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Physician Documentation

Updated: 05/10/11


What is an example of the physician's narrative on the face-to-face documentation?

The certifying physician's face-to-face description should be a brief narrative describing the patient's clinical condition and how the patient's condition supports homebound status and the need for skilled services.

For example:

"The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decompensation or adverse events from the new COPD medical regimen."


Can documentation requirements for the face-to-face encounter be satisfied if the certifying physician’s staff complete the document as part, or addendum to the certification using the patient’s medical record & physician reviews and signs?

The statute requires that the certifying physician document the encounter as part of the certification. A physician's own support staff can help the physician draft the face-to-face encounter documentation narrative in a number of ways which include but are not limited to: the certifying physician can dictate the narrative to the physician's support staff, the support staff can extract the narrative from the physician's own medical record documentation of the encounter, or the support staff can generate the narrative from the physician's electronic medical record software. Such are examples of common practice for physicians to document their patient encounters, and all would meet the statutory requirement that the certifying physician must document the encounter as part of the certification. CMS expects that because this same information is often present on the discharge summary and/or physician orders for home health services, the face to face encounter documentation narrative may satisfy multiple purposes. A physician's orders for home health services or an acute/post-acute discharge summary can be used to satisfy the face-to-face documentation narrative, if they reflect the clinical condition of the patient as seen during the encounter, they are drafted by the physician or the physician's support personnel, and they meet these requirements:

- documentation must be on the certification form itself or is an addendum to it, it must be separate and distinct.

- It must also include the following: 1) the patient's name; 2) date of the encounter; 3) how the patient's clinical condition as seen during the encounter supports homebound status and the need for skilled services; 4) the physician's signature (original signature, a faxed copy, copy of original document with signature or electronic signature - but not stamped signature); and 5) date of the physician's signature


Do both the plan of care and the certification have to be signed by the same physician?

Prior to Calendar Year 2011, CMS manual guidance required the same physician to sign the certification and the plan of care. Beginning in Calendar Year 2011, CMS will allow additional flexibility associated with the plan of care when a patient is admitted to home health from an acute or post-acute setting. For such patients, many asked that CMS allow the contact between the physician who attended to the patient during an acute or post-acute stay to satisfy the encounter requirement, even when the physician may not follow the patient in the community. These commenters asked CMS to allow such physicians to inform the community certifying physician as the law allows non-physician practitioners (NPPs) to do. We are limited by the law that requires the certifying physician to document that the encounter occurred with himself or herself, or a permitted NPP. To adopt as much flexibility as the law allows, we will allow physicians who attend to the patient in acute and post-acute settings to certify the need for home health care based on their face-to-face contact with the patient (which includes documentation of the face-to-face encounter), initiate the orders (plan of care) for home health services, and "hand off" the patient to his or her community-based physician to review and sign off on the plan of care. As we described above we continue to expect that in most cases the same physician will certify, establish and sign the plan of care. But the flexibility exists for home health post-acute patients if needed.

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