Face-to-Face documentation from the Physician is a good idea to have in Home Health Charts

When CMS requests an ADR from your home health agency, the contractor may deny the documentation supports the services due to its failing to contain the proper Face-to-Face documentation. 

We have seen the contractor deny claims based on a failure to locate the F2F documentation.  However, the contractor is probably able to find your physician’s attestation, which is a typical part of your home health chart notes.  More likely is that the denial is based on the lack of the physician’s own notes from the Face-to-Face encounter made by the physician within the time frame set forth by CMS, whether for certification or recertification.

CMS contractors make it the Home Health Agency’s responsibility to offer proof that the certifying physician’s medical record for the patient contains the actual clinical note for the Face-to-Face encounter visit.  This doctor’s office note will be the only proof that the encounter occurred in the required time frame, and was related to the primary reason the patient requires home health service.  And the information in the doctor’s clinical note is the basis for the certification for the home health services.   Therefore, without the notes, the services are not properly certified.

While 42 C.F.R. §424.22(c) requires the certifying physicians to provide, upon request, the medical records documentation that supports the certification of patient eligibility for home health, the contractor is not requesting the documentation from the physician.  Because that documentation is the only documentation that will show the encounter was made in the required time frame and was related to the primary reason the patient requires home health services, it is a good idea for the Home Health Agency to make those records available in their own charts when that chart is reviewed in an ADR or prepayment review situation.

CMS issued a hint that the documentation is essential in MLN Matters number 1436 Special Edition.  After going over home bound status and general home health requirements, the Supporting Documentation on page 5 includes the information that must be contained in the physician’s records.  However, the ADR process seems to hold the liability for the physician’s records on the home health agency submitting additional documentation.

Therefore, to prove the beneficiary is eligible, the physician’s notes must meet the requirements of the regulation.  But if the contractor isn’t going to request the notes of the physicians, payment won’t be made without them it seems. 

Sending your Home Health notes to the physician’s office is not enough either.  The physician must review and sign the note in order for it to bolster the certification made by the physician.   See MLN Matters 1436 Special Edition.  CMS includes examples at the end of the article that will give you a template for your documentation.