CMS Clarifies F2F Documentation Title and Date Policy

Face-to-face changes finalized in the 2013 Home Health PPS update Federal Register notice are effective for episodes ending on it after January 1. In this notice the Centers for Medicare & Medicaid Services (CMS) wrote: “We are finalizing regulatory text changes as proposed. The regulation text in part 424 will be changed to not be prescriptive as to what entity needs to date and title the face-to-face documentation, but will still require the same content and the certifying physician’s signature.”

In an effort to clarify the intent of changes related to titling and dating F2F encounter documentation, the National Association for Home Care & Hospice (NAHC) asked the CMS to confirm whether home health agencies are now permitted to title and date F2F encounters, and to clarify what “date” the change is referring to. “That is, is this the date of the encounter, the date of the signature, or is there some other date?”

In the response received by NAHC, CMS wrote: the new reg(ulation)s are not prescriptive as to what entity may date/title the encounter documentation.” CMS further qualified this statement saying “to comply with documentation requirements, the face-to-face encounter document has to have two dates: the date of the encounter and the date of the documentation. Our new reg(ulation)s are not prescriptive as to who can title or date the form, but the form must be signed by the physician. As such, the HHA may add the title and the date of the documentation if this was not done by the physician.”

CMS went on to say that the physician’s documentation must still contain the date of the encounter and a description of why the clinical findings from the encounter support that the patient is homebound and needs skilled care. Further, CMS said that, “if the physician does not date next to his/her signature, then it would be acceptable for the HHA to date the documentation and consider it the “date of documentation.” This date does not need to be the date that the physician affixed his/her signature in cases where the physician did not date the form at the time of signing.”

CMS plans to update its Manuals and F2F Questions and Answers to address the F2F regulatory and policy changes detailed in the notice.

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