The referral comes with a signed order, a discharge summary and a start of care date. What it does not come with is the clinical note from the visit where a practitioner actually saw the patient for the reason home health is needed. The agency starts care, bills, and months later a reviewer asks for that note. The physician's office sends a medication refill message from four months earlier.
The home health face-to-face encounter is a statutory condition of payment, and when the note behind it is missing or weak, the certification fails with it. CMS widened who can perform it on January 1, 2026. It did not change the timing window or the documentation standard. This guide covers both, explains what changed, and gives intake a checklist that catches a missing or misdated encounter before the start of care.
The Rule in One Paragraph
Under 42 CFR 424.22(a)(1)(v), the certifying physician or allowed practitioner must certify that a face-to-face patient encounter, related to the primary reason the patient requires home health services, occurred no more than 90 days before the start of care or within 30 days after it, and was performed by an allowed practitioner. The certifier must also document the date of the encounter as part of the certification.
The encounter is a condition of payment, not a clinical nicety. CMS states in the CY 2026 home health final rule that the requirement comes from section 1814(a)(2)(C) of the Social Security Act, and that because it is statutory, CMS has no regulatory discretion to eliminate it.
What Changed on January 1, 2026
The CY 2026 Home Health PPS final rule, effective January 1, 2026, revised who may perform the encounter.
Before, the regulation limited the encounter to the certifying physician or allowed practitioner, a certified nurse-midwife, or a practitioner with privileges who cared for the patient in the acute or post-acute facility from which the patient was directly admitted. Now 424.22(a)(1)(v)(A) lists, without those limits:
- a physician
- a nurse practitioner
- a clinical nurse specialist
- a physician assistant
- a certified nurse-midwife, as authorized by state law
CMS removed the old paragraph (a)(1)(v)(C) that tied the encounter to the certifying practitioner. The preamble gives the example that it is reasonable for a patient's primary care physician to certify eligibility even though a different practitioner in the same practice conducted the encounter.
Three things did not change, and the rule says so directly:
- 1.Intent and documentation. CMS reminds readers the changes only add flexibility and do not otherwise change the intent, documentation requirements or acceptable formats of the encounter.
- 2.Firsthand knowledge. The documentation still needs to support that the practitioner who performed the encounter has firsthand information about the patient's primary reason for needing home health.
- 3.Financial relationships. Under 424.22(d), a practitioner with a financial relationship with the agency that does not meet a Stark exception may not perform the encounter, and the same restriction applies to non-physician practitioners.
One trap: the Medicare Benefit Policy Manual, Chapter 7, section 30.5.1.1, still carries its 2020 revision, which describes the older provider limits. Section 30.5.3 also still says the practitioner who performed the encounter must sign the certification unless the patient came directly from a facility. The final rule said CMS would consider updating subregulatory guidance. Until the manual catches up, train intake on the regulation and the rule, and keep a copy of the rule's discussion with your policy.
The Timing Window, Worked
The window is 90 days before the start of care through 30 days after it.
For a start of care on Monday, November 9, 2026:
- Earliest qualifying encounter: August 11, 2026.
- Latest qualifying encounter: December 9, 2026.
The manual adds a condition that intake teams miss. If the practitioner orders home health based on a new condition that was not evident during a visit within the prior 90 days, the patient must be seen again within 30 days after admission. A visit in September for a stable chronic condition does not cover a November fall with a new fracture.
Encounters after the start of care carry more operational risk. If the plan relies on a post-admission visit, put the appointment date in the referral record on day one, assign someone to confirm it happened, and set a hard check at day 25 so there is time to escalate before day 30.
The manual describes one exception. If a patient dies shortly after admission before the encounter occurs, the certification can be deemed complete if the contractor finds a good faith effort by the agency to facilitate the encounter and all other certification requirements are met. Document every scheduling attempt as you go; that record is the good faith.
What the Record Must Contain
Section 30.5.1.2 of the same manual says the certifying practitioner's record or the acute or post-acute facility's record, if the patient was directly admitted, must contain the actual clinical note for the encounter visit, demonstrating 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.
The CY 2026 final rule clarified one point that has driven unnecessary rework. Diagnosis codes are not required on the encounter documentation and do not have to exactly match the primary diagnosis for home health. The documentation has to demonstrate that the encounter was related to the primary reason home health is needed.
Separately, 424.22(c) makes the certifying practitioner's or facility's records the basis for eligibility. Agency documents such as the plan of care or comprehensive assessment can support eligibility only if the certifying practitioner signs and dates them and other entries in the practitioner's or facility's record corroborate them. The homebound status guide covers the evidence for that half of eligibility.
An Intake Checklist for the Encounter
Run this before the start of care visit is scheduled, not after the first claim.
- 1.Encounter date. From a clinical note, not from the order. Calculate the window from the planned start of care.
- 2.Practitioner and credential. Physician, NP, CNS, PA, or certified nurse-midwife where state law allows. Note the name and NPI.
- 3.Relationship to the primary reason. One sentence linking what the note addresses to why home health is ordered. If you cannot write that sentence, the reviewer cannot either.
- 4.New condition check. If the reason for home health arose after the encounter, flag that a new encounter is needed within 30 days of start of care.
- 5.Where the note lives. Certifying practitioner's office or facility record, and who at that office will send it on request.
- 6.Financial relationship check. Confirm the encounter practitioner and certifier are not in a prohibited financial relationship with the agency.
- 7.Certification content. Confirm the certification will carry the encounter date and the certifier's signature and date.
- 8.Post-admission encounter tracking. If the encounter will happen after start of care, record the appointment, the owner and the day-25 check.
Telehealth Encounters
The regulation, at 424.22(a)(1)(v)(B), allows the encounter by telehealth in compliance with section 1834(m) and the list of payable Medicare telehealth services. The manual's section 30.5.1.1 describes originating site rules, and the CY 2026 rule pointed commenters asking for broader telehealth back to that manual section. Temporary statutory telehealth flexibilities have been extended and lapsed more than once in recent years, so confirm the current position with your MAC before accepting a telehealth encounter as qualifying.
Where Certifications Actually Fail
- The note is a refill or a phone call. An encounter is a visit with the patient, documented in a clinical note.
- The date on the certification does not match the note. A transcription error becomes a documentation conflict.
- The encounter is for something else. A dermatology visit does not support home health ordered after a hip fracture.
- Waiting for the end of the period. The manual says it is not acceptable for agencies to wait until the end of a 60-day period to obtain a completed certification, and the CY 2026 rule adds that a certification cannot be completed after discharge.
- Assuming Medicare Advantage follows the same rules. Commenters on the final rule asked whether MA plans must align; plans run their own authorization processes, as the Medicare Advantage home health guide explains.
Build It Into the Referral Stage
The face-to-face encounter is cheapest to fix before admission, when the practitioner's office is still engaged with the referral. The referral management guide describes separating "complete for outreach" from "complete for admission"; encounter evidence belongs in the second gate. Nuraflow is being designed so that intake and referral management prompts for missing information before admission, and so that care plans and plan of care track CMS-485 orders and signatures with version history.
This article is general information, not legal or billing advice. Confirm certification and documentation practices with your MAC, and watch for CMS updates to the Benefit Policy Manual that reflect the 2026 change.