Thank you for the guidance. Can we talk through an example?
Many of our referrals come from the hospital system so we use hospitalist H&P as F2F. If we get a referral from the discharge planner stating that they anticipate a client will need PT & OT, then send the hospital DC paperwork with a referral for home health that does not list any specific disciplines or treatments, we as an agency would then contact the community PCP to verify that they will sign the HH POC (485). At that point, would it be up to us (Clinical Manager, say) to decide to schedule SOC with PT based on clinical info provided? Do we have the ability to ask the PCP for RN SOC if we deem that to be clinically indicated?
It is our practice to complete the initial and comprehensive assessments at the same visit, so it would be a significant change in practice if we were to send a nurse for the initial then schedule SOC at a later date (though I can see the benefit in some cases.)
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Holly Johnson
Columbine Poudre Home Care
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Original Message:
Sent: 11-19-2025 09:58 AM
From: Mary Carr
Subject: HH Referral Order Requirements
There is no requirement to include all ordered disciplines on the F2F encounter. Nor is there a requirement for the encounter to include a narrative that supports homebound and the need for skilled services . The narrative was eliminated in 2015. Currently, the F2F encounter must include the following: Be conducted 90 days before or 30 days after the SOC, be related to the primary reason for home health services, be conducted by an allowed practitioner, and the certifying physician or allowed practitioner must also document the date of the encounter.
Documentation in the certifying physician or allowed practitioner's medical records and/or the acute /post-acute care facility's medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined. The link below is to the Medicare Benefit Policy Manual, chapter 7, scroll to section 30.5.1 - Physician or Allowed Practitioner Certification. This is where the discussion on the F2F encounter requirements and supporting documentation begins.
Medicare Benefit Policy Manual
Also, there is no requirement for the referring practitioner to be enrolled in PECOS unless they are also ordering services.
Original Message:
Sent: 11/18/2025 12:34:00 PM
From: Toi Riggs
Subject: RE: HH Referral Order Requirements
My understanding is that in order for the F2F requirements to be met, each discipline has to be listed with a reason for it. Why they are homebound and who will be doing follow up care (signing orders etc). We get lucky here because we are so small that typically we can send a request for an addendum to be added pretty quickly. We also do trainings with providers to help them understand what we need. It would be much easier if it could all just be on an individual form like in the past. We accept patients even without the information as it is typically in the DC summary and we have 30 days to get it. But again, the F2F should be listing all of that information so the need for a separate order is probably just extra?
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Toi Riggs
Chadron Community Hospital Home Health Services/Hospice
Original Message:
Sent: 11-17-2025 06:55 PM
From: Holly Johnson
Subject: HH Referral Order Requirements
I am looking for clarification on what is required in a physician/provider order to initiate home health care services. It is our practice to require a signed order specifying which disciplines are ordered (along with F2F and med list) prior to initiating home health services. This can be a barrier to care; often we receive a signed order that just says "Home Health" but does not specify RN, PT, OT, etc and it is very difficult to get that changed after the client has discharged from the hospital. I've read the CoPs and OASIS Guidance Manual but have not found an answer to this question. Are we being too restrictive? What is considered best practice?
Also, does the referring provider (hospitalist, say) have to be PECOS enrolled if they will not be signing the 485?
Thanks in advance.
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Holly Johnson
Columbine Poudre Home Care
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