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Glossary

Face-to-face encounter

A visit with a physician or allowed practitioner, related to the main reason the patient needs home health, that must occur within 90 days before or 30 days after the start of care and be documented in the certifying practitioner's own record. Without it Medicare does not pay for the episode.

Also F2F, face-to-face documentation

The face-to-face encounter is a condition of payment for Medicare home health, in place since 2011 and set out at 42 CFR 424.22. The certifying practitioner must document that the patient had an encounter related to the primary reason home health is needed, and the encounter must fall inside a window: no more than 90 days before the start of care, or no more than 30 days after it.

Three things about it decide whether a claim stands:

  • Who performs it. The certifying physician, the physician who cared for the patient in an acute or post-acute facility from which the patient was directly admitted to home health, or an allowed practitioner: a nurse practitioner, clinical nurse specialist or physician assistant, under the CARES Act change of 2020. Telehealth counts.
  • Where it is documented. The encounter lives in the certifying practitioner’s or the facility’s medical record. The agency’s own notes can support the certification but cannot substitute for it. This is the point most denials turn on.
  • What it has to show. That the encounter was related to the reason the patient needs skilled services. A visit for an unrelated complaint does not qualify.

For the agency the encounter is a document to obtain rather than to create. When the patient comes from a hospital, the encounter is usually the hospitalist’s note or the discharge visit, and it sits in the hospital’s system. When the patient comes from a community physician, it is in that practice’s chart. Either way the referral packet is supposed to carry it and often does not, and the clock to the initial assessment visit keeps running while someone calls for it.

Where it is defined

Vivlio for home healthThe face-to-face note, orders, discharge summary and medications, assembled before the first visit.

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