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Reviewing the Fundamentals of F2F Compliance

    Face-to-face (F2F) encounters are required to certify a patient’s eligibility for Medicare home health benefits. Face-to-face (F2F) documentation compliance has been a persistent challenge for numerous home health agencies, as it remains a leading cause of Medicare home health claim denials. The guidelines for F2F encounters may appear ambiguous, making it challenging for home health agencies to establish a consistent process for obtaining and ensuring compliance with the documentation.

    Defining F2F Encounter

    The face-to-face encounter requirement mandates that a physician or authorized non-physician practitioner must personally meet the patient before certifying their eligibility for home health services. This encounter needs to be documented, providing confirmation of the meeting and including vital information like the date, the patient’s condition, reasons for home health services, and an explanation of how their condition justifies skilled care at home.

    Requirements of a Valid F2F Encounter Documentation

    The F2F encounter note or documentation usually includes a brief description of the visit, which may cover things like a thorough assessment, vital signs, medication and diagnosis codes, treatments administered, and a review of the patient’s overall health. Supported documentation for the face-to-face encounter can include progress visit notes from a physician’s office, encounter notes from a healthcare facility, or discharge summaries. 

    The face-to-face documentation needs to demonstrate that the practitioner had a relevant encounter with the patient relating to the main reason for receiving home health services. To be considered complete, the face-to-face documentation needs to include the following details:

    • Patient’s name, date of birth, and additional identifiers if necessary
    • Date of the encounter, within 90 days before home health start of care or within 30 days after
    • Clear documentation of visual assessment (head-to-toe, review of systems, vital signs, etc.) by the provider
    • Documentation supporting the patient’s homebound status and the need for skilled home health services. If support is insufficient, a clinical narrative can be created, following a comprehensive assessment, explaining the professional need and homebound status, and signed by the certifying practitioner.
    • The documentation should relate to the primary diagnosis for home health, although it doesn’t need to be the main focus of the patient’s visit with the practitioner.
    • The assessing practitioner must sign and date the documentation, including their credentials.
    • If the face-to-face encounter is performed by a practitioner other than the certifying physician, the certifying physician must sign and date an attestation with the face-to-face encounter date.

    The guidelines allow for the home health agency-generated documents to be included in the certifying physician’s medical record to corroborate missing elements related to skilled need and homebound status. Corroboration documentation for the face-to-face encounter can include information from the Comprehensive Assessment and the Plan of Care. However, corroboration documentation cannot contradict the physician or facility’s documentation of diagnoses and conditions, and it cannot be the sole documentation supporting the need for home health. The agency’s information must be reviewed, signed, and dated by the certifying physician to be considered part of the medical record. When combined with the physician’s documentation, the additional information from the agency can greatly enhance the overall clinical picture.

    Persons Authorized to Perform F2F Encounters

    According to Medicare guidelines, the F2F can be done by the following:

    1. Certifying physician – The one who refers the patient to home health services and reviews and signs the Plan of Care (POC)
    2. Facility/hospitalist physician – The one who cares for the patient in an acute or post-acute facility before home health admission and collaborates with the patient’s community physician for ongoing care
    3. Certain non-physician practitioners (NPPs) such as Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse-Midwives, and Physician Assistants – They can practice under the supervision of the certifying or facility/hospitalist physician. However, it’s important to note that the F2F encounter cannot be performed by any physician or allowed NPP with a financial relationship to the home health agency providing care to the patient.

    F2F Requirement Across Home Health Timepoints

    1. F2F at Start of Care (SOC):
      • A F2F encounter is required only for the initial home health episode.
      • Whenever an agency completes a Start of Care (SOC) OASIS assessment to initiate services for a Medicare beneficiary, a F2F encounter is needed.
      • This requirement applies even if the patient is discharged from home care at their request or due to goals being met, with no intention of returning to home care.
      • Any future admission would require a new SOC and, therefore, a new F2F encounter.
    1. F2F at Recertification:
      • Recertifications performed every 60 days do not necessitate a new F2F encounter. However, it is crucial to meet the F2F requirements for the initial episode to receive payment for subsequent recertification periods.
      • The F2F encounter completed during the initial admission remains valid until the patient is discharged from home health services.
    1. F2F at Resumption of Care (ROC):
      • ROC does not require a new F2F encounter, unless the patient transfers to an inpatient facility, remains there until the 60-day episode ends, and then returns to the agency.
      • In such a case, the patient would be discharged from prior services, requiring a new SOC and a new F2F encounter.

    There are certain instances and reasons that may require new F2F encounter documentation. Learn more about these situations here.

    Alignment Between the Primary Diagnosis and F2F Documentation

    Face-to-face encounter documentation must align with the home health primary diagnosis. Simply listing the diagnosis is insufficient. The documentation should include relevant details such as diagnosis code, glucose level, assessment notes, current medication, and treatment plan changes. Learn more about common documentation deficiencies in specific code/diagnosis categories here.

    The F2F encounter is crucial for establishing the Focus of Care in home health. Agencies must ensure that any unacceptable PDGM diagnosis provided in the F2F encounter is clarified by querying the physician for the underlying cause. Following the coding guidelines is equally important, especially in code sequencing and selecting primary and secondary codes. Clinical judgment and consideration of etiology and causative conditions are necessary to ensure sufficient information supporting the home health referral.

    The Role of Coders in Ensuring F2F Compliance

    Understanding and adhering to the requirements of the Face-to-Face (F2F) encounter can be complex and challenging due to potentially confusing guidelines. Coders play a crucial role in reviewing the F2F documentation as they assign diagnosis codes. It is crucial to have knowledgeable coders who can evaluate the thoroughness and accuracy of F2F documentation not only to achieve compliance but also to optimize reimbursements. By fostering collaboration with the intake team, the clinicians, and other key members, agencies can ensure F2F compliance, proper reimbursement, and a steady cash flow.