Physicians are now required to document face-to-face visits with Medicare patients who require home health care services, but they’re not required to use a specific form for documenting the visits.
The Centers for Medicare and Medicaid Services (CMS) began enforcing the new rule on April 1, 2011. Even though a specific form is not required, documentation must support the need for the patient to receive home health services. This documentation could be cut and pasted directly from the medical record or discharge summary and attached to the certification form itself or as an addendum to it. It must be separate and distinct and contain the following information:
- Name of the patient
- Date of the face-to-face visit
- Description of how the patient’s clinical condition, as observed during the visit, supports the need for home health services (see an example)
- The physician’s signature (may not be a stamped signature) and date of signature
This documentation must occur no sooner than 90 days prior to the start of home health services, but no later than 30 days after care begins. The new rule does not apply to Medicare Advantage, Medicaid, or other payers.
You can find answers to
frequently asked questions on the CMS website. If you have additional questions, contact PAMED’s Division of Practice Economics and Payer Relations at (800) 228-7823, ext. 2644.