Chapter 4

❏ Face-to-Face visits

❏ In-person F2F visit.

❏ TeleHealth F2F visit.

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Start of CPO Training

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Chapter 4: Patient visit, care, and documentations
● Face2Face visit in-person visits and TeleHealth
The Centre for Medicare & Medicaid Services (CMS) of the US government, has established a

face-to-face (F2F) encounter (both eligible: in-person or telehealth visit), a mandatory

requirement for certification of eligibility for Medicare home health agency (HHA) & hospice,

commonly will be hereafter referred to as the HHA-H services (for the Doctor Alliance Training

purposes), by requiring the certifying physician (MD/DO/DPM, where applicable) to document

that he or she, or a non-physician practitioner (NPPs as per applicable state laws), working with

the physician, has seen the patient.

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 ● Face2Face in-person visit and TeleHealth
Face2Face or Face-to-Face (F2F) patient (Pt) visit is also commonly known by these terms:

● Clinical visit.
● Patient visit.
● F2F.
● FTF.
● Home Health eligibility determination visit.
● Hospice eligibility determination visit.

The above are the usual words used for a face-to-face but (in a few cases, very rarely) you may

even come across another similar words being used by different MD/DO/DPM/NPPs for F2F.

However, it is to be be clear that the concept remains exactly the same.

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A Face-to-face (F2F) visit is also called as a clinical visit, where the
MD/DO/DPM/other NPPs as per the state laws, examines the clinical status of
the patient including all the diagnosis of diseases & other conditions including
surgical ICDs & other pertinent conditions, active medications with
appropriate dose, frequency & refills, history, vitals, systemic examinations
and Subjective (S), Objective (O), Assessment (A), detailed Plan (P) of care
along with changes as suitable for the improvement of patient’s health.

All the details from the F2F is documented in a standard format on the
patient’s chart/the Electronic Health Record (EHR).

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Telehealth Visit
❏ The concept of telehealth existed in the past decade but the use was very
limited but after the COVID-19 pandemic, the US federal & state
governments including the Department of Health & CMS have accepted
telehealth as a valid way of remote clinical patient F2F.
A telehealth visit, which is done remotely, is also eligible to be considered as a
valid face-to-face (F2F) visit, provided it meets a few criterias:
❏ Telehealth visit must be done using a secure VIDEO & AUDIO (both) medium/software.
AUDIO only telehealth visits are not eligible for billing/reimbursements purposes.
❏ The patient, patient’s family members, or any care provider of the patient must have
access to a device which allows two-way audio & video communication with the
MD/DO/DPM or NPPs.

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As per US Department of Health & Human Services, ‘HIPAA-covered health
care providers may, in good faith, provide telehealth services to patients using
remote communication technologies, such as commonly used apps – including
FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype – for telehealth
services, even if the application does not fully comply with HIPAA rules’.

Avoid these & any other apps where anyone else (other than the
Physician/NPP and Patient can access the ongoing/recorded/logs of the
telehealth): The statement continues ‘However, providers should not use any
platforms that are public-facing — for instance, Facebook Live, Twitch, and TikTok
— to provide telehealth’.

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CMS Temporary Policy changes/relaxation to rules during COVID-19 Pandemic for
Telehealth
CMS has issued temporary measures to make it easier for people enrolled in
Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) to receive
medical care through telehealth services during the COVID-19 Public Health
Emergency.
The changes in policy allow providers to:
❏ Conduct telehealth with patients located in their homes and outside of
designated rural areas.
❏ Practice remote care, even across state lines, through telehealth.
❏ Deliver care to both established and new patients through telehealth.
❏ Bill for telehealth services (both video and audio-only) as if they were provided
in person.

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CMS significantly expanded the list of covered telehealth services that can
be provided in Medicare through telehealth to include:

❏ Emergency department visits.

❏ Initial nursing facility and discharge visits.

❏ Home visits.

❏ Therapy services.

Explanation of each sub-topics are in the next pages/slides of the Doctor Alliance (DA)’s training manual.

