ADULT HOME HEALTH CARE REFERRAL MRN # LAST NAME FIRST NAME BIRTHDATE SEX NATIONAL ORIGIN

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1 2000 Summer St NE, Ste 100 Minneaplis, MN ADULT HOME HEALTH CARE REFERRAL MRN # LAST NAME FIRST NAME BIRTHDATE SEX NATIONAL ORIGIN SOCIAL SECURITY # PHONE M F White Asian Pacific Black Eskim/Am Indian Unknwn Other APARTMENT # ADDRESS CITY ZIP HEALTH INSURANCE NAME OF POLICY HOLDER HEALTH INSURANCE # DATE FIRST VISIT NEEDED IS PATIENT/FAMILY AWARE OF REFERRAL EMERGENCY CONTACT (RELATIONSHIP) YES NAME PHONE # NO DIAGNOSES WITH ICD-9 CODES AND DATE OF ONSET Dx: ICD-10 CODE: DATE OF ONSET: Dx: ICD-10 CODE: DATE OF ONSET: Dx: ICD-10 CODE: DATE OF ONSET: REASON FOR REFERRAL SERVICES REQUESTED MEDICATIONS ALLERGIES DIET PRIMARY MD CLINIC NAME IS THIS MD WHO IS FOLLOWING PT? CLINIC PHONE SOCIAL WORKER/CASE MANAGER PHONE FAX TO

2 2000 Summer St NE, Ste 100 Minneaplis, MN PHYSICIAN FACE-TO-FACE ENCOUNTER DOCUMENTATION GUIDE The Centers fr Medicare and Medicaid Services (CMS) has utlined the dcumentatin requirements fr the Face-t-Face Encunter, which include a narrative with key data elements. This new rule ges int effect n January 1, In an effrt t assist yu with the required data pints, we have created this tl fr yur immediate use. Please see Face-t-Face Encunter Fact Sheet fr additinal details. Scenari: Mary Smith, an 83 year-ld female with a histry f CHF and hypertensin, presents with increased shrtness f breath, weight gain greater than 5 lbs this week, decnditined with increased weakness and questinable medicatin cmpliance. The Face-t-Face Encunter Narrative must be a separate and distinct sectin f r an addendum t the physician s rder/485 and must include the fllwing: Patient name and identificatin (if nt elsewhere n the page) A certificatin narrative that utlines: The date f the face-t-fact/in-persn visit with the physician r ther nnphysician practitiner (Nurse Practitiner, Clinical Nurse Specialist r Physician s Assistant) and that the visit was related t (cmpletely r in part) the medical cnditin fr which the patient requires hme health services Example: Patient was seen January 1, 2015 fr CHF which is the reasn fr hme care. The services requested (nursing and/r physical therapy and/r speech language pathlgy) are medically necessary and supprt the need fr the requested hme health services Example: My clinical findings supprt the need fr skilled nursing and physical therapy service. These services are medically necessary due t the fact Mary has gained mre than 5 lbs in ne week, has increased SOB, is decnditined with increased weakness, and is struggling with her medicatin cmpliance. The patient is hmebund (he/she exerts cnsiderable and taxing effrt t leave their residence fr medical reasns r religius services r infrequent utings f shrt duratin fr ther reasns) Example: Based n my clinical findings, this patient is hmebund because shrtness f breath limits ambulatin. The patient is under a physician s care nw, and while in the cmmunity, and the face-t-face visit was cnducted by the certifying physician r NPP and meets the requirements fr a face-t-face encunter Example: I certify that this patient is under my care and that I, r a nurse practitiner r physician s assistant wrking with me, had a face-t-face encunter that meets the physician face-t-face encunter requirements. The physician s signature and the date the narrative is signed. Thank yu in advance fr yur attentin t these new dcumentatin requirements. Please cntact us at if we can prvide additinal clarity r be f further assistance.

