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Group Effort
Due to increased scrutiny by CMS regarding documentation of Face
to Face, Homebound status and the justification for skilled services,
several Idaho Association of Home Care members worked together
to create a form that will meet the new requirements and
standardize the process of ordering home health services. Because
it is recommended that Face to Face/Homebound status and need
for skilled services be separated from actual home health orders,
two separate forms have been created. The IAHC will recommend
that all agencies consider using these forms to decrease the
differences that physicians encounter when using various forms
from different agencies. Please note that examples of required
documentation accompany the new forms and the Community
Liaisons/Marketing representatives are available to help with
office/physician orientation.
F2F Background
CMS implemented the F2F requirement,
January 2011, which insures that the orders
and certification for home health services are
based on a physician’s current knowledge of
the patient’s clinical condition.
Time Lines
The F2F encounter must occur within the 90
days prior to the Home Health Start of Care, or
within the 30 days after the Start of Care.
The condition assessed during the encounter
must support the primary diagnosis/reason
for Home Health.
It is acceptable for the certifying physician to
dictate the documentation content to one of
the physician’s support personnel to type. It is
also acceptable for the documentation to be
generated from a physician’s electronic health
Face to Face Context
The F2F documentation must include the date
when the physician or allowed NP saw the
patient, and a narrative composed by the
certifying physician who describes how the
patient’s clinical condition as seen during that
encounter supports the patient’s homebound
status and need for skilled services.
Guidelines for documentation
The face to face documentation must include the
following to be considered complete:
Date of the encounter
A brief narrative that explains the reason skilled
services are needed related to patients illness,
injury, diagnosis from the encounter
A brief narrative supporting the homebound
status must include specific clinical findings on
why it is difficult for the patient to leave their
Signature of certifying physician with date
Guidelines for documentation
Diagnosis cannot be used to solely support
the reason for skilled services or the
homebound status.
A physician dictated clinical note/office visit,
or discharge summary that clearly states all of
the above requirements would be considered
sufficient to meet face-to-face requirements
for CMS.
Need for skilled services
• Intermittent SN is needed to assess the effects of new
and/or changed medications, teach patient/family/CG
regarding new CHF diagnosis, and to provide wound
care to buttocks until wound is either healed or
family/CG able to perform unsupervised.
• PT is needed for patient s/p RTKA, PT to provide gait
training, strengthening and exercises to improve
mobility as well as provide fall and injury prevention to
enable patient to return to prior level of function.
Need for skilled services
• OT is needed for bathroom safety, evaluate for appropriate adaptive
equipment, provide home exercise program, and UE strengthening
to restore patient’s ability to dress independently.
• Patient currently has several unhealed/complicated surgical wounds
that require SN to provide wound care and education on
integumentary status. They are newly diagnosed with diabetes and
require insulin administration and teaching due to limited cognitive
and physical impairments resulting in a complicated treatment plan.
Further, patient is at a high risk for re-hospitalization and skilled
nursing is needed for observation and assessment for signs of
adverse events from the new medical regimen
Homebound Status
• Patient is temporarily homebound secondary to RTKA
and currently walker dependent with painful
• Patient is homebound d/t recent hospitalization for
pneumonia and is SOB when walking short distances,
unsteady gait, and unable to ambulate without
assistance of another person.
• Patient is homebound due to pain limiting ability to
ambulate safely and independently and is currently
wheelchair dependent.
• Patient is homebound d/t advanced dementia, poor
safety awareness and is a high fall risk.
Homebound Status
• Patient is unable to ambulate on uneven surfaces, is a high fall risk,
and requires a use of a FWW.
• Patient is paralyzed from a recent stroke and is unable to ambulate
safely, requires wheelchair for home mobility. Transfer and self care
ADL’s require assistance from another person and patient is limited
by low back pain. Patient also experiences dyspnea with minimal
exertion. When out of the home safety is an issue due to diagnosis
of dementia.
• Patient is blind and/or senile and requires the assistance of another
person in leaving their place of residence.
• A patient has just returned from a hospital stay involving surgery, is
suffering from resultant weakness and pain. The physician has
restricted and limited the patients activities such as getting out of
bed for only a specific period of time, walking stairs only once a day
Combined documentation for skilled
needs and homebound status
• Patient was recently hospitalized for COPD
exacerbation requiring SN for monitoring of respiratory
status and medication management. PT is needed for
recent decline in functional status to provide gait
training and strengthening. Patient is homebound d/t
SOB when ambulating 20 feet or more, unsteady gait
and requiring FWW.
• Patient has had several recent falls in the home
requiring PT services to evaluate for assistive device for
safety and gait training. Pt is homebound d/t pain in
leg and unsteady gait.
Combined documentation for skilled
needs and homebound status
The patient is temporarily homebound
secondary to the status post TKA and currently
walker dependent with painful ambulation.
PT is needed to restore the ability to walk
without support. Short-term SN is needed to
monitor for signs of decomposition or adverse
events from the new COPD medical regimen
What doesn’t support homebound
• Confusion, unable to get out of the home
• Weak, unable to drive, frail
• Unable to safely leave the home unassisted
• Dependent upon adaptive devices
• Medical restrictions
• SOB upon exertion
• Requires assistance to ambulate
Acceptable reasons for leaving the
• Attend day adult day care program
• Attend religious service
• Absence from the home is of infrequent or
relatively short duration