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❏ Telehealth for Emergency department visits:
❏ Telehealth is a fast & good service for minor emergencies (at least in most cases), but it is not a
very practical approach in cases where a healthcare professional needs to be present in-person
to attend patient’s health emergency, & provide care.
❏ However, telehealth has its own merits, where a MD/DO can guide the other person on-site with
the patient for steps till emergency/critical care services reach the patient.
❏ Telehealth service (video & audio) can reach the patient in seconds whereas the best emergency
services anywhere in the world, even the best in the US, will take at least a few minutes to reach
the patient.
❏ Telehealth can be a life saving technology in cases where a patient is at a very far distance from
healthcare services availability.
❏ A major limitation of telehealth for emergency visits is that if the steps are not followed properly
in panic by the patient or family, as per the physician’s instruction remotely, it may even lead to
drastic situations.
❏ Conclusion, for emergency department visits, telehealth has both advantages & disadvantages
and should be used cautiously.
❏ The patients admitted at the HHA-H may sometimes require emergency department services,
where telehealth may prove to be very useful. The Physician/NPPs overseeing the patient, who
provided initial F2F can be reached via telehealth by one of the attending personnel from HHA-H
to get the required instructions for minor emergencies where it is not life threatening for the
patient, which is only possible via telehealth.

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❏ Telehealth for the initial nursing facility and discharge visits
❏ Telehealth visits can be used as the first step in establishing a patient for the initial
nursing facility & discharge visits.
❏ Using telehealth initially, can save a lot of patient’s & the HHA-H’s time in understanding
the patient’s requirements from the HHA-H after the referral is received from the
MD/DO/DPM/other NPPs.
❏ Telehealth can be also used when there are restrictions (such as state restrictions due to
COVID-19) for in-person visits, and the patient’s case can be evaluated & cared for using
telehealth (an in-person visit may still be required for many cases).
❏ The discharge visits from HHA can be also done using telehealth services (this should be
decided carefully by the facility, on a case-to-case basis).

❏ Home visits
❏ Home visits can be conducted using telehealth services, as well. This should be decided
on a case-to-case basis where evaluations & care are possible via telehealth.

❏ Therapy services
❏ The PT/ST/OT/others can schedule & conduct initial visits & follow-ups using telehealth
services. The limitations of evaluation & proper care should be one of the major factors
which must be considered before therapy services are provided using telehealth.

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Practical problems associated with F2F via Telehealth
Telehealth (though it may be a boon for many cases to provide access to healthcare remotely), where the
patient and the Physician/NPPs are at a different location or there are restrictions or precautions for in-person
meet such as COVID-19 precautions or far distances, there are a few practical problems associated with using
telehealth.

❏ All the evaluations such as checking the different functions of body systems of patients such as
using a stethoscope or any such analysis by physician/NPPs are limited & may not be possible with
telehealth, as it is with in-person visits of F2F.
❏ There may be a lack of stable internet connection, weak or disconnecting mobile network and many
such hurdles at the patient’s side and even at physician/NPPs side, when the F2F via telehealth is
scheduled, which may make it difficult to conduct a video & audio visit.
❏ The understanding of use of the modern audio & video technology may be a hurdle for the geriatric
patient population (which is on an average of 10% to 30% in all the states of US), and one of the
main population who need constant care & regular monitoring by physicians/NPPs.
❏ The lack of modern devices and computer system with set of audio & video accessories availability
may be one of the many hurdles faced, when trying to implement telehealth healthcare services.

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Healthcare Provider(s) eligible for F2F
Type of Healthcare Providers eligible for F2F:

❏ Medicare-enrolled physicians (MD/DO/DPM) who are also the certifying

physician.
(MD = Doctor of Medicine, DO = Doctor of Osteopathy, DPM= Doctor of Podiatric Medicine).

❏ Non-Physician Practitioners (NPPs) are also allowed to perform the F2F

encounter.

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Non-Physician Practitioners (NPPs) allowed for F2F are:
❏ A Nurse Practitioner (NP) or clinical nurse specialist working in
collaboration with the certifying physician (MD/DPM/DO), in
accordance with State law.

❏ A certified nurse-midwife under the supervision of the certifying

physician (MD/DPM/DO), in accordance with State law.

❏ A Physician Assistant (PA) under the supervision of the certifying

physician (MD/DPM/DO), in accordance with State law.

