Medicare Home Health Benefit’s Face-to-Face Encounter Requirement

As a condition of payment for Medicare home health benefits, a physician must certify that a patient is confined to the home, needs skilled services, receiving the services under a plan of care established and periodically reviewed by a physician, and under the care of the physician.[1]  The Affordable Care Act (ACA) added a requirement that prior to such certification the physician must document that the patient had a face-to-face encounter with an allowed physician or non-physician practitioner (NPP) within a reasonable timeframe as established by the Secretary of the U.S. Department of Health and Human Services.[2] 

Implementation of the face-to-face (F2F) encounter requirement is effective for all home health claims with a start of care date on or after April 1, 2011. 

Who Can Perform a Face-to-Face Encounter?

A F2F encounter may be performed by the certifying physician.  It may also be performed by a physician who cared for the patient in an acute or post-acute facility directly prior to the home health admission, and who has privileges at the facility.  An allowed non-physician practitioner (NPP) working in collaboration with or under the supervision of the certifying or facility physician may also perform the encounter.  Allowed NPPs include a Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse-Midwife, and Physician Assistant.  The encounter cannot be performed by any physician or allowed NPP who has a financial relationship with the home health agency (HHA).[3]

Timing of the Face-to-Face Encounter

The regulations establish that a F2F encounter must have occurred no more than 90 days prior to or within 30 days after the home health start of care date, and must be related to the primary reason that the patient requires home health services.[4]  A F2F encounter may occur by tele-health as provided in §1834(m) of the Social Security Act.[5]

If the patient did not have a F2F encounter prior to admission, or had an encounter that was not related to the main reason the patient requires home health services, the patient would need to have a qualifying F2F encounter sometime during the 30 days after services begin.[6]  If an HHA chooses to terminate a patient’s services for failure to meet the F2F encounter requirement, the HHA should issue a Form CMS-10280 Home Health Change of Care Notice (HHCCN)[7] in advance so that the patient can attempt to cure the problem.[8]

Who Can Certify a Patient for Home Health Services?

To initially certify a patient for the Medicare home health benefit, a physician must attest that the eligibility criteria are met, including that the F2F encounter was performed by an allowed provider and related to the main reason the patient needs home health services.[9]  Additionally, the physician must document the date of the F2F encounter.  The certification must be signed and dated by the physician, and complete prior to when the HHA bills Medicare for reimbursement.[10] 

It is common for a hospitalist or physician who cared for a patient and has privileges at an acute or post-acute facility to directly refer the patient for home health services, initiate orders and a plan of care, and certify the patient’s eligibility.  In this scenario, however, the facility physician is expected to identify the community physician who will be assuming primary care responsibility for the patient upon discharge.[11] 

What Triggers the Need for a Face-to-Face Encounter?

As a general rule, a F2F encounter is required any time a Start of Care OASIS (Outcome and Assessment Information Set) is completed by the HHA to initiate services for a beneficiary.  Thus, a F2F encounter is necessary for a patient’s initial certification for home health services.[12]  

After an initial home health episode, recertification of the need for continued home care must be provided at least every 60 days, and must be signed and dated by the physician who reviews the plan of care.[13]  Medicare does not limit the number of continuous episodes for patients who continue to be eligible for the home health benefit.  Recertifications do not require a new F2F encounter.  It should be noted, though, that payment will not be made for recertification episodes if F2F requirements are not met for the initial certification episode.

When would a patient need to have a new F2F encounter?  Typically, if a home health patient is admitted to the hospital but returns home to resume home health services during the same 60-day episode of care, a new F2F encounter is not required.  However, if the patient is admitted to an inpatient facility and returns to home care after the episode ended, then a new F2F encounter is required to initiate and certify the patient for home care services under a new start of care.  Also, if a patient elected to be discharged from home care services or was discharged with goals met and/or no expectation of return to home care, a future initiation of home care would trigger a new certification, a new start of care, and the need for a new F2F encounter.

Supporting Documentation Requirement

CMS revised its medical review process for determining patient eligibility for home health claims with a start of care on or after January 1, 2015.  CMS and its contractors now review only the patient’s medical record from the certifying physician or the acute/post-acute care facility (if the patient was directly admitted to home health from that setting) that was used to support the physician’s initial certification, to determine whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care.[14] 

The regulation at 42 C.F.R. § 424.22(c) requires physicians and acute/post-acute care facilities to furnish such supporting medical documentation “upon request to the home health agency, review, entities, and/or CMS.”  If the documentation used as the basis for certification of eligibility is not sufficient to demonstrate eligibility (i.e., homebound status, need for skilled care, valid F2F encounter), payment will not be rendered for the home health services provided.[15]  

HHAs are permitted to supplement the medical record by furnishing information to the certifying physician that supports the patient’s homebound status and need for skilled care (e.g., SOC OASIS or Comprehensive Assessment generated by the HHA or another practitioner’s Clinical Note), so long as it “corroborates” and does not contradict the physician or facility’s entries regarding the patient’s diagnoses and condition.  The certifying physician must review and sign off on any additional evidence in order to incorporate it into the patient’s medical record.[16]

Importantly, the medical record must also contain the actual clinical note for the F2F encounter visit evidencing that the encounter occurred within the required timeframe, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type.  This will often be in the form of a Clinical or Progress Note, or Discharge Summary.[17]

As a practical matter, HHAs should try to obtain the clinical note from the F2F encounter and any other supporting medical documentation from the certifying physician and/or acute/post-acute facility needed to substantiate the certification of patient eligibility as soon as possible. Although these supporting documents are not required prior to billing, HHAs must be able to provide them to CMS and its review entities upon request. Therefore, it is advisable for HHAs to obtain them around the time of the patient’s referral and prior to billing.[18]

Additional Resources

Despite CMS’ revised guidance that discusses the new rules about F2F certification and supporting documentation (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1436.pdf), there continues to be confusion and uncertainty regarding how providers are expected to operationalize the requirements, and what will or won’t pass muster.[19]

November, 2016 – W. Kwok