3 Face t Face Referral Frm & Instructins If Medicare is the payer surce fr the hme health services being rdered, the patient must meet the Medicare definitin f hmebund. Medicare definitin f hmebund: Absences frm the hme that require cnsiderable taxing effrt, are infrequent, and are f shrt duratin with the exceptin f medical appintments and religius services. Please nte: Orders placed by advanced practice prviders r unlicensed physicians must be csigned by a licensed physician t initiate hme care services. PLEASE BE SURE TO INCLUDE THE CLIENT S PRIMARY PHYSICIAN! Questin Answer Face t Face Encunter-I certify that a physician, NP, CNM, CNS, r PA had a face t face encunter with this patient. Date f encunter: Name f prvider wh perfrmed the face t face encunter: The encunter with the patient was in whle, r in part, fr the fllwing medical cnditin which is the primary reasn fr referral t hme health care services: Is the patient hmebund-there exists a nrmal inability fr the patient t leave hme; ding s wuld require a cnsiderable and taxing effrt. Hmebund Reasn (see descriptin & check all that apply) Yes, because f illness r injury there is a need fr assistive devices, the use f special transprtatin r assistance f anther persn. OR -Yes, there exists a medical cnditin such that leaving the hme is cntraindicated. OR - NO Shrtness f breath Weakness Decnditined Pain pst-surgical cnditin with pain lcatin Limitatins in ambulatin Deterirating mental status Unable t leave hme unsupervised Other (specify in cmments): Patient is hmebund and in need f hmecare fr shrtness f breath due t: CHF COPD Asthma The patient s cnditin f (specify in cmments):

4 Face t Face Referral Frm & Instructins Patient is currently limited in mbility and needs assistance f: Patient is Hmebund and in need f hmecare fr Weakness/ Decnditining due t: Walker Cane Crutches Wheelchair Assistance f anther CVA MI Prlnged Hspitalizatin Pst-surgical cnditin (specify in cmments): The patient s cnditin f (specify in cmments): Patient is hmebund and in need f hmecare fr pain pst-surgical cnditin due t: Back Hip Knee Chest Other (specify in cmments): Patient is hmebund and in need f hmecare fr limitatins in ambulatin due t: CVA MI Prlnged Hspitalizatin Pst-surgical cnditin (specify in cmments): The patient s cnditin f (specify in cmments): Patient is hmebund and in need f hmecare fr deterirating mental status due t: I certify that the clinical findings supprt the need fr intermittent skilled nursing, physical therapy r speech therapy services, r a cntinuing need fr ccupatinal therapy. Dementia Depressin Biplar Disrder Psychsis Anxiety The patient s cnditin f (specify in cmments): Yes Medical cnditin(s) that supprt the need fr skilled hme care services:

5 Face t Face Referral Frm & Instructins Please identify the physician (n residents, n APRN, n PA, nly authrized physicians) wh will fllw the patient in the cmmunity and sign the nging plan f care befre services will start: Physician name: Please identify the physician wh is certifying the patient's eligibility fr the hme health benefit. This is the physician fllwing the patient in the setting where the hme care rder is initiated. Is skilled nursing needed? (specify detail belw) Disease/Symptm assessment and /r teaching: Medicatin management assessment/teaching: Drain Care: Fley Catheter Care: Ostmy Care: Wund Care:(specify detail belw) Wund lcatin Wund type Wund care plan cleansing agent Wund care plan dressing Wund care plan tpical Wund care plan frequency Wund care plan ther instructins

6 Face t Face Referral Frm & Instructins Other Skilled Nursing need - Define in cmments Physical Therapy is needed fr this cnditin, r what cnditin? (Check if applicable) Yes- Evaluate and Treat Occupatinal Therapy is needed fr this cnditin, r what cnditin? Yes Evaluate and Treat Speech Therapy is needed fr this cnditin, r what cnditin? Yes Evaluate and Treat Other hme care services (chse all that apply): Medical Scial Wrker Hme Health Aide