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Important Requirements for F2F (applicable to all
jurisdictions in US for HHA-H)
There are many requirements applicable to F2F for initial home health
certifications as follows:

❏ the certifying physician (who must be a MD/DO/DPM or NPPs-as per

applicable local state laws), must document that the physician
himself/herself, an allowed NPP, or a physician caring for the patient in an
acute or post-acute facility who has privileges at the facility had a F2F
encounter with the patient.

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❏ The F2F must have occured within 90 days prior to the start of care date at
HHA-H.
❏ This means that the Pt must have had an in-person visit by the MD/DO/DPM or NPPs,
as per applicable state laws.
❏ F2F must be within the past 3 months (maximum allowed: up to exact 90 days in the
past where visit was done).
❏ A F2F visit/encounter that was done, but without being properly documented, would
not be considered valid.
❏ The F2F must be documented by the Physician/NPPs using an electronic
documentation technique i.e. Electronic Health Records (EHRs) also was known as
Electronic Medical Records (EMR) earlier (we will discuss more on proper F2F
documentation techniques in next chapters of the Doctor Alliance Training).

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❏ F2F within 30 days time-frame of start of Pt care at HHA-H:
❏ It is possible to have F2F after Pt’s care is already started at HHA-H, within 30 days, with valid
supporting reasons for the Pt’s case (where it was not possible/difficult to have done F2F within 90
days prior to start of care of patient at HHA-H).
❏ The F2F encounter can also occur within 30 days after the start of care at HHA-H where there were
unavoidable circumstances to have the Pt’s done before HHA-H start of care (occured during early
pandemic COVID-19). This is rare but still can be acceptable with extensive documentation of valid
reasons.
❏ The F2F within 30 days of start of care at HHA-H is NOT a usual practice but is allowed as per the law
where a valid reason for same can be provided.
❏ The major drawback (why future/within 30 days F2F is NOT recommended):
MD/DO/DPM/NPPs, complete the F2F evaluations within past 90 days & provide proper
documentations with a referral to HHA-H which allows HHA-H to provide care to the Pt as per the
prescription/documentation by the MD/DO/DPM/NPPs. This becomes difficult in cases where F2F by
the Physician is to be done in future within 30 days (the evaluations & documents are not available
from the MD/DO/DPM/NPPs for the HHA-H to use as guidelines). A supervising/overseeing
MD/DO/DPM/NPP, as per applicable state laws is very important.
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Patient Eligibility for HHA-H (as per guidelines)
The patients must have met a few MUST HAVE requirements to be eligible for Home
Health Agency (HHA) or Hospice benefits by insurance. The insurance (including
Federal Government’s Medicare, will cover the Pt’s cost of HHA-H if:

❏ the patient is confined to the home.

❏ the patient is under the care of a physician.
❏ the patient receives services under a plan of care established and periodically
reviewed by a physician.
❏ the patient is in need of skilled nursing (SN) care on an intermittent basis or
physical therapy (PT), or speech language pathology / Speech Therapy (ST), or
need for occupational therapy (OT), or Medical Social Work (MSW), or Home
Health AIDE (Aide).
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Patient Eligibility for HHA-H:
1. The patient is confined to the home.
❏ For a patient to be eligible for HHA-H benefits, he/she must have one or multiple
disease (ICD) conditions (diagnosed by a MD/DO or DPM for eligible conditions of
podiatry), which must limit the Pt’s ability to move freely within home or leave
home like a healthy individual for daily activities.

❏ The patient must require assistance of another individual and/or assistive device
for mobility, Activities of Daily Living (ADL) and Instrumental Activities of Daily
Living (IADL).

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Patient Eligibility for HHA-H:
2. The patient is under the care of a physician.

❏ For a patient to be eligible for HHA-H benefits, he/she must be under the active
care of a physician. A physician can be usually a MD or DO licensed in the same
state of HHA-H’s location.

❏ In a few cases (where eligible), a DPM is the physician certifying (if eligible by only
Podiatry diagnosis, but usually the Pt has multiple other systems’ diseases which
makes the DPM as a secondary physician & MD or DO has to provide active care
to the patient).

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Patient Eligibility for HHA-H:
3. The patient receives services under a plan of care established and
periodically reviewed by a physician.

❏ The initial F2F and services provided by HHA-H are to be continued under the
supervision of the same certifying Physician or NPPs as per the state laws.

