January 6, 2016 - Updated November 2021
Missing Home Health Face-to-Face Encounter Documentation
Through review of the Comprehensive Error Rate Testing (CERT) error report and claims selected for the probe and educate project, CGS has seen that home health providers are not sending the actual face-to-face (FTF) encounter note in response to requests for medical documentation. Most often, providers are sending a form that includes the date the FTF took place. According to the Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7
, section 30.5.1.2, home health agencies must be able to provide supporting documentation to review entities, upon request. The documentation must support the certification of home health eligibility. The documentation from the certifying physician's and/or the acute/post-acute care facility's medical records must contain the actual clinical note for the FTF encounter visit to demonstrate that the encounter occurred timely, was related to the primary reason the patient required home health care, and was performed by an allowed provider type.
To avoid denial of home health services, when medical documentation is requested by CGS or other review entities, such as the CERT Documentation Contractor (CDC), please ensure the medical record submitted includes the FTF documentation. FTF documentation (for start of care (SOC) and subsequent episodes) would include, but not be limited to, submitting the actual clinical notes (i.e. discharge summary/history & physical/progress notes, or physician office visit note), for the primary reason the beneficiary was referred to homecare. Additionally, included in determining appropriateness of the FTF documentation, the initial home health SOC plan of care, along with any certifying physician's attestations, must be submitted with every episode.
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