Use this checklist to teach physicians or your employees about face-to-face encounter requirements or to evaluate the quality of face-to-face documentation.
 
General:
□ Is the face-to-face document labeled and dated?
□ Is it performed within the time frame (90 days before — 30 days after)?
□ Is it legible?
□ Is it signed and dated prior to the submission of the claim for billing?
□ Does it contain the date of the encounter?
 
Clinical Findings:
□ Does it describe the patient’s condition and symptoms, not just a list of diagnoses?
□ Is this a new problem or an exacerbation of a previous problem?
 
If this is a post-operative patient:
How long ago was the surgery? ___________________________________________________________
Were there any complications? ___________________________________________________________
If pain is documented, how severe is the pain? _______________________________________________
 
Skilled Need:
□ Is there evidence that skilled Physical Therapy (PT) is needed? (Note this is not an all-inclusive list.)
□ Assessment of functional deficits and home safety evaluation
□ Therapeutic Exercises
□ Restore joint function for post joint replacement patient
□ Gait Training
□ ADL Training
□ Is there evidence that Speech Therapy is needed? (Note this is not an all-inclusive list.)
□ Therapeutic exercise to improve swallowing
□ Therapeutic exercise to improve language function
□ Therapeutic exercise to improve cognitive function
□ Is there evidence that Nursing is needed? (Note this is not an all-inclusive list.)
Assessment and observation for: ___________________________________________________                                                                             
Teaching and training for: _________________________________________________________                                                    
□ Complex wound assessment and care
□ Management of new/changed medications
Direct nursing care for: ___________________________________________________________
 
Homebound Status:
□ Description is not limited to weakness, considerable and taxing effort, poor endurance
□ Does it contain a description of the patient's condition and symptoms, not just a diagnosis and not just the need for an assistive device?
If shortness of breath is applicable, describe the severity (severe at rest, with minimal exertion, etc.)
Weakness as evidenced by: ______________________________________________________________
□ Does the patient exhibit symptoms when attempting to walk (increase pain, shortness of breath, etc.)
The patient has medically restricted the patient to the home due to: ________________________
□ Patient is homebound due to a psychiatric condition/symptoms
 
Source: Palmetto GBA