What does Medicare's face-to-face encounter rule require for home health in 2026?

The federal rule, 42 CFR 424.22, says the encounter has to be "related to the primary reason the patient requires home health services," has to happen no more than 90 days before the start of care or within 30 days after it, and has to be performed by one of the practitioner types the rule lists. The certifying practitioner "must also document the date of the encounter as part of the certification."

CMS doesn't require a specific form; Medicare's example certification covers the encounter in one sentence with the date. The certification has to be finished before you bill.

A visit inside the 90 days can still fall short. If the practitioner orders home health for a new condition that wasn't evident at that earlier visit, the Benefit Policy Manual says the patient has to be seen again within 30 days after admission. The test CMS gives is whether the patient's condition changed enough that standards of practice would call for the practitioner to examine them before setting the treatment plan.

Until the end of 2025, the visit had to be done by the certifying practitioner, by a practitioner working with or supervised by them, or by the hospital or facility practitioner who cared for the patient right before home health. CMS's 2026 home health payment rule removed that limit. Since January 1, 2026, the regulation lists five practitioner types who can do the visit, with no tie to who certifies: a physician, a nurse practitioner, a clinical nurse specialist, a physician assistant, or a certified nurse-midwife as authorized by state law.

In the rule, CMS calls it reasonable for a primary care physician to certify when a colleague in the same practice did the visit. It also says it wouldn't be appropriate for a practitioner who specializes in optometry to certify home health needed for orthopedic reasons. In our read, when the certifier and the visit practitioner differ, check that the certifier's care fits the reason you're admitting before you accept the referral.

Medicare's Benefit Policy Manual hasn't caught up: section 30.5.1.1 of chapter 7 still ties nurse practitioners, clinical nurse specialists, physician assistants and nurse-midwives to the certifying or facility physician, and section 30.5.3 still says the practitioner who did the visit signs the certification. If a reviewer applies that wording to a visit from 2026 on, answer with the regulation's current text, 42 CFR 424.22(a)(1)(v)(A).

Some limits stayed. A practitioner with a financial relationship with your agency can't certify or perform the encounter unless the relationship meets one of the exceptions in federal self-referral law, and reviewers only consider face-to-face documentation from practitioners without one.

The same manual says the certifying practitioner's record, or the acute or post-acute facility's record if the patient came straight from there, "must contain the actual clinical note for the face-to-face encounter visit." That note has to show the visit happened in the window, related to the primary reason, and was done by an allowed provider type. CMS says you'll most often find it in clinical and progress notes and discharge summaries.

Your plan of care and start of care assessment can still support homebound status and skilled need if the certifying practitioner signs and dates them, which brings them into their record, and if they agree with the rest of that record. CMS's Program Integrity Manual says that sign-off counts as on time when it happens before or when you submit the claim. It also says agency-generated documentation, by itself, isn't enough to show eligibility.

A hospital discharge adds a requirement. When a hospital or facility practitioner certifies the patient but won't follow them at home, they have to name the community practitioner who will. Without that, the manual says, the certification is not valid.

CGS, the Medicare contractor for home health in 15 states and Washington, D.C., publishes its targeted review results. For July to September 2026, its top home health denial reason was code 5HC01, face-to-face documentation "missing, incomplete, or untimely," at 26.3% of the denials from those reviews. Second, at 19.7%, was 5HC09, an invalid initial certification. Beyond a missing note, CGS's reasons under 5HC01 include a visit outside the window, a visit unrelated to the primary reason, and a certification or plan of care signed before the encounter date. CGS posted those reasons in July 2025, before the wider list of practitioners took effect.

The timing in this plan is our suggestion; CMS sets the window and what the record must hold.

1. Get the visit note itself. A progress note, clinic note or discharge summary from the visit.
2. Check the date against your planned start of care. Within 90 days before, or schedule a visit for no later than 30 days after.
3. Check the reason. The note should be about the same problem as the primary reason on your referral.
4. Check who did the visit. One of the five practitioner types, with no financial relationship with your agency.
5. For a hospital or facility discharge, get the discharge summary or the progress note from that stay, and confirm who will follow the patient at home.
6. For a new problem since the last visit, ask the practitioner's office to book a visit within 30 days of admission, and make sure the certification is signed after that visit and carries its date.
7. Before you bill, confirm the certification is signed, dated and includes the encounter date, and that anything of yours used for support is signed and dated by the practitioner.

For a community referral, ask the certifying practitioner's office for the visit note itself, by date. For a hospital or nursing facility discharge, start with the case manager or discharge planner, then medical records.

Enzo is a home health EHR. Enzo Intake checks each referral package for face-to-face documentation the moment it arrives and flags gaps before your team gets involved. Enzo QA reviews every chart before submission, including Plan of Care alignment, and explains what needs attention and why. Your team makes the call.

Does a telehealth visit count?

Yes, under the regulation, if it follows Medicare's telehealth rules and the visit is on Medicare's list of payable telehealth services. CMS's telehealth FAQ says patients can get Medicare telehealth services anywhere in the United States through December 31, 2027; from January 1, 2028, most will again need to be in a medical facility in a rural area.

Does every recertification need a new face-to-face visit?

No. The recertification list in the Benefit Policy Manual has four items, and the face-to-face encounter isn't one of them. But CMS tells its contractors to review the certification for any period that began with a start of care assessment, and if the certification fails, later periods are non-covered even when the recertification is fine. If you get an additional documentation request for a later period, send the certification and the encounter note with it.

Our patient died before the visit happened. Is the certification lost?

Not necessarily. If a patient dies shortly after admission, before the encounter happens, the certification can be treated as complete when the contractor finds your agency made a good-faith effort to arrange the visit and every other certification requirement is met.