FACE to FACE ENCOUNTER ATTESTATION - EXAMPLES
EXAMPLES OF ACCEPTABLE DOCUMENTAION TO JUSTIFY SKILLED NURSING
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Patient has several unhealed/complicated surgical wounds that require skilled nursing to provide wound care and
education on integumentary status
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Patient needs wound care to buttocks until wound is either healed or family/caregiver is able to perform
unsupervised
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Skilled nursing is needed to assess the effects of new medication and teach side effects to patient or caregiver
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Teach patient/family/caregiver signs and symptoms of newly diagnosed CHF including medication compliance,
diet, when to contact physician.
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Patient currently has several unhealed/complicated surgical wounds that require skilled nursing to provide
wound care and education on integumentary status.
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Patient is newly diagnosed diabetic and requires insulin administration and teaching due to limited cognitive and
physical impairments resulting in complicated treatment plan
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Patient is at high risk for rehospitalization, skilled nursing is needed for observation and assessment for signs of
worsening of condition or adverse events from new medical regimen
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Patient recently hospitalized for COPD exacerbation, skilled nursing needed for monitoring respiratory status and
med management
EXAMPLES OF ACCEPTABLE DOCUMENTATION TO JUSTIFY SKILLED THERAPY
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Physical therapy is needed for patient following right total knee arthroplasty to provide gait training,
strengthening and exercises to improve mobility, provide fall and injury prevention to enable patient to return to
prior level of function
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Physical therapy is needed for recent decline in functional status to provide gait training and strengthening.
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Occupational therapy needed for bathroom safety training, evaluate for appropriate adaptive equipment, provide
home exercise program and upper extremity strengthening to restore patient’s ability to dress independently

Speech therapy needed to evaluate patient for swallowing difficulties following recent stroke and educate patient
and family re: S/S of aspiration and provide instructions to prevent aspiration
EXAMPLES OF CMS ACCEPTABLE DOCUMENTATION TO JUSTIFY HOMEBOUND STATUS
Note both Criteria-One and Criteria-Two must be completed.
Criteria-One:
Describe what assistive devices the patient is dependent on (if any) & specifically why the patient’s
condition warrants special transportation or the assistance of another person OR describe the condition that makes
leaving home medically contraindicated:
 Patient is temporarily homebound secondary to right total knee arthroplasty and currently walker dependent
with limited painful ambulation
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Patient is unable to ambulate on uneven surfaces, is high fall risk and requires use of a four wheel walker
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Patient is paralyzed from recent stroke and is unable to ambulate safely, requires wheelchair for home mobility
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Patient is blind and/or senile, requires the assistance of another person when leaving place of residence
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Patient is homebound due to pain limiting ability to ambulate safely and independently, is currently wheelchair
dependent
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Patient is homebound due to shortness of breath when ambulating greater than 20 feet, unsteady gait and
requires a four wheel walker making it a great effort and taxing to leave their home
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Patient had several recent falls in the home requiring physical therapy services to evaluate for assistive devices
for safety and gait training. Patient is homebound due to significant leg pain and unsteady gait
AND
Criteria-Two:
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Describe why the patient has a normal inability to leave home and why leaving home must require a
considerable and taxing effort:
Patient is homebound due to advanced dementia, poor safety awareness and high fall risk
Patient is homebound due to recent hospitalization for pneumonia and is short of breath when walking short
distances, unsteady gait, and unable to ambulate without assistance of another person
Patient just returned from hospital stay involving surgery, is suffering from resultant weakness and pain.
Physician has restricted and limited patient’s activities such as getting out of bed for short periods of time,
walking stairs only once daily
Patient is homebound due to severe leg pain secondary to even slight exertion following recent falls at home
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Does NOT support homebound status if used alone:
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Confusion, unable to get out of the home alone
Weak, unable to drive, frail
Unable to safely leave home unassisted
Poor ambulation/ fall risk
SOB upon exertion
• Homebound per CMS guidelines (need specifics)
• Unable to leave home due to Fx hip/surgery
• Dependent upon adaptive devices
• Medical restrictions
• Requires assistance to ambulate