Coding has become an increasingly important and complex task for home health agencies. There have been recent updates to the guidelines related to the Face-to-Face Encounter and its relevance in primary diagnosis coding, further emphasizing the need for accurate and thorough documentation. On top of that, agencies are facing heightened scrutiny from Medical Review and the Review Choice Demonstration (RCD), prompting them to prioritize improvements in their coding processes.
In addition to understanding when to code, one key requirement in home health coding is that the primary diagnosis must receive active treatment during the face-to-face encounter. This should be clearly documented in the face-to-face encounter note and reflected in the Plan of Care. However, many home health providers may struggle to determine when a new or updated face-to-face encounter note is necessary, which can lead to confusion and potential coding errors. To help clear this up, we have compiled a list of scenarios and reasons why a new face-to-face encounter note may be required.
F2F Encounter Documentation FAQs
- Since the encounter can be completed within thirty days of the start of care date, can agencies go ahead and code the chart now and get a valid face-to-face encounter later?
No, it is not recommended. Although the face-to-face (F2F) encounter can occur within 90 days before or 30 days after the Start of Care (SOC), coding should be done with an existing F2F encounter note. This will prevent auditing issues and extra administrative work to recode the chart. Some agencies may finalize the Plan of Care and send it to the certifying practitioner for signature before completing the F2F encounter visit, which is unacceptable because the certification must include the date of the encounter, which cannot happen until it takes place.
To avoid these issues, it is highly recommended that agencies never code a new SOC without an adequate F2F encounter note.
- Do we HAVE TO get a new Face-to-Face encounter when the clinician finds a wound that isn’t mentioned in the encounter that we have?
Yes. If a clinician discovers a wound that is not documented in the existing encounter note and that wound is identified as the primary reason for home health services, then a new Face-to-Face encounter note is required. This new encounter note must address the wound and become the basis for the primary diagnosis on the plan of care. It is important to note that the Face-to-Face encounter should always address the reason for home health services.
- Won’t an addendum or diagnosis query and confirmation work?
No. If a wound is the primary reason for home health services and will be coded as the principal/primary diagnosis, a new Face-to-Face encounter must be acquired from the physician addressing the wound. An addendum or diagnosis query and confirmation will not meet the Face-to-Face requirements. This is because auditors look for a diagnosis that is actively treated during the encounter, and home health principal diagnoses listed without active treatment can cause auditing issues.
If the patient had active treatment during the encounter but the physician failed to clearly document the active treatment, then a physician addendum to the Face-to-Face encounter note can be used. However, an addendum written by the home health agency is not allowable.
If there were no active treatment during the encounter, the agency would need a new Face-to-Face encounter.
- In what other instances might a new Face-to-Face encounter be needed?
- When the allowed practitioner documents that the actively treated condition has been resolved
- When the actively treated condition is a diagnosis that is not a PDGM-acceptable primary diagnosis
- When the Face-to-Face encounter is solely a pre-op note and home health will focus on skilled post-op care
- When the Face-to-Face encounter is a note from an in-patient stay and the patient was not directly admitted to home health services following that stay
- When the Face-to-Face encounter is a note from a community physician (urgent care, specialist) that will not be the certifying physician or a non-physician practitioner working under the certifying physician. It is important to note that when the certifying allowed practitioner is a non-physician practitioner, the community Face-to-Face encounter is required to be done by the same non-physician practitioner.
Failure to meet these standards may result in the Face-to-Face encounter not being accepted as valid, and the agency may not be reimbursed for the services provided.
Updating the F2F encounter note to obtain accurate and comprehensive information about a patient’s condition is essential for providing appropriate care and ensuring proper reimbursement. Coders play a critical role in this process by initiating the query process and assigning the correct codes. However, efficient care coordination is essential, and all members of the team, including coders, intake staff, and physicians, must work together. By prioritizing effective communication and collaboration, home health businesses can improve patient outcomes and financial viability altogether.