The face-to-face encounter is a condition of payment for Medicare home health. Under 42 CFR 424.22(a)(1)(v), the certifying practitioner attests that an encounter happened, that it related to the primary reason for home health, that it fell inside a window around the start of care, and that an allowed provider type performed it.
This page is for the intake coordinator asking whether the encounter in a referral packet is valid. For the overview, see who qualifies for home health care and referral to first visit.
The regulation is 42 CFR 424.22 as amended by the CY 2026 home health final rule (90 FR 55342), which says "These regulations are effective on January 1, 2026." The guidance is the Medicare Benefit Policy Manual, chapter 7, sections 30.5.1 through 30.5.1.2 and 30.5.3.
The Rule, Word for Word
"A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, 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 and was performed by physician or non-physician practitioner defined in paragraph (a)(1)(v)(A) of this section. The certifying physician or certifying allowed practitioner must also document the date of the encounter as part of the certification."
Four checks: who did it, when, what it was about, and whether the date is on the certification.
Two Lists: Who Performs, Who Certifies
Who certifies: 424.22 says "a physician or allowed practitioner as defined at § 484.2 of this chapter certifies," and 484.2 says "Allowed practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as defined at this part."
Who performs: 424.22(a)(1)(v)(A) says "The face-to-face encounter must be performed by one of the following" and lists five.
| Practitioner | May perform the encounter | May certify | Source |
|---|---|---|---|
| Physician (as defined at 484.2) | Yes | Yes | (v)(A)(1); 484.2 |
| Nurse practitioner | Yes | Yes | (v)(A)(2); 484.2 |
| Clinical nurse specialist | Yes | Yes | (v)(A)(3); 484.2 |
| Physician assistant | Yes | Yes | (v)(A)(4); 484.2 |
| Certified nurse-midwife | Yes, "as authorized by State law" | No | (v)(A)(5); 484.2 |
| Any of these with a financial relationship with your agency | Not unless an exception applies | Not unless an exception applies | 424.22(d) |
The nurse-midwife is the asymmetry. A midwife's visit can be the encounter, but a physician, NP, CNS or PA has to certify and document its date.
The financial bar covers both jobs. Under 424.22(d)(1), a practitioner with a financial relationship with the agency may not "certify or recertify" or "conduct the face-to-face encounter" unless an exception applies. Paragraph (d)(2) extends it to nonphysician practitioners.
One certifier rule from manual section 30.5.1 still matters at discharge. When the facility practitioner certifies but "will not be following the patient after discharge, then the certifying physician or allowed practitioner must identify the community physician or allowed practitioner who will be following the patient after discharge." The manual adds: "Otherwise, the certification is not valid."
What Changed on January 1, 2026
The 2026 rule rewrote (v)(A) and removed (v)(C). The final rule says (v)(C) limited the encounter to the certifying practitioner unless a certified nurse midwife did it, or a practitioner "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." That was the hospitalist path. Now a hospitalist is simply a physician under (v)(A)(1), and so is the partner who saw the patient while the primary care physician was out.
CMS used that case: "it would be reasonable for the patient's PCP to certify eligibility under the Medicare home health benefit and establish the plan of care even though a different physician or allowed practitioner in the same practice conducted the face-to-face encounter." And set a limit: "it would not be appropriate for a practitioner who specializes in optometry to certify a patient for home health services that are needed due to orthopedic reasons."
In a comment response, not regulation text, CMS said the documentation should show the encounter practitioner "has firsthand information" and is "the most appropriate (that is, the most knowledgeable) provider." Otherwise, CMS said, the intent and documentation requirements are unchanged.
Warning
The manual has not caught up. On cms.gov, chapter 7 section 30.5.1.1 is still Rev. 10438, issued 11-06-20. It says the encounter "must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care facility ... or an allowed non-physician practitioner (NPP)." Section 30.5.3 still says whoever performed the encounter "must sign the certification of eligibility" outside the facility case. Both describe the rule the 2026 amendment replaced. An intake checklist copied from that text will turn away encounters the regulation now accepts.
