Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
L C W
IMITED  OMPLIANCE  ITH 
 
 
M  H H
EDICARE S  OME  EALTH 
 
 
F - -F
ACE TO ACE 
 
  D
OCUMENTATION 
 
  R  
EQUIREMENTS 
 
Daniel R. Levinson   
Inspector General  
 
April 2014 
OEI-01-12-00390   
   
EXECUTIVE SUMMARY:  Limited Compliance With Medicares Home Health 
Face-to-Face Requirement 
OEI-01-12-00390 
 
WHY WE DID THIS STUDY 
The Patient Protection and Affordable Care  Act (ACA) requires that physicians (or 
certain practitioners working with them) who certify beneficiaries as eligible for 
Medicare home health services documentas a condition of payment for home health 
servicesthat face-to-face encounters with those beneficiaries occurred.  This study 
(1) determined the extent to which physicians who certified home health care 
documented the face-to-face encounters, (2) described the nature of face-to-face 
documentation, and (3) assessed the Centers for Medicare & Medicaid Services (CMS) 
oversight of the face-to-face requirement. 
 
HOW WE DID THIS STUDY  
We reviewed 644 face-to-face encounter documents to analyze the extent to which the 
documents confirmed encounters and contained the required elements.  We interviewed 
the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to 
describe how they ensure that home health agencies met the face-to-face encounter 
requirements.  We also reviewed guidance documents and policies from CMS or the    
HH MACs about monitoring the face-to-face requirement.  
 
WHAT WE FOUND 
For 32 percent of home health claims that required face-to-face encounters, the 
documentation did not meet Medicare requirements, resulting in $2 billion in payments 
that should not have been made.  Furthermore, physicians inconsistently completed the 
narrative portion of the face-to-face documentation.  Some face-to-face documents 
provide information that, although not required by Medicare, could be useful, such as a 
printed name for the physician and a list of the home health services needed.  CMS 
oversight of the face-to-face requirement is minimal. 
 
WHAT WE RECOMMEND     
We recommend that CMS (1) consider requiring a standardized form to ensure that 
physicians include all elements required for the face-to-face documentation,  
(2) develop a specific strategy to communicate directly with physicians about the face-to-
face requirement, and (3) develop other oversight mechanisms for the face-to-face  
requirement.  CMS concurred with all three of these recommendations.   
 
 
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................8 

For 32 percent of home health claims that required face-to-face 

encounters, the documentation did not meet Medicare requirements, 

resulting in $2 billion in payments that should not have been made  .....8 

Physicians inconsistently completed the narrative content of the 

face-to-face documentation ....................................................................9 

Some face-to-face documents contain elements that, although not 

required by Medicare, provide information that could be useful .........13 

CMS oversight of the face-to-face requirement is minimal .................14 

 
Conclusion and Recommendations ............................................................15 

Agency Comments and Office of Inspector General Response ...........17 

 
Appendixes ................................................................................................18 

A: Samples of Face-to-Face Documents .............................................18 

B: Confidence Intervals ......................................................................24 

C: Agency Comments  .........................................................................28 

Acknowledgments......................................................................................31 

 
   
   
OBJECTIVES 
1. 	  To determine the extent to which physicians who certified home health 
services documented face-to-face encounters with the beneficiaries 
within the required timeframe. 
2.	   To describe the nature of the face-to-face documentation.  
3.	   To assess the Centers for Medicare & Medicaid Services (CMS) 
oversight of the face-to-face requirement.   
BACKGROUND 
The Patient Protection and Affordable Care Act (ACA) provides new tools 
to enhance CMSs efforts to prevent and detect fraud in its programs.  For  
example, the ACA requires certain categories of providers with an 
increased risk for fraud, such as home health agencies (HHAs), to comply 
with enhanced fraud-prevention provisions.  Among other steps, the ACA  
requires that physicians (or certain practitioners working with them) who 
certify beneficiaries as eligible for Medicare home health services 
documentas a condition of payment for home health servicesthat 
face-to-face encounters with those beneficiaries occurred.1  
Medicare Requirements for Home Health Services 
Medicare beneficiaries who are generally confined to their homes may be 
eligible to receive certain medical services at home.2  These home health 
services include part-time or intermittent skilled nursing care, physical 
and/or occupational therapy, speech-language pathology, medical social 
services, and part-time or intermittent home health aide services.3   To  
qualify for home health services, Medicare beneficiaries must (1) be 
homebound; (2) need intermittent skilled nursing care, physical therapy or 
speech therapy, or continuing occupational therapy; (3) be under the care 
of a physician; and (4) be under a plan of care that has been established 
and periodically reviewed by a physician.4  For each 60-day episode of 
care that a beneficiary receives from an HHA, Medicare makes a 
standardized payment.  For the HHA  to receive that payment, a physician 
 
1 P.L.  111-148,  6407(a), as revised by  10605 (adding the face-to-face requirement at 
Social Security Act,  1814(a)(2)(C)).  Face-to-face encounters may be performed 
through telehealth visits subject to the requirements in   1834(m).  
2 Social Security Act,  1814(a)(2)(C).  
3 Social Security Act,  1861(m); CMS, Medicare Benefits Policy Manual  (MBPM), Pub. 
 
No. 100-02,  ch. 7,  40. 
 
4 42 CFR   424.22. 

Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   1 
   
   
must certify the beneficiarys initial need for home health services and 
homebound status and must recertify the need at least every 60 days.5   
Homebound Status 
Medicare considers beneficiaries homebound if, because of illness or injury, 
they have conditions that restrict their ability to leave their places of  
residence. Homebound beneficiaries do not have to be bedridden, but 
should be able to leave their residences only with considerable and taxing 
effort. Absences from home should be infrequent, for short durations, or for 
health care treatment.6    
Intermittent Skilled Nursing or Therapy Services 
The Social Security Act defines part-time or intermittent services as 
skilled nursing care that is either provided or needed on fewer than 7 days 
each week or less than 8 hours of each day for periods of 21 days or less.7   
The skilled nursing care must be provided by a registered nurse or licensed 
practical (vocational) nurse under the supervision of a registered nurse.8   
Home health aide services may include personal care, such as bathing and 
dressing; feeding; and simple dressing changes that do not require the skills 
of a licensed nurse.9   Therapy services must be performed by a qualified 
therapist or therapy assistant under the supervision of a qualified therapist.10  
Requirement To Be Under the Care of a Physician 
Medicare requires that to be eligible for home health services, 
beneficiaries be under the care of a doctor of medicine, osteopathy, or 
podiatric medicine.11   As of April 1, 2011, CMS began requiring full 
compliance with the requirement that the certifying physician or clinician 
have a face-to-face encounter with the beneficiary as a condition of 
payment for home health care.12    
Established Plan of Care  
Medicare pays for home health services only if they are provided under a 
plan of care that a physician establishes and periodically reviews.13   The 
physician must review, sign, and date the plan at least once every 60 days.14   
 
5 42 CFR   424.22. 

6  MBPM,  ch. 7,  30.1.1.  

7 Social Security Act  1861(m). 
 
8  MBPM,  ch. 7,  40.1.1. 
 
9  MBPM,  ch. 7,  50.2. 
  
10  MBPM,  ch. 7,   40.240.2.4.3. 
 
11 42 CFR   424.22(a)(iv).  

12 ACA,  6407(a), as revised by  10605; CMS notice accessed at http://www.cms.gov 
 
on  November 14, 2013. 
 
13 42 CFR   424.22(a)(iii). 

14  MBPM,  ch. 7,  30.2.6. 
 
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If a beneficiary does not receive at least one covered skilled nursing visit, 
physical therapy visit, speech-language pathology service visit, or 
occupational therapy visit within the 60-day episode, CMS considers the 
plan to be terminated.15    
Face-to-Face Requirement 
For the initial home health episode of care only, the certifying physician 
must document a face-to-face encounter with the patient.16  The HHA must 
obtain documentation that the face-to-face encounter with the patient 
occurred and that the encounter was related to the primary reason the 
beneficiary needs home health care.  If the certifying physician does not 
complete the documentation correctly, CMS can deny the HHA payment 
because the face-to-face requirement is a Medicare condition of payment.17   
CMS holds the HHA financially accountable for ensuring that the 
documentation from the physician meets the applicable criteria.   
CMS allows physicians to use a standard form to document the visit.  
However, CMS does not permit a form that the HHA completes and the 
physician merely signs; the physician must actually complete the 
documentation.  The documentation must include the following elements 
to meet the condition of payment.18  
1. 	  The certifying physician must complete and sign the face-to-face 
documentation, regardless of who performs the face-to-face 
encounter.  Federal law mandates as a condition of payment that 
the certifying physician, the physician who cared for the patient in 
an acute-care or post-acute-care facility, or a permitted 
nonphysician practitioner have a face-to-face encounter with the 
patient whom the physician is certifying for home health services.  
CMS has clarified that a patients  physician for acute care or post-
 
15  MBPM,  ch. 7,  30.2.9.  
16  Social Security Act,  1814(a)(2)(C);  see also 42  CFR  424.22(a)(1)(v) (2012) (prior  
to  the amendment at 77 Fed. Reg. 67068  (Nov. 8, 2012)  (effective Jan.1, 2013)).  
17 The existence of an evaluation and management (E&M) claim does not  fulfill the 
face-to-face requirement.  E&M claims include  visits and consultations performed by 
physicians and nonphysician  practitioners.  In most situations, if the provider billed  
Medicare for a face-to-face visit with the home health beneficiary, he or she would use an  
E&M code on the claim.   
18 Social Security Act,   1814(a)(2)(C).  See  also 42 CFR   424.22(a)(1)(v) (2012) (prior  
to  the amendment at 77 Fed. Reg. 67068  (Nov. 8, 2012)  (effective Jan. 1, 2013)); MBPM, 
ch. 7,  30.5.1.1; and CMS, MLN Matters  Article #SE1219, A Physicians Guide to  
Medicares Home Health Certification, including the Face-to-Face Encounter, release 
date May 7,  2012.    
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acute care can conduct that encounter as long as he or she informs 
the certifying physician of that encounter.19   
2. 	  The certifying physician must title, date, and sign the document.20    
3.	   The face-to-face documentation must be titled as such.  CMS does 
not require physicians to use a specific form to document the 
face-to-face encounter; as long as the face-to-face encounter 
documentation contains all content requirements and is properly 
titled, the certifying physician can use a discharge summary, a 
clinic note, or an original form to satisfy the requirement. 
4.	   The date of the encounter must be on the document. 
5. 	  The face-to-face encounter must occur within 90 days prior to the 
start of care or within 30 days after the start of care.  
6.	   As required by Medicare, this documentation must include a brief 
narrative that describes (1) why the patient is homebound and     
(2) why the skilled service(s) is necessary to treat the patients  
illness or injury.  This narrative can address the homebound status 
and reason for skilled service(s) in two separate sections or 
combine them in one section.   
Related Office of Inspector General Work 
In 2012, the Office of Inspector General (OIG) found through a medical 
record review that 98 percent of beneficiaries met Medicare coverage 
requirements for home health services.21  However, OIG also found that 
HHAs submitted 22 percent of claims in error because services were not 
medically necessary or claims were coded inaccurately, resulting in $432 
million in improper Medicare payments.  OIG concluded that given the 
general concern about risks to the Medicare program in the home health 
area, further investigations beyond the medical record review are needed 
to determine whether beneficiaries are eligible, services are furnished, and 
Medicare requirements for payment are met.   
 
