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What is a Face-to-Face Sheet?

Published in Medical Documentation 3 mins read

A "face-to-face sheet" isn't a standardized document with a universally agreed-upon definition. The term refers to various types of documentation resulting from an in-person meeting or encounter. The content and purpose vary greatly depending on the context. Here are some interpretations:

1. Medical Documentation of an In-Person Visit

In healthcare, a "face-to-face sheet" or encounter note often summarizes an in-person consultation between a patient and a healthcare provider. This documentation is crucial for medical billing and record-keeping. It typically includes:

  • Brief narrative: Describing the reason for the visit.
  • Head-to-toe assessment: A physical examination summary.
  • Vital signs: Measurements like blood pressure, heart rate, and temperature.
  • Medication list: A record of current medications.
  • Diagnosis codes: Codes identifying the patient's conditions.
  • Treatment performed: Procedures or interventions conducted.
  • Review of systems assessment: A check of various body systems.

This type of "face-to-face sheet" is essential for Medicare home health services, as mandated by the Affordable Care Act (ACA) as a condition for payment. [Source: Medicare Home Health Face-to-Face Requirement, https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/downloads/face-to-face-requirement-powerpoint.pdf] Some agencies use specific forms for this purpose. [Source: Face-to-Face Encounter Form, https://elitehc.net/wp-content/uploads/2017/02/Home-Health-Care-Face-to-Face.pdf] Failure to document this properly can lead to claim denials. [Source: Home Health Denial Fact Sheet: Denial Reason 5HC01: Missing ..., https://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5HC01_factsheet.pdf]

2. Other Contexts for "Face-to-Face" Documentation

The term might also appear in other settings, referring to a record of an in-person meeting. For example:

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