Part B Insider (Multispecialty) Coding Alert

Don’t let missing title, date torpedo your claim.

Physicians and home care providers alike are often mystified by what reviewers accept, and don’t, for face-to-face encounter documentation.

Here are the elements the OIG says must be in the F2F documentation to meet the Medicare condition of payment:

1. The certifying physician must complete and sign the F2F documentation, regardless of who performs the F2F encounter. Federal law mandates as a condition of payment that the certifying physician, the physician who cared for the patient in an acute-care or post-acute-care facility, or a permitted nonphysician practitioner have a F2F encounter with the patient whom the physician is certifying for home health services. CMS has clarified that a patient’s physician for acute care or post-acute care can conduct that encounter as long as he or she informs the certifying physician of that encounter.

2. The certifying physician must title, date, and sign the document.

3. The F2F documentation must be titled as such. CMS does not require physicians to use a specific form to document the F2F encounter; as long as the F2F encounter documentation contains all content requirements and is properly titled, the certifying physician can use a discharge summary, a clinic note, or an original form to satisfy the requirement.

4. The date of the encounter must be on the document.

5. The F2F encounter must occur within 90 days prior to the start of care or 30 days after the SOC.

6. F2F documentation must include a brief physician narrative that describes (1) why the patient is homebound and (2) why the skilled service(s) is necessary to treat the patient’s illness or injury. This narrative can address the homebound status and reason for skilled service(s) in two separate sections or combine them in one section. 

Note: CMS has clarified that the HHA is permitted to title the F2F document, and that it can enter.