The Face-to-Face Encounter

The face-to-face encounter has been required for every start-of-care home health certification since 1 January 2011. Without a compliant one, the episode is not payable — and it is not something you can fix after the fact.

When it has to happen

The encounter must occur no more than 90 days before the start of care, or within 30 days after it.

There is one trap inside that window that costs agencies real money:

If the encounter happened within the 90 days before SOC but was not related to the primary reason for home health, it does not count. The certifying physician or allowed practitioner must then have a face-to-face encounter within 30 days after the start of care.

An old visit note that does not cover the new condition is not valid. This comes up constantly with patients who saw their doctor routinely a month before something acute happened.

Who can perform it

• The certifying physician
• A physician who cared for the patient in an acute or post-acute facility, with privileges there
• A qualified non-physician practitioner (NPP) — nurse practitioner, physician assistant, certified nurse midwife, or clinical nurse specialist — working either:
  • in collaboration with an acute or post-acute care physician who has privileges and cared for the patient in that facility, or
  • under the supervision of the certifying physician, or of an acute/post-acute physician who has privileges and cared for the patient there

The person performing the encounter cannot be employed by, or have a financial relationship with, the home health agency. That restriction is set out in 42 CFR 424.22(d).

Where it can happen

There is no location requirement. Medicare-eligible telehealth visits are allowed.

What the documentation has to show

Since 1 January 2015, it is the certifying physician's medical records and/or the acute or post-acute facility's records that establish eligibility — not a form the agency writes.

Those records must include information justifying the referral, showing the patient's:

• Clinical condition supporting eligibility
• Homebound status
• Need for skilled services

The agency must be able to produce that documentation on request to review entities and CMS. So if what comes over from the physician's office is a bare signature line with no clinical narrative, it is not enough, and chasing it is not optional.

What the encounter sets up

The face-to-face is not a box to tick — it sets the direction for the whole episode:

• It establishes the treatment needs, which are the reason for home health
• Coding must reflect the treatment needs identified in the face-to-face, plus the physician-confirmed diagnoses obtained at your assessment
• The plan of care — interventions and goals — must reflect those same treatment needs and coding

When the face-to-face says one thing and the plan of care says another, that inconsistency is exactly what a reviewer pulls the chart for.

Quick check before you accept a referral

• Encounter date falls within 90 days before, or 30 days after, SOC
• Performed by an allowed provider — MD, DO, NP, PA, CNM, or CNS under the right relationship
• Performer has no employment or financial relationship with the agency
• Encounter is related to the primary reason for home health, and the condition is acute
• The physician's own record documents clinical condition, homebound status, and skilled need
• A physician is willing to oversee the plan of care

Reference

CGS Administrators, Face-to-Face (FTF) Encounters for Home Health Certification, H-052-11, revised 23 March 2021. CMS Medicare Benefit Policy Manual, Chapter 7. Encounter restrictions at 42 CFR 424.22(d).