There are no magic words that Medicare providers must use for the physician Home Health Face-to-Face (HH F2F) encounter, but there are critical concepts that must be communicated. Those critical concepts can be effectively communicated using the categories already defined by the International Classification of Functioning, Disability and Health (ICF). This post provides examples of such critical concepts for musculoskeletal conditions.

Rehabilitation services can be ordered for the management of musculoskeletal conditions or following surgical procedures like total knee and hip replacements. While these orders must be supported by specific clinical records (i.e., the physician HH F2F encounter) that communicate Functional Status Information (FSI) to the home health agencies (HHAs) actually providing the rehabilitative services, there is currently no well-established or well-accepted method for communicating this FSI.  Many of these physician HH F2F encounter notes are housed in office, acute and post-acute care electronic health records (EHRs) and could benefit from the well-defined structure of the ICF.

Effective, efficient, and sustainable improvements are needed in the communication of FSI supporting the physician HH F2F encounter. The ICF is a taxonomy (classification system) that contains key (standard) definitions for health domains and categories that are understood by clinicians and critical to communicating the necessary FSI to support both the clinical and administrative work flows of physicians, hospitals, and HHAs. While not required by Medicare for claims processing, the concepts available in the ICF taxonomy are relevant to the physician’s HH F2F documentation supporting many conditions, including musculoskeletal conditions. They can be used to capture and categorize the impairments of structure and function, and relate them to the specific activity limitations being addressed by the nurses and therapists of the HHA.

According to Grill et al (2011) “very typically, patients with musculoskeletal conditions are characterized by pain, limited mobility, subsequent loss of sleep and loss of function of the musculoskeletal system leading to restrictions in activities of daily living such as self-care and ambulation”. Organizing and communicating this knowledge through an EHR would help convey the Medicare administrative concepts of “confined to the home” and “need for skilled services” for musculoskeletal conditions and procedures of the lower extremity. These administrative concepts can be represented in a clinical record by utilizing combinations of specific impairments and activity limitations using ICF categories.

As you read through the below classes of information, please think about where this FSI currently resides in your physician records. Together the sixteen musculoskeletal impairments and activity limitations listed represent the core of the FSI necessary to efficiently and effectively communicate the HH F2F physician encounter for musculoskeletal conditions and procedures of the lower extremities. The amount of human assistance and any necessary durable medical equipment required by the patient to accomplish mobility and self-care activities should also be noted.

Structural impairments

s750 Structure of lower extremity

s810 Structure of areas of skin

Potential functional impairments requiring the skills of a nurse or therapist

b260 Proprioceptive function

b280 Pain

b530 Weight maintenance functions

b710 Mobility of joint functions

b730 Muscle power functions

b740 Muscle endurance functions

Potential activity limitations requiring the skills of a nurse or therapist

d410 Changing basic body position

d420 Transferring oneself

d450 Walking

d460 Moving around in different locations

d465 Moving around using equipment

d510 Washing oneself

d530 Toileting

d540 Dressing

These sixteen ICF categories were among those identified by public health researchers in Europe and published in 2011 (Grill E, Strobl R, Müller M et al. ICF Core Sets for early post-acute rehabilitation facilities J Rehabil Med 2011; 43: 131–138), but not yet adopted in the United States.  By incorporating the above concepts into your physician records, especially EHRs,  you will be helping to establish the effective, efficient, and sustainable solution required to “get it right the first time”, thus avoiding the denials and appeals currently associated with the Medicare HH F2F encounter.





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