Education And Resources

CMS Face-to-Face Documentation

Fax Referral Form And F2F
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To Physicians regarding Face-to-Face documentation:

In recognition of the increasing demands on physician time, and with respect to CMS requirements, we have created this quick instruction section to assist you in supplying the necessary documentation.

The Face-to-Face Encounter Requirements may be satisfied by supplying copies of your progress notes, discharge summaries, or home health orders if they include:

  • The patient name
  • Date of the Face-to-Face patient encounter
  • Aspects of the patient condition that necessitate homebound status or initiation of skilled home health care
  • Your signature and date

The Face-to-Face encounter must occur between

  • 90 days prior to, or
  • Within 30 days after the start of home health care, and must be related to the reason you ordered home health care.

Time saving suggestions

  • Marking Progress Notes – when seeing a patient you are referring for home health care, include the face-to-face required information in the progress notes or discharge summary.  Attach either to the referral.
  • CMS will allow you to dictate your face-to-face encounter for the discharge manager or staff to document.
  • Optimize EMR – if you utilize EMR, save frequently used phases to save time typing.  You can create a commonly used phrases template to apply in like situations.
  • Instruct your staff to extract required face-to-face encounter information from the chart or EMR, then attach to your 485 plans for care for your review and signature.
  • If a face-to-face form would assist you, you can create one for you office, or you can download the one we have provided.  A form is not required, however.

Billing Opportunity

  • Don’t forget that you may bill for certification of home care services.
  • Care Plan Oversight: G0181
  • Certification: G0180
  • Re-Certification: G0179

As always, we are committed to working with you and CMS to assure the highest quality home health care for your patients.


Examples of Clinical Findings that Support the Need for Home Health

(examples but are not limited to)

  • Unhealed/complicated surgical wound
  • Diabetic – exacerbation or new insulin patient
  • Post Knee or Hip Replacement with limited ambulation and strength
  • Unstable Cardiac patient with new meds
  • Acute exacerbation of CHF and/or COPD
  • Post Surgical with wound care
  • Infection requiring IV antibiotics
  • Patients with Cognitive/Physical impairments requiring complicated treatment plans
  • High Risk for re-hospitalization
  • Patients with multiple co-morbidities (wounds and uncontrolled DM for examples)


Examples of Clinical Findings that Support Homebound

(examples but are not limited to)

  • Open/draining wound or surgical incision
  • Unable to leave home safely without assistance or device
  • Pain
  • Shortness of breath
  • Unsafe ambulation due to gait/balance abnormalities
  • Altered Mental status requires supervision when leaving home
  • Unable to ambulate more than 200 feet
  • Risk for infection
  • Post surgical restrictions and/or condition limit ability to leave home


Examples of Clinical Findings support need for Services:

(examples but are not limited to)

  • Therapist is needed due to the complexity of the therapy needed to treat the injury, illness, or condition
  • Nursing is needed for teaching/training the patient/caregiver to manage the treatment regimen for this illness or condition
  • Nursing is needed to provided treatments and care safely and effectively
  • Nursing assessment/observation is needed due to the potential for complications or exacerbation of the patient's condition