CMS Contractors to Review of Denials Relating to Face-to-Face Requirements for HHA Services


The Centers for Medicare & Medicaid Services (“CMS”) has recently instructed contractors to reopen certain claims that were previously denied for failure to meet the “face-to-face” requirements in certain circumstances and assuming all content requirements of the certification and the face-to-face documentation are otherwise met.  It came to CMS’ attention that certain claims were being denied by some CMS contractors for patients who use Home Health Agency (“HHA”) services following an acute or post-actue stay when:

  • The HHA uses a single form (i.e., 485) for the plan of care and the certification with a single signature by the community physician who assumes oversight of the patient’s home healthcare.
  • The physician who cared for the patient in the acute or post-acute setting is the certifying physician and has provided and signed attached documentation of the face-to-face encounter.

CMS does not mandate that a specific form be used for the certification or plan of care.  Many providers, however, have chosen to use the no-longer-required CMS-485 form to satisfy the plan of care and the certification.  Since April 2011, providers who use this form typically attach the face-to-face encounter documentation to the CMS-485, as an addendum.  This is because the CMS-485 contains only one physician signature line for both the plan of care and the certification of eligibility.

In the case of patients admitted to an HHA following an acute or post-acute stay, the Medicare Benefit Policy Manual (“BPM”) language allows for one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care.  If the face-to-face encounter documentation and the CMS-485 form collectively satisfy all of the  certification and plan of care content requirements as defined in Chapter 7 Section 30 of the BPM, Medicare contractors have been directed to accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements.  In this scenario, the certifying physician is the acute or post-acute physician, has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation.  The physician who signs the CMS-485 assumes care for the patient’s home healthcare.

Additionally, CMS acknowledged that some contractors are denying claims for failure of the acute or post-acute physician to identify the community physician who will assume care for the patient.  CMS has not mandated the acute or post-acute physician to follow a specific documentation protocol to hand-off a patient to the community physician. Therefore, these claims will be reviewed as well.

If you have questions or concerns regarding the foregoing or would like additional information, please contact your regular Hall Render attorney, or Todd Selby at or 317.977.1440, or Kendra Conover at or 317.977.1456