FACE TO FACE ENCOUNTER

1. FACE TO FACE ENCOUNTER

2. Group Effort Due to increased scrutiny by CMS regarding documentation of Face to Face, Homebound status and the justification for skilled services, several Idaho Association of Home Care members worked together to create a form that will meet the new requirements and standardize the process of ordering home health services. Because it is recommended that Face to Face/Homebound status and need for skilled services be separated from actual home health orders, two separate forms have been created. The IAHC will recommend that all agencies consider using these forms to decrease the differences that physicians encounter when using various forms from different agencies. Please note that examples of required documentation accompany the new forms and the Community Liaisons/Marketing representatives are available to help with office/physician orientation.

3. F2F Background CMS implemented the F2F requirement, January 2011, which insures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition.

4. Time Lines The F2F encounter must occur within the 90 days prior to the Home Health Start of Care, or within the 30 days after the Start of Care. The condition assessed during the encounter must support the primary diagnosis/reason for Home Health.

5. It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.

6. Face to Face Context The F2F documentation must include the date when the physician or allowed NP saw the patient, and a narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.

7. Guidelines for documentation The face to face documentation must include the following to be considered complete: • Date of the encounter • A brief narrative that explains the reason skilled services are needed related to patients illness, injury, diagnosis from the encounter • A brief narrative supporting the homebound status must include specific clinical findings on why it is difficult for the patient to leave their home • Signature of certifying physician with date

8. Guidelines for documentation Diagnosis cannot be used to solely support the reason for skilled services or the homebound status. A physician dictated clinical note/office visit, or discharge summary that clearly states all of the above requirements would be considered sufficient to meet face-to-face requirements for CMS.

9. Examples:Need for skilled services • Intermittent SN is needed to assess the effects of new and/or changed medications, teach patient/family/CG regarding new CHF diagnosis, and to provide wound care to buttocks until wound is either healed or family/CG able to perform unsupervised. • PT is needed for patient s/p RTKA, PT to provide gait training, strengthening and exercises to improve mobility as well as provide fall and injury prevention to enable patient to return to prior level of function.

10. Examples: Need for skilled services • OT is needed for bathroom safety, evaluate for appropriate adaptive equipment, provide home exercise program, and UE strengthening to restore patient’s ability to dress independently. • Patient currently has several unhealed/complicated surgical wounds that require SN to provide wound care and education on integumentary status. They are newly diagnosed with diabetes and require insulin administration and teaching due to limited cognitive and physical impairments resulting in a complicated treatment plan. Further, patient is at a high risk for re-hospitalization and skilled nursing is needed for observation and assessment for signs of adverse events from the new medical regimen

11. Homebound Status • Patient is temporarily homebound secondary to RTKA and currently walker dependent with painful ambulation. • Patient is homebound d/t recent hospitalization for pneumonia and is SOB when walking short distances, unsteady gait, and unable to ambulate without assistance of another person. • Patient is homebound due to pain limiting ability to ambulate safely and independently and is currently wheelchair dependent. • Patient is homebound d/t advanced dementia, poor safety awareness and is a high fall risk.

12. Homebound Status • Patient is unable to ambulate on uneven surfaces, is a high fall risk, and requires a use of a FWW. • Patient is paralyzed from a recent stroke and is unable to ambulate safely, requires wheelchair for home mobility. Transfer and self care ADL’s require assistance from another person and patient is limited by low back pain. Patient also experiences dyspnea with minimal exertion. When out of the home safety is an issue due to diagnosis of dementia. • Patient is blind and/or senile and requires the assistance of another person in leaving their place of residence. • A patient has just returned from a hospital stay involving surgery, is suffering from resultant weakness and pain. The physician has restricted and limited the patients activities such as getting out of bed for only a specific period of time, walking stairs only once a day etc…

13. Combined documentation for skilled needs and homebound status • Patient was recently hospitalized for COPD exacerbation requiring SN for monitoring of respiratory status and medication management. PT is needed for recent decline in functional status to provide gait training and strengthening. Patient is homebound d/t SOB when ambulating 20 feet or more, unsteady gait and requiring FWW. • Patient has had several recent falls in the home requiring PT services to evaluate for assistive device for safety and gait training. Pt is homebound d/t pain in leg and unsteady gait.

14. Combined documentation for skilled needs and homebound status The patient is temporarily homebound secondary to the status post TKA and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term SN is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen

15. What doesn’t support homebound • Confusion, unable to get out of the home alone • Weak, unable to drive, frail • Unable to safely leave the home unassisted • Dependent upon adaptive devices • Medical restrictions • SOB upon exertion • Requires assistance to ambulate

16. Acceptable reasons for leaving the home • Attend day adult day care program • Attend religious service • Absence from the home is of infrequent or relatively short duration