19  76  Fed.  Reg. 68526, 68593, and 68606 (Nov. 4, 2011).  After our review period, CMS 
further revised 42  CFR  424.22(a)(1)(v)  to allow an  acute-care or post-acute-care  NPP 
to perform the face-to-face encounter in collaboration with or under the supervision of 
the acute or post-acute physician and to allow that physician to inform the certifying  
physician.  77  Fed. Reg. 67068, 67106, and  67163 (Nov. 8, 2012) (effective Jan. 1, 
2013). 
20 After our review period, CMS revised 42 CFR  424.24(a)(1)(v)(F), effective 
January 1,  2013, so that it no  longer provides that only the certifying  physician can title 
and date the certification. 77  Fed. Reg. 67068, 6716364  (Nov. 8, 2012). 
21 OIG,  Documentation of Coverage Requirements for Medicare Home Health Claims,  
OEI-01-08-00390, March  2012. 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   4 
   
   
In 2012, OIG found that HHAs did not meet all Federal reporting 
requirements for Outcome and Assessment Information Set (OASIS) data, 
which are the basis for home health payments, quality assessments, and 
information for consumers.22  In 2009, HHAs did not submit required 
OASIS data for 392,180 claims (6 percent), which represented over 
$1 billion in Medicare payments.  OIG recommended that CMS identify 
all HHAs that failed to submit OASIS data and that the agency apply a 
2-percent payment reduction to them. 
In 2009, OIG found aberrant billing patterns in home health outlier 
payments in 24 counties nationwide.23 One county in Florida, 
Miami-Dade, accounted for more home health outlier payments in 2008 
than the rest of the country combined.   
METHODOLOGY 
SCOPE 
This study determined the extent to which certifying physicians 
documented face-to-face encounters with beneficiaries.  This study is 
national in scope. It is based on Part A claims from January 1, 2011, 
through December 31, 2012. 
Claims Analysis.  We obtained all home health Part A claims (7,835,502) 
from January 1, 2011, until March 31, 2012, to determine the number of 
initial home health episodes because only these episodes require face-
to-face encounters. We determined that 4,226,413 of those claims                 
(54 percent) required face-to-face encounters with the physicians who 
certified home health services.  We  then looked at all claims dated on or 
after April 1, 2011 (2,471,332), which was when CMS started enforcing 
the requirement.  
For those beneficiaries in the first episode of home health care, we 
obtained all Part B claims with dates of service from 90 days prior to or  
30 days after the start of home health care.  We used the physicians 
National Provider Identifier (NPI) number from the Part A home health 
claim and linked it with any Part B claims coded for E&M that had the 
same NPI number.  We found that 68 percent of claims (1,679,050) had  
matching Part B E&M claims with the ordering physicians and 32 percent 
(792,282) did not. 
 
22 OIG,  Limited Oversight of  Home Health Agency OASIS Data, OEI-01-10-00460, 
February 2012. 

23 OIG,  Aberrant Medicare Home Health Outlier Payment Patterns in Miami-Dade  

County and Other Geographic Areas in 2008, OEI-04-08-00570, December 2009. 

Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   5 
   
   
Face-to-Face Encounter Documentation.   We selected a stratified random  
sample of 680 home health claims and requested from the HHAs the 
documentation of the corresponding face-to-face encounters.  To  
determine whether home health claims with matching E&M claims were 
more likely or less likely to meet the Medicare face-to-face requirement, 
we stratified the sample on the basis of whether the Part A home health 
claims had corresponding E&M claims.  
The first stratum included 340 claims that lacked corresponding E&M 
claims.  We received 313 face-to-face documents, a 92-percent response 
rate from this stratum.  The second stratum included 340 claims that had 
corresponding E&M claims.  We received 331 face-to-face documents, a 
97-percent response rate from this stratum.  We had a 95-percent total 
response rate for our data collection of face-to-face documents.24  We  
analyzed the extent to which the documents confirmed encounters.  We  
also analyzed the face-to-face document to determine the extent to which  
it met the required elements.  We compared the percentages of face-to-face 
documents with E&M visits and those without them.  
We found no relationship between the presence of an E&M claim and the 
likelihood that home health agency submitted the face-to-face 
documentation.  Thus, we present data in the aggregate.  All results are 
weighted to the proportion of the stratum in the population.  
Interviews and Document Review  
We conducted structured interviews with the four Home Health and 
Hospice Medicare Administrative Contractors (HH MACs) regarding how 
they ensure that HHAs meet the face-to-face requirements.  We reviewed 
guidance documents or policies from CMS and the HH MACs about 
monitoring the face-to-face requirement.  
Limitations 
This study did not assess the necessity of home health services, and we did 
not make clinical determinations about the appropriateness of the narrative 
portion of the face-to-face document.  We limited our analysis to 
describing this narrative text and the absence of required information.  We  
also did not independently verify that the information on the face-to-face 
documents was accurate or that the face-to-face encounters were related to 
the primary reasons that the beneficiaries needed home care.  
 
