Progress Note Draft Template


Progress Note Guidance
The purpose of this Progress Note is to assist the Physician, and/or Medicare allowed Non-Physician
Practitioner (NPP)*, in documenting patient eligibility for the Medicare home health benefit. This document can
be placed in the “progress notes” section of the patient’s medical record. The use of this Progress Note is
entirely voluntary/optional and is intended ONLY to assist the physician or allowable Medicare NPP in
documenting patient eligibility (i.e. the encounter and homebound status of the patient.)
The completion of this Progress Note alone will not substantiate eligibility for the Medicare Home Health
Medicare Home Health Services Patient Eligibility Certification Requirements:
The face-to-face encounter is one of several requirements for the initial certification of eligibility for Medicare
home health services. For the initial certification of eligibility for Medicare home health services, a physician
must certify (attest) that the patient meets all of the following criteria:
1. The patient is, or was, confined to the home at the time home health services were furnished;
2. The patient needs, or needed, skilled services;
3. The patient is under the care of a physician;
4. The patient is receiving or received home health services while under a plan of care established and
reviewed by a physician; and
5. The patient has had a face-to-face encounter that:
• occurred no more than 90 days prior to the home health start of care date or within 30 days of
the start of the home health care;
• was related to the primary reason the patient requires home health services; and
was performed by a physician or allowed non-physician practitioner.
The certifying physician must also document the date of the encounter.
Who Can Complete this Progress Note:
The following practitioners are eligible to satisfy the face-to-face encounter requirement described in #5 above
and may complete this Progress Note:
1. The physician who certifies the patient’s eligibility for home health benefit/services;
2. A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which
the patient was directly admitted to home health; or
3. A Medicare allowed NPP*, defined as a nurse practitioner, clinical nurse specialist, certified nurse
midwife or a physician assistant (as those terms are defined in section 1861(aa) (5) of the Social
Security Act).
The Home Health agency cannot complete this form and send to the physician for his signature.
The Patient’s Medical Record is the Basis for Certification:
The certifying physician shall use the patient’s medical record as a basis for certification of home health
eligibility. Therefore, in cases where an eligible entity other than the certifying physician completes the face-to-
face encounter, the certifying physician may review, sign-off (evidencing his/her review) and incorporate the
completed Progress Note into the patient’s medical record held by the certifying physician.


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