Part 2: Meeting the F2F Challenge

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Last week, we covered the Face-to-Face encounter documentation requirements, how to provide additional information that might be missing from the provider’s original F2F encounter visit note, and some tips from Palmetto’s frequently asked questions on RCD regarding F2F.

Since many F2F encounter notes by providers (physicians, PAs and NPs) are missing some required details, agencies are usually finding it necessary to supplement the original F2F documentation.  This may be done by several methods we outlined last week:

  • Agency may send information from their assessment, evaluations, case conferences or care coordination notes,
  • Agency may send other information from the acute or post acute facility clinicians/staff,
  • Agency may use a supplemental form to organize the additional information,
  • Agency may include this additional information specifically labeled on the Plan of Care (485) itself

Remember, the certifying provider must review and sign off on anything incorporated into the patient’s medical record used to support F2F requirements.  One way to do this is via a statement on the Plan of Care (485) that is signed by the certifying provider.  Here is the specific tip from Palmetto:

  • The certifying provider must acknowledge the F2F encounter by documenting it either on the certification, which the provider signs and dates, or on a signed addendum to the certification which must be signed and dated by the certifying provider (which must be a physician or allowed non-physician provider). This certification statement must include the date of the F2F encounter visit, the name of the person who performed the visit, and the date the certifying provider signs to accept the F2F as valid.
    • If the person who did the F2F encounter visit is also the certifying provider for home care services, no separate attestation statement is necessary, although we recommend that the acknowledgement be included to include any supplemental information.
    • If the certifying provider is different from the F2F encounter provider, the certifying provider must acknowledge the F2F encounter document itself, usually by signature OR must have a certification statement on the POC as described above.

Here is the standard generic certification statement on the Plan of Care (485): I certify/ recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. This patient is under my care, and I have authorized the services on this plan of care and I or another physician will periodically review this plan. I attest that a valid face-to-face encounter occurred (or will occur) within timeframe requirements and it is related to the primary reason the patient requires home health services.

Examples of incorporating the specifically required F2F information into the POC itself

Sample certification statement incorporating the F2F attestation requirements:

I certify that this patient is confined to her home and needs intermittent skilled nursing for wound care and assessment, and physical therapy for balance and gait training using new walker due to fall risk.  The patient is under my care, and I have authorized the services on this plan of care and I will periodically review this plan.  I attest that a valid face-to-face encounter occurred on 2/24/2020 with J. Kirk FNP related to the primary reason this patient requires home health services:  diabetic ulcers right foot requiring wound care/assessment and unsafe ambulation requiring training in use of new walker.

Patient meets homebound status:

Criteria 1: requires a walker to ambulate due to open ulcers on right foot, pain and weakness, high fall risk; needs assistance of 1-2 people to safely ambulate with walker and negotiate 5 steps in/out of home.

Criteria 2:  patient has a normal inability to leave home due to limited weight bearing on right foot causing poor balance and draining wound with pain; leaving home requires a taxing effort and limited ambulation due to foot pain, poor balance/BLE strength, and high risk of falls and infection.

Sample clinical note (usually part of the narrative note on the comprehensive assessment), may also be copied onto the POC (485):

80 year old female admitted to home health services following recent hospitalization/rehab due to right  foot diabetic ulcer associated with cellulitis (now resolved), uncontrolled DM, CKD, CHF, Obesity, HTN.  The primary reason for home health and the focus of care is wound care to diabetic foot ulcer and DM with venous insufficiency and uncontrolled hyperglycemia.

F2F additional information to supplement the provider’s documentation, placed on the POC (485); remember, this must be specifically labeled:

Face to Face Addendum:

Face to Face encounter occurred on 1/6/2020 by Dr. Dolittle prior to discharge from SNF.
Primary reason for home health referral is for wound care, recent discharge from hospital and SNF r/t diabetic ulcer, cellulitis (resolved), uncontrolled diabetes, venous insufficiency, HTN, CHF, CKD, and complicated by poor pain control and dementia. Hospital treatment:  surgical procedure to foot ulcer and started on Insulin, was transferred to rehab from 12/16/19-1/7/20 for wound care and therapy. Past medical history: Obesity hypoventilation syndrome, HTN, PVD, HLD, Gout, history of MRSA and C-diff.

Focus of care and all above diagnoses were verified with interdisciplinary team including Physicians confirming all diagnoses.

Patient is homebound related to:  unable to leave the home without walker and the assistance of another person and client has difficulty leaving the home with considerable and taxing effort due to weakness, shortness of breath with transfers and ambulation 10-12 feet. Patient’s requires the following skilled home health services:  Skilled Nursing for wound care, assessment of healing/complications, instruction of knowledge deficits (wound care, diabetic management, medications, dietary restrictions), patient / caregiver unable to perform wound care, unaware what medications are prescribed and purpose, unable to use glucometer. Patient requires Physical Therapy to address deficits of balance / weakness / gait / high fall risk, unable to ambulate and maintain partial weight bearing status using new walker. Patient requires a Home Health Aide to see patient for personal care and ADL assistance related to patient unsafe to perform tasks at this time.
Physician Attestation Statement: I agree with the clinical summary information above that supports the need for the ordered skilled services and reason patient is homebound. I have incorporated this document as part of the patient’s medical record.

Other changes affecting F2F in the CARES Act, effective March 1, 2020

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act to allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This is a permanent change that will continue after the Public Health Emergency.

Just as a reminder, NPs, PAs and CNSs (NPPs) have been allowed to complete the face-to-face encounter documentation, but not certify the patient for home care or sign the Plan of Care and other orders. As of March 1 (made retroactive) the NPPs may complete the face-to-face encounter, certify the patient for home care AND sign all orders. State practice acts should be consulted prior to accepting orders from NPPs.

For additional help on F2F, PCR, & more check out these resources:

Teresa Northcutt, BSN, RN, HCS-D, COS-C, HCS-H
Senior Associate Consultant | Selman-Holman, a Briggs Healthcare

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