24 We will refer all HHAs that did not provide  copies of the face-to-face documents to 
CMS. 
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For a variety of reasons, an E&M claim corresponding to the home health 
beneficiarys face-to-face visit may not exist.  The physician may not have 
submitted a claim for the service, or the face-to-face encounter may have 
occurred outside of the physicians office.  For example, if the encounter 
occurred in the hospital, the certifying physician may use the hospital 
physicians documentation of that encounter.  In addition, the presence of 
an E&M claim alone does not fulfill the face-to-face requirement; the 
certifying physician must also complete the documentation confirming 
that visit.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   7 
   
   
FINDINGS 
For 32 percent of home health claims that required 
face-to-face encounters, the documentation did not 
meet Medicare requirements, resulting in $2 billion in 
payments that should not have been made   
Medicare requires as a condition for payment for home health services that  
physicians who certify home health eligibility provide appropriate 
supporting documentation of face-to-face encounters for the initial 
episodes of care. The face-to-face encounter alone does not satisfy the 
requirement; the certifying physician must also complete documentation 
that is clearly titled, signed, and dated.  Our review of claims for initial 
episodes of home health care showed that 32 percent either had no      
face-to-face documents or had face-to-face documents that lacked at least 
one of the required elements (see Table 1).  We found no difference 
between the home health claims that had corresponding E&M claims and 
the home health claims that did not in the percentage of claims that did not 
meet Medicare requirements.   
Face-to-face documentation was missing in 10 percent of 
claims 
The 10 percent of claims without face-to-face documents totaled  
$605 million.  The HHAs either confirmed when we asked them that they 
did not have those documents, or they sent other documents, such as 
physicians orders, home health referrals, and inpatient notes, which do 
not meet Medicares requirements if not appropriately titled as the 
face-to-face documentation. 
Of the face-to-face documents that were submitted, 25 percent 
were missing one of the required elements 
The most commonly missing element was the signature of the certifying 
physician. Seventeen percent ($941 million) of the face-to-face 
documents were signed by persons other than the certifying physicians.  
Medicare regulations allow attending physicians who cared for the 
patients in a recent acute-care or post-acute-care setting, or nonphysician 
practitioners working with the certifying physicians, to conduct the exams.  
However, the certifying physician must document that the encounter took 
place, regardless of who performed the encounter.  For 10 percent of 
documents, we were unable to determine whether the signature was that of 
the certifying physician because the physicians printed namewhich is 
not a required elementwas missing.  (We did not consider these 
documents to be missing in our calculations.)  The remaining elements 
an encounter date within the required timeframe, an appropriately titled 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   8 
   
   
document, the date of the encounter, the date the physician signed the 
document, and the existence of a physicians signature (from either the 
certifying physician or another physician)were missing much less often.  
(See Appendix A  for examples of face-to-face documents.)25  
Table 1: Home Health Documents That Did Not Meet Medicare 
Requirements 
Percentage Missing  Claim Amount  
Medicare Requirement  
From Document*  (in Millions) 
Face-to-Face Documentation  10%   $605.3  
Elements Required for Face-to-Face  Percentage Missing  Claim Amount  
Documentation   From Document   (in Millions)  
Signature of Certifying Physician  17%   $941.1  
Date of Encounter Within the Required Timeframe  4%   $310.7  
Appropriate Title  3%   $150.2  
Date of Encounter   2%   $118.8  
Date When Physician Signed Document   2%   $106.7  
Physician Signature**  1%   $42.3  
Total Claims Missing the Face-to-Face Document 
32%   $2,037.0  
or Elements of the Face-to-Face Document***  
    Source:  OIG analysis of  face-to-face documents, 2013. 

*All percentages significant at  the p<.05 level. 

**Physician signature left blank. 

***Does not add because of overlapping errors. 

Physicians inconsistently completed the narrative 
content on the face-to-face documentation  
The face-to-face documentation must include a brief narrative that 
describes that patients clinical condition and the way in which the 
patients clinical condition supports his/her homebound status and the 
need for skilled services.   This can be accomplished in as little as three 
sentences. CMS provided the following example in a guidance document: 
The patient is temporarily homebound secondary to status post 
total knee replacement and currently walker dependent with 
painful ambulation.  PT [physical therapy] is needed to restore the 
ability to walk without support.  Short-term skilled nursing is 
needed to monitor for signs of decomposition or adverse events 
 
25 These are examples of face-to-face documents collected during this study.  We are not 
expressing an opinion whether these  examples meet Federal requirements. 
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from the new COPD [chronic obstructive pulmonary disease] 
medical regimen. 26  
Physicians can document this information in a variety of ways.  Some  
physicians use separate statements for each need for skilled services and 
reason that patient is homebound (see Appendix A-1).  Others write one 
combined statement similar to the CMS example (see Appendix A-5).  
CMS gives physicians discretion as to how they document this 
information; however, CMS will consider the face-to-face documentation 
incomplete without this narrative.  Because the face-to-face requirement is 
a Medicare condition of payment, CMS will deny the payment for the 
initial and all subsequent episodes of care.27   
Narratives did not always appear to follow CMS guidance for 
describing homebound status and necessity for skilled 
services 
Some face-to-face documentation failed to specify why the patient was 
homebound or to include the reason the skilled service was necessary.  In 
those face-to-face documents that had separate statements for each piece 
of the narrative, 12 percent were missing narratives supporting the 
patients homebound status and 6 percent were missing narratives 
regarding the need for skilled services.28   
Some of the language in the narratives does not appear to conform to 
guidance about what constitutes appropriate and sufficient documentation.  
CMS and its contractors released guidance that included examples of 
language that would be considered inappropriate if used alone.29, 30 (See 
Table 2 for examples.)  We found that, in their descriptions of the 
beneficiaries homebound status, 16 percent of documents said that the 
beneficiaries were weak and 14 percent said that the beneficiaries were  
unable to leave home unassisted.  (See Table 3 for the reasons most 
commonly cited in the narrative text.)   
 