The Window: 90 Days Before, 30 Days After
The regulation: "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." The anchor is the start of care date. The referral clock is a different rule, the 48-hour rule.
| Situation | What the text says | Source |
|---|---|---|
| Encounter in the 90 days before start of care | Inside the window | 424.22(a)(1)(v) |
| No encounter yet at start of care | It can still happen within 30 days after | 424.22(a)(1)(v) |
| Home health ordered for "a new condition that was not evident during a visit within the 90 days prior to start of care" | "the physician or an allowed NPP must see the patient again within 30 days after admission" | BPM 30.5.1.1 |
| Patient dies after admission, before the encounter | Certification "is deemed to be complete" if the contractor finds "a good faith effort" and all other requirements are met | BPM 30.5.1.1 |
A changed patient counts too. The 2026 rule lists, among guidance that still applies, "a requirement that a new face-to-face encounter is required if the patient's condition has changed."
A post-admission encounter still has a paperwork deadline. The manual says "The certification must be complete prior to when an HHA bills Medicare for reimbursement," and the 2026 rule says "the certification also cannot be completed after a patient is discharged from home health services." Practice, not rule: when a patient is admitted without an encounter, assign the follow-up that day.
"Related to the Primary Reason"
CMS answered the question intake asks most: "diagnosis codes are not required to be on the face-to-face documentation and do not exactly have to match the primary diagnosis for which the patient is receiving home health services. Rather, the face-to-face documentation has to sufficiently demonstrate that the encounter was related to the primary reason that home health services were needed."
The test is clinical content, not code matching. An illustration, not a CMS ruling: a surgeon's post-op note on a hip fracture repair, with weight-bearing orders and a gait description, relates to a referral for therapy after that repair. A routine eye exam the same week does not.
The note does not have to carry everything. Section 30.5.1.2: "While the face-to-face encounter must be related to the primary reason for home health services, the patient's skilled need and homebound status can be substantiated through an examination of all submitted medical record documentation." For the homebound part, see the homebound status walkthrough.
Telehealth
424.22(a)(1)(v)(B): "The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation."
Asked for more flexibility in 2026, CMS answered: "Telehealth face-to-face encounters can be performed at an approved originating site as specified in the Medicare Benefit Policy Manual (Pub. 100-02, chapter 7, section 30.5.1.1)." Which section 1834(m) rules applied on a given date is outside the text quoted here.
What Has to Be Documented, and Where
| Document | Whose record | What it must show | Source |
|---|---|---|---|
| The certification | Signed by the certifying practitioner | That the encounter occurred and was related to the primary reason, and its date | 424.22(a)(1)(v); BPM 30.5.1 |
| The encounter note | The certifier's record, or the facility's if the patient was directly admitted | That it "Occurred within the required timeframe," "Was related to the primary reason the patient requires home health services," and "Was performed by an allowed provider type" | BPM 30.5.1.2 |
| The supporting record | The same, plus agency documents the certifier signed | Skilled need and homebound status | 424.22(c)(1); BPM 30.5.1.2 |
The record "must contain the actual clinical note for the face-to-face encounter visit." A date on the certification is the attestation. The note is the evidence.
Agency documents count only on conditions. Under 424.22(c)(1), HHA documentation may support certification "but only if" the certifier's or facility's record corroborates it and the certifier "signs and dates the HHA documentation." Under (c)(2), if the documentation "is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment is not rendered for home health services provided."
The certifier also has an enrollment condition. Under 42 CFR 424.507(b)(1), the ordering/certifying practitioner must "Be identified by his or her NPI" and "Be enrolled in Medicare in an approved status" or "Have validly opted-out of the Medicare program." That paragraph names the certifier, not the encounter practitioner. The ordering doctor check looks a certifier up.
An Intake Check: Is This Encounter Valid?
Practice, not rule, for the order. Each answer comes from the cited text.
