The documentation of clinical findings by the physician/nonphysician practitioner should show:
- The encounter was related to the primary reason for home care;
- How the patient’s condition supports the patient’s homebound status; and
- How the patient’s condition supports the need for skilled services
Acceptable face-to-face documentation does not have to be lengthy or overly detailed. However, the face-to-face documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.