26 CMS, Home Health Face-to-Face Question & Answer, February 28, 2013.  Accessed 
 
at http://www.cms.gov on August  7, 2013. 

27 Ibid. 

28  Because we did not render an  opinion about the appropriateness of the narratives, we 

did not determine whether these face-to-face documents failed to meet CMS 

requirements. 

29 CMS, Home Health Face-to-Face Question & Answer, February 28, 2013.  Accessed  
at http://www.cms.gov on August  7, 2013. 

30 CGS, Face-to-Face Documentation for Home Health Certification: Important  

Information for Certifying Physicians  and Nonhysician Practitioners.   Accessed at 

http://www.cgsmedicare.com/ohb/pubs/mb_J15/2013/08_2013/index.html  on August 7,
  
2013. 

Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   10 
   
   
Table 2:  CMS Contractors Examples of Text That Is Insufficient To 
Support Home Health Claims  
 
Text Insufficient To Support  Text Insufficient To Support 
Homebound Status   Need for Skilled Services  
 
Weak  Family is asking for help  
 
Unable to drive   Continues to have problems  
 
Unable to leave home   List of tasks for nurse to do 
 
Dementia or confusion  Patient unable to do wound care  
 
Functional decline  Diabetes 
Source:  CGS,  2013 Face-to-Face Documentation  for Home Health Certification:  Important  Information for  
 
Certifying    Physicians and Non-physician Practitioners.  
       
 
Table 3:  Most Commonly Used Narrative Text Supporting 
Homebound Status 
Percentage of Narrative Texts That 
Characteristic  
Cited Characteristic  
Taxing effort to leave home   17%  
Weakness/fatigue  16%  
Unable to leave home unassisted  14%  
Unsteady gait/risk of falls  13%  
Decreased mobility   10%  
Shortness of breath/dyspnea   9%  
Poor endurance   7%  
 
Source:  OIG analysis of  face-to-face documents, 2013. 
 
The most commonly used phrase was taxing effort to leave home.   
Physicians used this phrase in 17 percent of face-to-face documentation to  
explain their patients homebound status.  In fact, in about half of those 
documents, the physicians did not list any other reasons.  The phrase 
taxing effort to leave home is included in CMSs definition of 
homebound, and, therefore, offers no specific statement about the patients 
condition.31    
 
31  MBPM,  ch. 7,  30.1.1.  
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Some of the language in the narratives was similar to the language that 
CMS and its contractors cited as inappropriate.  Moreover, the 
combinations of many of these phrases in the same document raised 
questions about whether using multiple phrases that are considered 
inappropriate individually constitutes a narrative that CMS and its 
contractors would find sufficient to justify the need for home health when 
used together. 
HH MACs vary as to whether they accept forms with 
checkboxes in the face-to-face documentation 
HH MACs appear to interpret CMSs guidance on forms with 
checkboxesi.e., forms that list several possible conditions or 
characteristics, with a box next to each that the physician can mark with a 
checkdifferently.  CMS allows forms with checkboxes in limited 
situations; however, the option next to each checkbox must contain the 
physicians assessment specific to that patient.  In our interviews, one of 
the four HH MACs offered that it does not accept forms with checkboxes 
unless the physician writes additional information. 32   Another HH MAC 
said that it looks at each form on a case-by-case basis and makes its 
determination, in part, on the basis of whether the form was designed by 
the HHA or the physician.  The use of checkboxes in some forms also 
raised questions about the extent to which the narrative content meets 
Medicare requirements.  Six percent of face-to-face documents used 
checkboxes on the forms.  (See Image 1.)   
Image 1: Checkboxes on Face-to-Face Document 
  I certify that my clinical findings support that this patient is homebound (i.e., absences 

from the home require a taxing effort, are for medical appointments and services, or are 

  infrequent and of short duration for other reasons such as religious services, etc.) as 

evidenced by: 
 
 
 	  Patient is unable to drive (permanently or temporarily) due to current illness, 
surgery, or debility  
 
 	  Patient is non-weight bearing or requires assistance/assistive device(s)  
  	   Patient requires constant  supervision  for safety reasons (either cognitive or  
functional, or  both) 
Some face-to-face documents contain elements that, 
	   Patient has a mental health diagnosis that prevents their ability to leave home  
although not required by Medicare, provide 
	   Other:_____________________________________________________  
information that could be useful 
 
Source:  Example from OIG face-to-face document review, 2013. 
 
