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HH&H FAQs – Home Health Face-To-Face (FTF) Encounters

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  1. What is meant by the actual clinical note that must be submitted in the documentation?

    • The actual clinical note is the physician's/practitioner's documentation to show he/she actually saw the patient. It will include such things as vital signs, weight, and specific comments from the examination. The actual clinical note must address the primary reason the patient is receiving home health services and a complete review of systems. Other conditions may be addressed in the same visit.

      Reviewed 12/22/2025
  1. If skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) are all ordered disciplines, does each discipline need to be addressed separately on the FTF document. Is it sufficient to meet the standard for justifying home health care through one discipline?

    • It is not necessary for the face-to-face to address each discipline individually, however, the face-to-face must be related to the primary reason for home health services. For example, the patient may need skilled nursing to perform wound care to a stasis ulcer, the face-to-face must be related to the stasis ulcer, any additional medically necessary disciplines would be allowed in medical review.

      Reviewed 12/22/2025
  1. Does the patient meet homebound criteria if the statement by the physician indicates that they are 'medically restricted', immunocompromised' or at 'high risk of infection' or does the statement still need to indicate that the patient needs assistance of another person/device to exit the home?

    • None of the statements, including 'patient needs assistance of another person/device to exit the home' are sufficient to support the beneficiary's homebound status. While the face-to-face encounter must be related to the primary reason for home health services, the patient's skilled need and homebound status can be substantiated through an examination of all submitted medical record documentation from the certifying physician, acute/post-acute care facility, and/or home health agency incorporated documentation.

      Reviewed 12/22/2025
  1. If the agency sends the physician a FTF form and he returns to the agency a clinic note signed and dated with all the correct data from our FTF form, can we accept as FTF form?

    • CMS does not require a specific form or format to be used for the FTF, as long as the FTF encounter documentation contains all content requirements the HHA could use the clinic note.

      Reviewed 12/22/2025
  1. Does the face-to-face encounter documentation need to be completed every time a patient is recertified, or only the first time they are admitted to a home health agency?

    • The HH face-to-face encounter is only mandated at the SOC, not upon each recertification. (CMS-1611-FExternal PDF) A face-to-face encounter is only required if there is a new Start of Care OASIS.

      Reviewed 12/22/2025
  1. If the physician/practitioner is signing a multiple page Center for Medicare and Medicaid Services (CMS) form 485, does the physician/practitioner have to sign every page to be considered as reviewed and approved by the physician/practitioner?

    • With a multiple page document, each page should be identified as being part of the entire document. For example; page 1 of 4, page 2 of 4, page 3 of 4 and page 4 of 4. The physician/practitioner is aware he/she is signing the entire document and only needs to affix their signature and date to one page of the document.

      Reviewed 12/22/2025
  1. Is CMS form 485 required for the physician/practitioner certification?

    • The 485 is not a required form, but is used frequently by home health agencies.

      Reviewed 12/22/2025
  1. What should the physician/practitioner certification include?

    • The physician/practitioner certification should state the patient is confined to their home, needs skilled services, a plan of care is established and periodically reviewed, the patient is under the care of a physician/practitioner and the date of the face-to-face encounter.

      Reviewed 12/22/2025
  1. When does the hospitalist need to identify the community physician/practitioner who will be following the patient?

    • If the hospitalist certifies the patient for home health but will not follow the patient after discharge, he/she must identify the community physician/practitioner who will follow the patient by name.

      Reviewed 12/22/2025
  1. The hospitalist completed the face-to-face but will not be the certifying physician/practitioner. Does the certifying physician/practitioner also have to cosign the hospitalist's face-to-face encounter?

    • The certifying physician/practitioner does not need to cosign the face-to-face document. The certifying physician/practitioner needs to document the date the face-to-face encounter was completed as part of the certification to the home health benefit.

      Reviewed 12/22/2025
  1. What does the certifying physician/practitioner need to do if another physician or allowed non-physician practitioner (NPP) performs the face-to-face encounter?

    • In cases where the beneficiary is directly admitted to home care from the community setting, and the certifying physician is attesting to the date another allowed provider type performed the face-to-face (FTF), documentation must contain evidence that the certifying provider collaborated with the provider who performed the FTF prior to the certification. Or, if it can be determined that the certifying provider and the provider who performed the FTF are from the same practice, no evidence of collaboration is required. In cases where the beneficiary is admitted from the acute or post-acute care setting, the community physician taking over care must attest to the date of the FTF.

