need for an exception.
What are some examples of appropriate F2F documentation? Physician Discharge Summary, MD once visit note or progress note from acute/post-acute facility. A Note on MD letterhead summarizing the required information. a Clinical Summary or Admission Summary or a History & Physical. These are not the only appropriate documents. Documents need to contain the elements directly pertaining to the referral for home health services. The F2F encounter date (if performed by a different MD) must be acknowledged by the certifying physician on a signed Attestation, a signed communication, a signed Addendum, or on the signed Plan of Care (POC). Any document utilized must be dated by the certifying physician along with their signature
Inadequate Documentation might include a list of diagnosis, recent procedures or recent injuries. Generic statements without specific clinical finding to indicate what makes the patient homebound, such as, taxing effort to leave home, gait abnormality, weakness, muscle weakness.
What happens if the F2F does not occur within 30 days after SOC but it does occur, for example, on the 35th day, how should the OASIS data be collected and submitted? If the F2F does not occur within 90 days prior to or within 30 days after the SOC, then MCR Home Health eligibility criteria have not been met and the episode is not covered or billable. A F2F occurring on day 35 would represent a change in Pay Source (payer) and therefore, a new SOC would be generated. The new SOC OASIS could be completed based on data from the prior OASIS in this instance. The new SOC would have a start of episode date 30 days prior to F2F and may not have a visit associated with that date. The (M0090) date assessment completed would be reported as the actual date of the new OASIS assessment even if no visit provided. M0110 and M2200 would need to be adjusted to reflect the new episode and should exclude any visits provided prior to date of eligibility. If the prior SOC has been submitted, it will need to be inactivated and the new SOC submitted.
Some common reasons for denial of payment might include the actual F2F visit date doesn’t match the date on the F2F form, the referral diagnosis doesn’t match primary reason for home health care, or the documentation does not support homebound status or need for skilled service.
Last, but not least, here are some strategies for F2F success. Contact the MD for an attestation statement to update the F2F information if documentation does not match primary reason for home care. An example of this would be an MD F2F states muscle weakness, falls. During the comprehensive assessment, the nurse documents patient has Parkinson’s Disease and Neuropathy. Agency should notify the MD of need for additional services that may not be included on the F2F and generate a verbal order updating the primary reason for home care. For instance, PT only ordered at SOC but found the have unstable blood sugars with multiple new medications.
Make sure dates on F2F are congruent with actual visit note date, if dates don’t match, the claim can possibly be denied. Start with an effective referral order for Home Health Services, verify who will be the certifying physician, request documentation supporting the need for skilled service and homebound status. Have a process in place to monitor for pending F2F visits. Also have a policy to assess for scheduled F2F visits and have agency assist patient (or family care giver) with making appointments if not already scheduled. Be proactive, not reactive to prevent errors.
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