❏ If the certifying provider retires, migrates to other state or country or is not

eligible to practice medicine as per the law, then the patient care under HHA-H
has to be supervised by another Physician or NPPs as per law. It is permitted to
change Physician or NPPs with a valid reason (as above).
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Patient Eligibility for HHA-H:
4. The patient is in need of skilled nursing care on an intermittent
basis or physical therapy or speech language pathology, or need for
occupational therapy.
For a patient to be eligible for the HHA-H services:

A. The patient should be in need of an active care by a skilled nurse on regular or periodic
basis (as per the disease/condition requirements of the patient) with supervision &
signature on all documents by the F2F Physician/NPPS, as per the state laws . or/and
B. The patient should be in need of regular or periodic Physical Therapy (PT) services due
to eligible diseases which require a Physical Therapist’s certification & regular care, to
be countersigned & supervised by the F2F Physician/NPPs, as per the state laws. and/or
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For patient to be eligible for the HHA-H services (cont’ d):

C. The patient should be in need of regular or periodic Occupational Therapy (OT)

services due to eligible diseases, which require a Occupational Therapist’s
certification & regular care, to be countersigned & supervised by the F2F
Physician/NPPs, as per the state laws. and/or

D. The patient should be in need of regular or intermittent Speech Therapy (ST) /

Speech Language Pathology services, from a qualified Speech language therapist
as per the state laws, and the F2F Physician/NPPs should oversee the patient care,
as per state laws.

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Hospice Referral Eligibility:
❏ A patient who has one or more serious
diseases/illness/conditions with a life expectancy of 6 months
or less (which can be certified by a Physician or NPPs, as per
applicable state laws).
❏ Hospice care should help patient with comfort care and
symptom management for improved Health Related Quality of
Life (HR-QOL).
❏ Curative treatment is no longer the patient’s choice or option.
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Hospice Referral Eligibility:
A patient referral to hospice may be done by anyone, including but not limited to the
following:

❏ Physicians
❏ Hospital Discharge Planners
❏ Social Workers
❏ Patients (self)
❏ Family Members
❏ Nursing Homes or other Long Term Care Facilities
❏ Friends
❏ Any other caregiver of patient (specify)

NOTE: Same other requirements of F2F by a licensed Physician/NPPs guidelines for HHA-H
applicable, as discussed earlier for Hospice.

An evaluation of Hospice eligibility is a MUST.

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Home Health Agency Patient Referrals
❏ For Home Health Agency (Home Care) patient referrals, there’s no
one-size-fits-all approach.

❏ Each HHA business is different and needs to find the referral sources that
work best for them from all different sources available (discussed in next
slide/page).
❏ While there are many different ways to get clients for a HHA, the most
common method to get new business is HHA referrals from past and
current clients/patients and their loved ones.

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Home Health Agency Patient Referrals
According to the 5th edition of the Private Duty Benchmarking Study released by the Home Care
Association of America, the following were the top home care referral sources:

❏ 19.5% – Past and current clients and their loved ones

❏ 8.8% – Hospital discharge planners
❏ 7.1% – Medicare-certified home health agencies
❏ 5.9% – Skilled nursing facilities
❏ 5.7% – State Medicaid waiver programs
❏ 5.1% – Hospices
❏ 4.2% – Geriatric care managers
❏ 4.0% – Area Agency on Aging case managers
❏ 3.7% – Assisted living facilities
❏ 64% = Total from above
❏ 36% = others including Local Physicians, Other Sources (Veterans Affairs,
Self, Technology Companies, and any other new sources) 27
Eligible Physician for HHA-H Certification Requirements
❏ When a resident physician is not enrolled in Medicare as per the requirements,
another Medicare-enrolled teaching physician who is supervising the resident, would
sign the certification (the F2F and oversights for HHA-H can be only provided by
resident physician under supervision of a Medicare-enrolled Physician).

❏ The certifying physician must certify that the patient is receiving HHA-H services under
the care of a physician who is a MD, DO, or DPM; and

❏ The certifying physician must not have a financial relationship with the home health
agency, as defined in 42 CFR 411.354, unless exceptions to the referral prohibition
defined in Section 1877 of the Social Security Act apply.
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