Face to Face Requirements

One of the biggest areas of concern we have in our audits, is the Face to Face. There is lack of information, difficulty getting the proper documentation from your referral sources, and risk involved in taking a patient without a valid face to face. Here is a quick checklist for your staff to help them make sure its right!

Home Health Face-to-Face (F2F) Requirements Checklist

1. Timing of Encounter

☐ F2F occurred within 90 days before or 30 days after SOC

☐ Encounter date is clearly documented

2. Qualified Provider Performed Encounter

☐ Encounter completed by one of the following:

• ☐ Certifying physician

• ☐ Facility physician (if direct discharge)

• ☐ Nurse Practitioner (NP)

• ☐ Physician Assistant (PA)

• ☐ Clinical Nurse Specialist (CNS)

• ☐ Certified Nurse Midwife (CNM)

☐ Provider is authorized under Medicare and state law
☐ Provider relationship to certifying physician is appropriate (if NPP)

3. Documentation Requirements

☐ F2F documentation is present in medical record

Documentation includes:

• ☐ Date of encounter

• ☐ Provider name/credentials

• ☐ Clinical findings

• ☐ Diagnosis/condition addressed

☐ Documentation supports medical necessity
☐ Documentation is legible and complete

4. Relationship to Home Health Need

Documentation clearly explains:

• ☐ Why patient needs skilled services

• ☐ How condition limits function

• ☐ Why homebound status applies

• ☐ How findings relate to ordered care

☐ Narrative is patient-specific (not generic)

5. Certification Integration

F2F information is incorporated into:

• ☐ Physician certification

• ☐ Plan of Care (485)

• ☐ Verbal/written orders

☐ Certifying physician signed and dated certification

6. Telehealth (If Used)

☐ Telehealth encounter meets Medicare rules (must note it was a video visit, date, time and confirm it was HIPAA-compliant).
☐ Platform is compliant
☐ Encounter is allowable under current policy (check for date of current extension).
☐ Telehealth visit is documented as F2F