When reviewing face-to-face forms, agencies should consider these examples Medicare administrative contractor NGS provided during a recent webinar.
 
 
EXAMPLES OF ACCEPTABLE FACE-TO-FACE ENCOUNTERS:
 
1. 
FACE-TO-FACE ENCOUNTER
Patient name — James Doe
Date of encounter — February 19, 2013
Face-To-Face Certification — “I attest that I or an allowed NPP working with me had a face-to-face visit with this patient on the date above.”
Clinical Condition — Diagnoses: Acute Emphysema/Chronic Obstructive Pulmonary Disease. Patient has become increasingly short of breath with activity, weakness and decreasing oxygen saturation levels over the last 3 weeks resulting in her becoming wheelchair bound, requiring 2 assist for transferring, thus causing homebound status. Nursing services are needed for skilled assessment and education. Physical & Occupational Therapy evaluations are ordered.
Certification to support the need for skilled services & homebound status — “I certify that this patient is homebound and requires intermittent skilled nursing and/or physical/Occupation/Speech-Language Pathology services. He/she is under my care and the plan of care is periodically reviewed by a physician.”
Dated Signature — Electronically signed by William Smith MD on 2/22/13
 
2.
Primary Care Office Visit Progress Note: (FACE-TO-FACE) - 4/2/13
James Doe visits today because of worsening bilateral knee pain. The patient has had an orthopedic evaluation for severe osteoarthritis but is not a candidate for surgery at this time due to his worsening pulmonary disease. He has been taking the prescribed nonsteroidal anti-inflammatory medication without relief and continues to have difficulty with ambulation and climbing stairs. (5 steps into/out of house and 8 to bedroom) Balance is worsening and he presents today due to a fall last evening on the steps to get into the house that resulted in some minor abrasions and bruising to the right hip and knee (x-rays without fracture). Patient requires physical therapy and occupational therapy evaluations and requires an assistive device for safety with all ambulation. PT/OT to determine most appropriate device. This patient is declared homebound due to recent falls secondary to severe debilitating chronic osteoarthritis causing an unsteady gait, and need for assistive device when ambulating. Referral to ABC HH sent. Electronically signed by M. Jones MD on 4/2/13.
*Certification statement on the Plan of Care also signed by Dr. M. Jones 22 National Government Services, Inc.
 
3. 
FACE-TO-FACE
• I (or an allowed NPP) had a face-to-face encounter with Jane Doe on March 8, 2013.
• Clinical information: I am treating this patient for coronary artery disease and congestive heart failure following coronary stint placement. The patient requires rest when walking >20 feet due to severe fatigue and shortness of breath. Balance is poor-requiring use of a walker. She is homebound due to these issues. Home health nursing is needed for observation, assessment and education about new medications and physical/occupation therapy evaluations for gait training and assistive devices for activities of daily living.
• Certification statement: “I certify that this patient is homebound and requires intermittent skilled nursing and/or physical/Occupational Therapy. He/she is under my care and the plan of care is periodically reviewed by a physician.”
• Date & Signature: Electrically signed by Charles Williams MD on March 13, 2013 23 National Government Services, Inc.
 
4. 
Discharge Note
(FACE-TO-FACE ENCOUNTER)  (Title added by agency)
Dr. Jones,
• I treated Ms. Doe in the Emergency Department of Community General Hospital on 2/28/13 after she suffered a fall in her home. She was accompanied by her daughter who states this is her second fall in <30d. X-rays of her left hip and shoulder are normal but there is significant bruising and abrasions. She is alert & oriented to person and place. Disoriented to time with short-term memory loss noted. Breath sounds clear, no cough. Abdomen soft with active bowel sounds. All pulses present. No pedal edema noted. Patient is legally blind and requires assistance to leave home. A PT evaluation was done as well as gait training with a cane. Patient is very hesitant to use a cane. The patient will benefit from additional gait training for safety. Need for a cane and blindness results in her being homebound. I provided a referral to ABC Home Health for continued PT. I informed the home health agency that you will be the physician approving the plan of care.
• (From Dr. Williams)
• Electronically signed by N. Jones MD 3/13/13 24
 
5. 
FACE-TO-FACE
Patient: Jane Doe
Date of encounter: January 11, 2013
The above named patient requires nursing service assessments and PT/OT evaluations because of pneumonia/COPD exacerbation resulting in increased shortness of breath, severe weakness, cough and decreased oxygen saturation levels. Diabetic patient with elevated glucose levels secondary to steroid medications will now require insulin injections & diabetic education. She is currently homebound with a new walker for her unsteady gait and requires training and education with her assistive device and insulin therapy.
• Certification statement: “I attest that I had a face-to-face encounter with the above patient on the date noted above.”
Electronically signed by Dr. James Smith
Received on January 15, 2013  (Added by HHA)
 
6. 
FACE-TO-FACE ENCOUNTER
Patient: John Smith
Date of encounter: September 4, 2013
Clinical information: Nursing services are required for this 42 year old wheelchair bound paraplegic male patient to include wound care of infected stage 4 sacral decubitus ulcer. Prescription medication for dressing change requirements provided. Dressing to be changed 3x/day.
• Homebound Status: This wheelchair bound patient remains homebound
• Certification statement: “I attest that I had a face-to-face encounter with the above patient on the date noted above.”
Signed electronically by A. Jones MD on 9/9/13
 
 
 
 
 
EXAMPLES OF UNACCEPTABLE FACE-TO-FACE ENCOUNTERS:
 
1.
Date of encounter- January 21, 2013
Patient name- Jane Doe
Clinical condition- Pernicious anemia, chronic bronchitis. Requires nursing services for vitamin B12 injections and assessment and education about her illnesses
Homebound status- unable to drive
• Certification statement- “I attest that I had a face-to-face encounter with the above patient on the date noted above.”
Electronically signed by N. Jacobs MD on 1/23/13
Note: This form is missing a title and the homebound status description is very vague, NGS says.
 
2.
Face-to-Face Encounter
Date of encounter: March 28, 2013
Patient name: Jane Doe
Clinical condition: Diabetes, Hypertension
Homebound status: Taxing effort to leave home
• Certification statement: “I attest that I had a face-to-face encounter with the above patient on the date noted above.”
Electronically signature by M Davis MD on April 4, 2013
Note: This form should include what services the patient needs, NGS says. Also, the phrase “taxing effort to leave home” is copied directly from the CMS manual; the homebound status needs to be more specific.
 
3.
FACE-TO-FACE ENCOUNTER
Patient Name-Jane Doe
Clinical Condition-total knee replacement 7/30/13
Homebound status-requires assistance of 1 and a walker - status post total knee replacement surgery
Electronically signed by Dr. W. Moore. 8/1/2013
Note: This encounter is not dated. Also, there is no information about services needed, NGS says.
 
Source: NGS