Documentation: Face to Face for Home Health Certification

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jul 9th, 2018

As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.

Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:

    The encounter was related to the primary reason for home care
    How the patient's condition supports the patient's homebound status; or
    How the patient's condition supports the need for skilled services

Acceptable FTF documentation does not have to be lengthy or overly detailed. However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient's illness or injury, based on the physician's clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.

Below are examples of FTF documentation that, used alone, are considered insufficient documentation.

Examples of appropriate documentation include:

"Wound care completed to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Skilled nurse visits to perform wound care and assess wound status. Patient on bed to chair activities only."

"Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema. Short of breath with talking and ambulation of 1-2 feet. Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status."

HCPCS used for Home Health Plan of care;

G0179 - Physician re-certification for medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per re-certification period.

G0180 - Physician certification for medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per certification period.