Medicare-Documentation Guide

Physician Face-to-Face Encounter

Documentation Guide

NEW MEDICARE REQUIREMENT EFFECTIVE JANUARY 1, 2011

The Patient Protection Affordable Care Act has mandated a physician face-to-face encounter (in-person visit) for Medicare home health services.

The in-person visit with the patient must be done by one of the following:

• Community physician who will certify the plan of home health care, OR
• Hospitalist in the hospital, as long as he/she can identify community physician who will certify plan of home health care, OR
• Non-Physician Practitioner (NPP) such as Nurse Practitioner, Clinical Nurse Specialit or Physician’s Assistant, who must document the clinical findings and provide them to the certifying physician

The in-person visit timeframes must occur:

• No earlier than 90-days before the admission visit to home health services, OR
• Within 30-days after the admission visit to home health services

The narrative documentation must have (See Documentation Guide):

• The patient name
• The date of the in-person visit and that the visit was related to, completely or in part, the medical condition for which the patient needs home health services
• Clinical findings that support the medical necessity and need for Medicare-covered skilled nursing, physical therapy and/or speech therapy services, AND
• Clinical findings that support the patient is homebound

The in-person visit documentation must be a separate and distinct section of, or an addendum to, the physician’s orders/485 and must be clearly signed and dated by the certifying physician who either performed the visit or received documentation form their NPP.

The home care agency is required by Medicare to maintain this documentation.

Please contact Lawrence Home Care of Westchester at (914) 961-2818 if we can be of further assistance.