 
32  CMS does not allow checkboxes created  by HHAs.  CMS does allow checkboxes 
created by  physicians or  generated from  physicians electronic health records.  CMS,  
Home Health Face-to-Face Question  &  Answer, February 28, 2013.  Accessed at 
http://www.cms.gov on March 12, 2014.  
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   12 
   
   
Some face-to-face documents contain elements that, 
although not required by Medicare, provide 
information that could be useful  
Medicare requirements specify which elements must appear on the 
face-to-face document; however, additional elements could add clarity to 
the document.     
NPI.  Seven percent of documents listed the certifying physicians NPIs.  
Including this number makes it easier to identify the physician, especially 
when the handwriting is illegible. The printed names of the physicians 
were illegible in 4 percent of the documents. 
Printed Name of Physician. In addition to the required physician 
signature, most documents included the printed (either handwritten or 
typed) names of those physicians.  Ten percent of face-to-face documents 
were missing a printed name.  Many signatures were illegible, and a 
printed name may be the only way to identify the certifying physician.  
Name of Nonphysician Practitioner.  Medicare regulations allow a 
nonphysician practitioner to complete the face-to-face encounter.  Five  
percent of documents provided a dedicated space to identify those 
individuals. 
Letterhead of HHA or Hospitals.  Slightly over half (58 percent) of the 
documents contained the letterheads of either the HHAs or the hospitals.  
This could indicate that these facilities use standardized forms for the 
physicians to complete.  
List of Home Health Services Needed. Most face-to-face documents had 
checkboxes to indicate a need for nursing (81 percent), physical therapy 
(80 percent), or speech/language pathology (76 percent).  Far fewer 
documents included checkboxes for occupational therapy (36 percent), 
home health aide services (21 percent), or a medical social worker 
(20 percent).  (See Image 2 for an example.) 
Image 2: List of Home Health Services Needed 
 
I certify that, based  on my findings, the following  services are medically 

reasonable and necessary:  
 
 
   Skilled Nursing   
     Physical Therapy  
   Speech Language Pathology   
 
   Occupational Therapy  
     Medical Social  Worker Consult  
   Home Care Aide (for personal care)  
 
 Source:  Example from OIG analysis of face-to-face documents, 2013.  
 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   13 
   
   
CMS oversight of the face-to-face requirement is 
minimal  
CMS does not have a specific program to oversee compliance with the 
requirement for face-to-face documentation.  Instead, it reviews the 
documentation when it conducts a medical record review as part of its 
general effort to deter and detect home health fraud.  Because the 
face-to-face encounter is required for the initial episodes only, just a 
fraction of those reviews would include the face-to-face document.33   
In their medical record reviews, the four HH MACs do not verify the 
information on the face-to-face documents.  In particular, they do not 
confirm that the physician who signed the document is actually the 
certifying physician. HH MACs cited lack of access to Medicare Part B 
physician claims and limited time and resources as major reasons why 
they do not verify the information.   
Although they do not verify the face-to-face document, the HH MACs do 
offer guidance and training on the requirement.  All four HH MACs point 
to training that they offer HHAs about the face-to-face requirement, 
including Web sites, Web seminars, and provider presentations.  Two     
HH MACs also reached out to the physician community in an attempt to 
address problems they have seen, such as insufficient narratives and 
failure to sign and date the documents.  However, in our interviews with 
HH MACs, they told us that they are limited in their interactions with 
physicians, because activities such as training for those providers are not 
the responsibility of the HH MACs. 
Like the HH MACs, HHAs rely on physicians accurately completing the  
face-to-face documents.  All four HH MACs reported that HHAs had 
expressed frustration about the burden that the face-to-face document 
imposes.  HHAs are held financially accountable for failure to obtain the 
face-to-face documentation but have no authority to compel physicians to 
complete it either timely or accurately. 
   
 
33 Reviews of claims for continuing home health care do not require a face-to-face visit. 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   14 
   
   
CONCLUSION AND RECOMMENDATIONS 
Home health fraud has been well documented, and efforts to uncover it are 
ongoing. In July 2013, CMS issued a temporary moratorium on new 
home health providers in parts of Florida and Illinois to fight fraud in 
Medicare.34  As another fraud prevention strategy, Medicare also requires 
as a condition of payment that a beneficiary have a face-to-face encounter 
with the physician, or certain practitioners working with them, who 
initially certified that patient for Medicare home health services.  
However, our findings show that 32 percent of claims for home health 
services that required face-to-face encounters did not meet Medicare 
requirements, resulting in $2 billion of payments that should not have been 
made.   
We also found that CMS lacks an adequate oversight mechanism to ensure 
that this face-to-face requirement is met.  Ensuring that an oversight 
mechanism is in place will also prove instructive for CMS as it 
implements a similar face-to-face requirement for durable medical 
equipment in the future.  
We recognize that the very design of the Medicare home health payment 
system makes oversight of the face-to-face requirement difficult.  Four 
HH MACs process Part A and B home health claims.  However, the actual 
physician encounter that would establish the face-to-face eligibility is 
covered under Part B, which may be administered by a separate MAC.  As 
a result, matching claims associated with one beneficiary under the two 
separate systems is not readily achievable.  In addition, HHAs, which are 
required to obtain the face-to-face documents in order to receive payment, 
have no authority to compel physicians to complete and sign the 
documents. 
As a way to help bridge this gap and to further the intent of the 
face-to-face requirement, we recommend that CMS:  
Consider requiring a standardized form to ensure that 
physicians include all elements required for the face-to-face 
documentation  
To enhance oversight and to clarify completion of the required elements, 
CMS should consider requiring the use of a standardized form to serve as 
the face-to-face documentation.  Because over half of the face-to-face 
documents are completed using standardized forms from hospitals or 
HHAs, this should not be a significant adjustment for most physicians.   
 
