Face-to-Face Encounter Progress NoteCMS recently posted a proposed electronic progress note template that it developed for physician’s to use to document and support the physician face-to-face encounter requirements. Because the form has not yet been approved by the OMB, use of the progress note is entirely voluntary and optional. It is intended ONLY to assist the physician or allowable Medicare non-physician practitioner (NPP) in documenting patient eligibility (i.e. the encounter and homebound status of the patient). Supportive documentation was also released by CMS.

The three-page progress note includes checkboxes and fill-in-the-blank areas that cover the major areas of attention required during the Face-to-Face Encounter. These include chief complaint, history of present illness, review of systems, physical assessment findings, plan for skilled home care services, and documentation of homebound status.

Beginning in 2011, as part of the Affordable Care Act, home health agencies have been required to demonstrate that a Face-to-Face Encounter was completed for new certifications (admissions) prior to the attending physician certifying a patient’s eligibility for the home health benefit. The physician certifying home health services is required to document that a Face-to-Face Encounter was completed by a physician or a non-physician practitioner (NPP) no more than 90 days prior to the home health start of care date or within 30 days of the start of home health care.

CMS implemented changes to the Face-to-Face requirements in January 2015 to reduce the administrative burden to home health agencies. Prior to these changes, physicians were required to complete a narrative as part of the Face-to-Face Encounter documentation. This requirement for this narrative was eliminated in January 2015. However, the certifying physician is still required to certify that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility. Documentation in the physician’s medical record or the acute/post-acute care facility’s medical records is necessary to support findings of the Face-to-Face Encounter.

What are your thoughts on this new template? Do you think it will reduce the administrative burden?