Face to Face documentation requirements for Medicare coverage of home health services —

  • Upon referral, CVHHH’s Intake Department will request a copy of the physician’s F2F encounter with the patient.
  • Physician records must contain details supporting Medicare coverage of home health services (including that patient is homebound and requires skilled need (see below for more details).

NEW in 2015:

  • If additional supporting details are needed to complete the physician’s F2F encounter, CVHHH will send a F2F form generated from our own electronic records.
  • The form will include excerpts from the CVHHH clinician’s documentation of the initial assessment.
  • This form must be completed and signed by the physician and returned to CVHHH.
  • REQUIRED by CMS: The physician must incorporate a copy of this F2F form into the physician record as evidence of the need for home health services.

You may download a summary of these changes here.

If you have any questions about Face to Face documentation, contact Derek Kouwenhoven, Director of Clinical Services, at 802-224-2269.

HOMEBOUND Status – Please describe prescribed activity limits, signs of activity intolerance, need for assistance or an assistive device.

Examples:

  • “S/P TKR; currently walker-dependent with painful ambulation.”
  • “Weak & deconditioned – unable to walk across the room without needing to rest.”
  • “Minimal weight bearing on L foot; restrictions on walking to promote wound healing.”
  • “Patient on bed to chair activities only.”
  • “Short of breath with talking and with ambulation of short distances.”
  • “Requires a walker; unable to safely negotiate uneven surfaces & stairs without assistance.”

SKILLED NEEDS – Please describe the need for interventions that must be either performed or supervised by a licensed professional.

Examples:

  • “Nurse needed to assess for s/s of adverse events from new Coumadin regimen.”
  • “Skilled Nursing needed for wound care, assess for s/s of infection, and education on
    wound care for family to perform dressing changes.”
  • “CHF, weakness, 3+ edema bilateral legs, needs nurse for cardiac assessment,
    assessment for s/s of disease, & patient education.”
  • “Lung sounds coarse throughout. COPD patient finished antibiotic therapy today for pneumonia. Nurse to assess respiratory status for s/s recurring infection/changes in respiratory status.”
  • “Wound care to left great toe. Patient at risk due to diabetic status. Skilled nurse visits to
    perform wound care & assess wound status.”
  • “S/P right THR. Needs Physical Therapy to restore ability to walk without assistance and RN for pain management”