34  78  Fed.  Reg. 46339 (July 29, 2013). 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   15 
   
   
Develop a specific strategy to communicate directly with 
physicians about the face-to-face requirement  
CMS needs to provide additional formal training and outreach about the 
importance of completing the face-to-face document.  Because HH MACs  
responsibility to conduct provider outreach does not extend to physicians, 
HH MACs are not directly training physicians.  It is therefore incumbent 
upon CMS to identify ways to educate the physician community about the 
requirements. 
Develop other oversight mechanisms for the face-to-face 
requirement 
Relying on medical record reviews to ensure that HHAs are meeting the 
face-to-face requirement is clearly not sufficient.  CMS could work with 
the various payment contractors to develop other review procedures to 
ensure compliance.  This charge has heightened importance given CMSs 
plans to implement the face-to-face requirement for durable medical 
equipment. 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   16 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all three of the recommendations in this report. To 
address our first recommendation, CMS stated that it will consider 
whether requiring a standardized form will help resolve issues identified in 
our report. We recognize that using a standardized form may eliminate 
some flexibility for physicians; however, CMS must ensure that all 
required elements are present on the face-to-face document. 
To address our second recommendation, that CMS develop a specific 
strategy to communicate directly with physicians about the face-to-face 
requirement, CMS plans to issue additional educational materials to 
physicians. 
To address our final recommendation, CMS stated that it is implementing 
an oversight plan through the Supplemental Medical Review Contractor 
(SMRC).  CMS will have the SMRC conduct document-only reviews for 
every HHA in the country to validate a sample of the face-to-face 
encounters. 
Lastly, we withdrew a recommendation from our draft reports that CMS 
require physicians to include their NPIs on the face-to-face document.  As 
of July 1, 2014, CMS will require that HHAs report the NPI of the 
certifying physician and the physician who signed the plan of care, if 
different from the certifying physician.35  We believe that this new 
requirement satisfies our original recommendation without imposing any 
additional burden. 
For a full text of CMSs comments, see Appendix C. 
     
 
35 CMS Manual System, Pub. No. 100-04, Medicare Claims Processing, Transmittal 
2789, Change Request 8441, Sept. 20, 2013. 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   17 
   
   
 
APPENDIX A-1: SAMPLES OF FACE-TO-FACE DOCUMENTS 

  
 
 
 
 
 
 
 
 
 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  18 

   
   
APPENDIX A-2 

 
 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  19 

   
   
APPENDIX A-3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  20 

   
   
APPENDIX A-4 

 
 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  21 

   
   
APPENDIX A-5 

 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  22 

   
   
APPENDIX A-6 

 
 
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  23 

   
   
APPENDIX B  CONFIDENCE INTERVALS 

   
 
 
  Characteristic   Sample Size   Percentage  
  (95-Percent Confidence 
  Interval) 
 
 
 
  Claims that did not meet the face-to-face  32.2% 
  requirement   644 
  (28.4%36.0%)  
 
 
  Claims without face-to-face  9.7% 
  documentation   644  (7.2%12.1%)  
 
 
  Face-to-face documents that were   25.0%  
  missing at least one required element  583 
  (21.2%28.6%)  
 
 
  Face-to-face documents without   2.8%  
  appropriate titles   583 
(1.5%4.2%)  
 
 
  Face-to-face documents that were not  2.0%  
 
  dated by physicians   583  (0.2%1.8%)  
 
 
  Face-to-face documents missing dates of  1.6%  
  face-to-face encounters   583 
  (0.5%2.7%)  
 
 
Face-to-face documents not signed by    1.0%  
physicians  583 
(0.2%1.8%)  
Face-to-face documents not signed by   17.0%  
certifying physicians   583 
(13.8%20.2%)  
Face-to-face documents not completed  4.2%  
within the required timeframe   583 
(2.5%6.0%)  
Face-to-face documents not dated by   2.0%  
physicians  583 
(.9%3.2%)  
Face -to-face documents lacking printed 
13.7%  
names or contraining llegible printed 
583 
names for the signing physicians  (10.7%16.7%)  
Face-to-face documents using  6.1%  
checkboxes  583 
(4.0%8.1%)  
  Source:  OIG  analysis of face-to-face  documents, 2013                                                    Contd  
   
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   24 
   
   
 
 
 
 
     
Characteristic  
  Sample Size   Percentage  
(95-Percent CI)  
 
  Face-to-face documents for which it was 
11.9%  
not possible to determine whom the 
583 
 
signatures belonged to   (9.0%14.7%)  
 
  Face-to-face documents missing at least  21.5%  
one required element  583 
  (18.0%25.0%)  
  Face-to-face documents missing 
11.9%  
narrative justifying beneficiaries 
  583 
homebound status  (9.0%14.7%)  
 
  Face-to-face documents without narrative  5.9%  
  for beneficiaries need for skilled services   583  (3.9%7.9%)  
 
Face-to-face documents with narrative 
  17.3%  
citing taxing effort for beneficiaries to 
583 
  leave home  (14.0%20.6%)  
 
Face-to-face documents with narrative  16.0%  
 
listing beneficiaries weakness/fatigue   583 
(12.9%19.2%)  
 
  Face-to-face documents with narrative 
14.2%  
  describing beneficiaries as unable to  583 
leave home unassisted   (11.2%17.3%)  
 
  Face-to-face documents with narrative  13.1%  
  listing beneficiaries unsteady gait   583 
(10.2%16.1%)  
 
  Face-to-face documents with narrative  9.6%  
listing beneficiaries  decreased mobility    583 
  (7.1%12.2%)  
 
Face-to-face documents with narrative 
  listing beneficiaries shortness of  9.0%  
583 
  breath/dyspnea   (6.4%11.5%)  
 
Face-to-face documents with narrative  6.0%  
  listing beneficiaries poor endurance   583 
(4.6%8.1%)  
 
