For patients with Medicare as primary or secondary payer, documentation of a completed, Face-to-Face encounter signed by a physician (PAs or NPs encounter notes must be co-signed by the attending physician) is required for a home health services referral.
What’s included in a Face-to-Face document?
- A clinical note written by an MD, DO, podiatrist, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife
- Documentation addressing the primary reason for homecare
- Documentation supporting homebound status.
- The provider’s signature with date. If the encounter was performed by a resident, the supervising attending at the resident’s facility must also sign.
- Date of the assessment up to 90 days prior to SOC or up to 30 days after
- Co-signature of the Physician signing the plan of care if they are not the one performing the encounter (Referrals team does not need to evaluate for this criterion.)
Examples of Face-to-Face Documentation include office visit notes, progress notes, ED notes, DC summaries.
Be careful to note if a facility labels a document DC and/or clinical summary or progress notes that does NOT include an assessment related to the reason for home care and only includes med lists, instructions, nursing or therapy notes, etc. This does not qualify as a Face to Face encounter.
Questions? We’re here to help.
The VNH Intake Team is here to help make the referral process go smoothly. If you have questions, please contact us at 800-575-5162.