- Who saw the patient: physician, NP, CNS, PA, or a nurse-midwife as State law authorizes? (424.22(a)(1)(v)(A))
- Any financial relationship with your agency, for either practitioner? (424.22(d))
- Encounter no more than 90 days before start of care, or within 30 days after? (424.22(a)(1)(v))
- Ordered for something that visit did not show? Then a new encounter within 30 days after admission. (BPM 30.5.1.1)
- Related to the primary reason? Codes need not match. (90 FR 55413)
- An actual clinical note in the practitioner's or facility's record? (BPM 30.5.1.2)
- Certifier a physician, NP, CNS or PA, enrolled or opted out, with the encounter date on the certification? (424.22; 484.2; 424.507(b))
- Facility practitioner certifying who will not follow the patient? Community practitioner named. (BPM 30.5.1)
Can this practitioner certify home health?
Check any doctor, nurse practitioner or physician assistant against Medicare's ordering and referring list before the referral turns into a denied claim.
Key Takeaways
- Two lists. Physicians, NPs, CNSs, PAs and certified nurse-midwives may perform the encounter. Only physicians, NPs, CNSs and PAs may certify.
- Since January 1, 2026, the encounter need not be by the certifier or a facility physician, whatever the 2020 manual text says.
- The window is no more than 90 days before start of care or within 30 days after. A new or changed condition needs a new encounter.
- "Related to the primary reason" is a clinical test. The codes do not have to match.
- The certification carries the date. The practitioner's or facility's record carries the actual note. The certification is complete before the agency bills.
Frequently asked questions
Who can perform the face-to-face encounter for home health?
Since January 1, 2026, 42 CFR 424.22(a)(1)(v)(A) lists five: a physician, a nurse practitioner, a clinical nurse specialist, a physician assistant, or a certified nurse-midwife as authorized by State law. It no longer has to be the certifying practitioner or a physician from the discharging facility. A practitioner with a disqualifying financial relationship with the agency cannot perform it.
Can the practitioner who certifies be different from the one who did the encounter?
Yes. The CY 2026 final rule says it would be reasonable for the patient's primary care physician to certify even though a different physician or allowed practitioner in the same practice did the encounter. The certifier must be a physician, nurse practitioner, clinical nurse specialist or physician assistant, and must document the encounter date on the certification.
How many days before or after the start of care can the face-to-face encounter happen?
No more than 90 days before the home health start of care date, or within 30 days after it. If home health is ordered for a new condition that was not evident at a visit in the 90 days before start of care, the Medicare Benefit Policy Manual says the patient must be seen again within 30 days after admission.
Does the face-to-face diagnosis have to match the home health primary diagnosis?
No. In the CY 2026 final rule CMS said diagnosis codes are not required on the face-to-face documentation and do not have to exactly match the primary diagnosis. The documentation has to show the encounter was related to the primary reason the patient needs home health.
Can a nurse-midwife's visit count as the face-to-face encounter?
Yes. A certified nurse-midwife may perform the encounter as authorized by State law. A nurse-midwife is not an allowed practitioner under 42 CFR 484.2, so a physician, nurse practitioner, clinical nurse specialist or physician assistant has to certify and document the encounter date.
Sources
- 42 CFR 424.22: introductory text, (a)(1)(v), (a)(1)(v)(A) and (B), (c)(1) and (2), (d)(1) and (2), as amended at 90 FR 55607.
- 42 CFR 484.2: allowed practitioner and physician.
- 42 CFR 424.507(b): the ordering/certifying practitioner on home health claims.
- CMS, CY 2026 Home Health Prospective Payment System final rule, 90 FR 55342 (December 2, 2025), section II.F, pages 55411 to 55414.
- CMS, Medicare Benefit Policy Manual, Chapter 7, sections 30.5.1, 30.5.1.1, 30.5.1.2 (Rev. 10438) and 30.5.3 (Rev. 10738).
- Related on this site: who qualifies for home health care, referral to first visit, homebound status walkthrough, the 48-hour rule.