 
Face-to-face documents listing the  6.8%  
  physicians NPIs  583 
(4.6%9.1%)  
 
  Face-to-face documents with illegible  4.1%  
  printed names for the signing physicians  583 
(2.2%5.8%)  
 
 
  Source:  OIG  analysis of face-to-face  documents, 2013                                                     Contd  
                     
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   25 
   
   
 
 
 
   
     
Characteristic  
  Sample Size   Percentage  
  (95-Percent CI)  
 
Face-to-face documents with a space to  5.0%  
 
list a nonphysician practitioner   583 
  (3.2%6.7%)  
 
  Face-to-face documents with letterhead  58.3%  
  of hospitals or HHAs  583  (54.1%62.6%)  
 
 
Face-to-face documents with a checkbox  81.4%  
  for nursing   583 
(78.0%84.8%)  
 
 
Face-to-face documents with a checkbox  79.7%  
 
for physical therapy   583 
  (76.3%83.2%)  
 
  Face-to-face documents with a checkbox  76.2%  
  for speech therapy   583  (72.5%79.9%)  
 
 
Face-to-face documents with a checkbox  36.1%  
  for occupational therapy  583 
(32.0%40.3%)  
 
 
Face-to-face documents with a checkbox  20.9%  
 
for home health aide services  583 
  (17.4%24.4%)  
 
  Face-to-face documents with a checkbox  19.8%  
  for medical social worker  583  (16.4%23.2%)  
 
Source:  OIG analysis of  face-to-face documents, 2013      
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   26 
   
   
  Table B1:  Claims That Should Not Have Been Paid 
 
 
 
   
 
  Reason Claim Should Not Have  Been   
Dollars  
  Paid  Sample Size  
(95-Percent Confidence 
  Interval) 
 
 
  Claim did not meet Medicare  $2,027.0  
  requirements  644  ($1,728.7$2,325.3)  
 
  Claim did not provide a face-to-face   $605.3  
  document  583 
($479.5$731.1)  
 
  Face-to-face document was signed by   $941.1  
  someone other than certifying physician   583 
($820.6$1,061.7)  
 
 
Face-to-face document was not  $310.7  
  completed within the required timeframe   583 
($222.1$399.2)  
 
 
  Face-to-face document did not have an  $150.2  
appropriate title  583 
  ($100.4$200.0)  
 
  Date of face-to-face encounter was  $118.8  
  missing   583 
($55.6$182.1)  
 
 
Face-to-face document was not signed  $42.3  
  by a physician  583 
($22.0$62.7)  
 
 
  Face-to-face document was not dated by   $106.7  
physician  583 
  ($60.6$152.8)  
Source:  OIG analysis of  face-to-face documents, 2013            
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   27 
  APPENDIXC 
Agency Comments 
DEPARThfENT OF HEALTH & HUMAN SERVICES 
Cantors for Modlcaro & Medicad Services 
~- - --~ ------------ ~--------~-~ --~ ~ =~ --~- ---
Atlmlttlstrator 
Washington, DC 20201 
DATE:  JAN 3 1 2014 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Marilyn Tavenner 
Administrator 
SUBJECT:  Otlice of Inspector General (O!G) Draft Report:  ''Limited Compliance with 
Medicare's Home Health Face-To-Face Documentation Requirements" 
(OEI-0 1-12-00390) 
Thank you for the opportunity to review and comment on the subject report.  Congress mandated 
face-to-face encounters in order to increase physician involvement with Medicare home health 
(1111) beneficiaries :md, as part of the certification for Medicare HH services, to assure a patient's 
eligibility for the Medicare HI! benefit. 
The OIG reports that 32 percent of HH claims that required a face-to-lace encounter did not meet 
Medicare requirements, either missing the face-to-face documentation altogether or lacking in at 
lt::ast one of the required elements. To address those inadequacies, OIG recommends that CMS 
consider requiring a st:mdardized form for documenting the physician encounter, conducting 
physician specific outreach, and evaluating alternative oversight mechanisms. The OIG's 
analysis and recommendations are focused on strengthening the HI-I face-to-face requirements to 
ensure that valid and meaningful physician involvement is occurring, and that the health care 
needs of Medicare HH beneficiaries are met. CMS appreciates OIG's analysis and 
recommendations, and will continue lo work with health care providers. specifically physicians, 
non-physician pmctit.ioners, and home health agencies (!!HAs), to help them comply with the 
HH face-to-face requirements 
The OIG recommendations and ClviS responses to those recommendations are discussed below. 
OIG Recommendation 
The OTG recommends that CMS consider requiring a standardized form to ensure that physicians 
document all clements required for the face-to-face documentation. 
Limited Compliance With Medicare's Home Health Face-to-Face Documentation Requirements  (OEI-01-12-00390)  28   
   
 
 
 
 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  29 
   
   
 
 
 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)  30 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Joyce Greenleaf, Regional 
Inspector General for Evaluation and Inspections in the Boston regional 
office; Russell Hereford, Deputy Regional Inspector General; and 
Kenneth Price, Deputy Regional Inspector General.  
Danielle Fletcher served as the team  leader for this study.  Other Office of 
Evaluation and Inspections staff from the Boston regional office who 
conducted the study include Amy Glynn.  Central office staff who 
provided support include Clarence Arnold, Heather Barton, 
Mandy Brooks, and Christine Moritz. 
 
Limited Compliance With Medicares Home Health Face-to-Face Documentation Requirements   (OEI-01-12-00390)   31 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General  
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.