Health Information Compliance Alert

Published on Sun Jun 10, 2012 PDF

CMS weighs in on handing out sample documentation.

Medicare officials insist that physicians' documentation of the face-to-face encounter should be quick and easy, but many home health agencies are having a much different experience when trying to solicit that documentation from their docs.

In its latest set of questions-and-answers about the F2F requirement, a provider asks the Centers for Medicare & Medicaid Services, "Is it allowable for a home health agency to provide a certifying physician and his or her office support staff, a completed 'sample' face-to-face encounter documentation to use as a guide for how to complete actual face-to-face documentation?"

OK: Some types of sample documentation would pass muster, CMS indicates. F2F documentation must reflect the physician's "experience with the patient. A home health agency providing physicians with sample face-to-face documentation as a guide to what would be considered acceptable face-to-face documentation to assist them in preparing their particular face-to-face documentation for a patient, would be allowable," the agency says.

Not OK: But, "the home health agency cannot provide the specifics of a certain patient's face-to-face encounter in a document, call it a 'sample,' with the expectation, possibility, or probability that the physician would have all the information he or she would need to document the face-to-face for that particular individual and thus simply sign it as the official face-to-face documentation," CMS warns.

If you're looking for a sample narrative statement to give to your docs, you may want to use the one CMS includes in its Q&As. Remember, "the certifying physician's face-to-face description should be a brief narrative describing the patient's clinical condition and how the patient's condition supports homebound status and the need for skilled services," the agency explains.

The example: "The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen."

Note: The new 21-page F2F Q&A document is at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/QandAsFull-5-4-12.pdf.