      References:

      Reviewed 12/22/2025
  1. Can I use the face-to-face forms we have been using?

    • There are no specific forms required for face-to-face documentation. The encounter note from the physician/practitioner is required. Your face-to-face form that you used to use is optional. If your face-to-face form has wording that suggests it is also a certification, there is an additional requirement, IF the certifying physician/practitioner is not the one performing the face-to-face. If the face-to-face form is also a certification, the person completing the form must also indicate who the community physician/practitioner will be.

      Reviewed 12/22/2025
  1. If the patient visits the doctor within 90 days prior to the start of care and the reason for the visit relates to the home health services provided, do we need to get another face-to-face encounter completed?

    • No, as long as the visit is timely and is focused on the reason for home health services, another face-to-face visit is not required. If a patient saw the physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patient's condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.

      Reviewed 12/22/2025
  1. What if the face-to-face encounter did not discuss the patient's homebound status?

    • As stated in the Medicare Program Integrity Manual (CMS Pub. 100-08, Ch. 6 §6.2.3External PDF) – The physician's/acute/post-acute care facility's record, in conjunction with appropriately incorporated HHA documentation (e.g., Form 485/Plan of Care, OASIS, etc.), may also substantiate the certification of eligibility for home health services. The HHA's generated medical record documentation for the patient, by itself, is not sufficient in demonstrating the patient's eligibility for Medicare home health services. Any documentation used to support certification that was generated by the home health agency must be signed off by the certifying physician and incorporated into the medial record held by the physician or the acute/post-acute care facility's medical record. Once incorporated into the certifying physician's medical record for the patient, the HHA information can be used to support the patient's homebound status and need for skilled care, the reviewer shall consider all documentation for the HHA that has been signed off in a timely manner and incorporated into the physician/hospital record when making its coverage determination.

      Reviewed 12/22/2025
  1. If the provider receives outstanding documentation and a copy of the encounter note, but the encounter note is nothing more than three sentences, does that meet requirements?

    • If both the documentation and the copy of the encounter note meets all the requirements. CGS is able to look at anything within the patient's medical record from the acute or post-acute care facility, as well as any documentation submitted from the agency, as long as the certifying physician incorporates it into their medical record by signing and dating the documentation and it corroborates the overall findings.

      Reviewed 12/22/2025
  1. Can a resident perform and sign the home health face-to-face encounter?

    • The physician and not the resident must sign the home health plan of care. The resident working under their physician could perform the face-to-face; however, the supervising physician must co-sign the face-to-face encounter. The physician must sign the plan of care.

      According to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §50.5External PDF), home health services include the medical services of interns and residents-in-training under an approved hospital teaching program if the services are ordered by the physician or allowed practitioner who is responsible for the plan of care and the HHA is affiliated with or is under common control of a hospital furnishing the medical services. Approved means:

      • Approved by the Accreditation Council for Graduate Medical Education;
      • In the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association;
      • In the case of an intern or resident-in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or
      • In the case of an intern or resident-in-training in the field of podiatry, approved by the Council on Podiatric Education of the American Podiatric Association.
      Reviewed 12/22/2025
  1. If the face-to-face form includes information from the visit, is the encounter note still required?

    • The actual clinical note from the face-to-face encounter must always be submitted.

      Reviewed 12/22/2025
  1. Does the certifying physician/practitioner need to co-sign the face-to-face form?

    • No, the certifying physician/practitioner does not have to co-sign the face-to-face form. However, the certifying physician/practitioner must document the date of the face-to-face encounter, whether by co-signing the face-to-face form OR including the date of the face-to-face encounter on the certification form.

      Reviewed 12/22/2025
  1. If the clinical note from the face-to-face encounter does not include all the necessary information, may a face-to-face form be submitted which includes the missing information?

    • Yes, both the clinical note and the face-to-face form will be reviewed.

      Reviewed 12/22/2025
  1. Is it required for the provider to have a face-to-face to complete the recertification paperwork?

    • There is no face-to-face requirement at recertification for home health.

      Reviewed 12/22/2025
  1. Can the face-to-face encounter be a compilation of data from the patient's Electronic Health Record (EHR), or must it be a single encounter with all of the information documented?

    • FTF is a note documenting the one-on-one visit with the physician or NPP and is related to the primary reason the patient requires home health services.

      Reviewed 12/22/2025

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