Florida Review Choice Demonstration: what referring physicians need to know in 2026
A clinical reference for Florida physicians, hospitalists, cardiologists, oncologists, case managers, and discharge planners certifying Medicare home health episodes under the Review Choice Demonstration. Built around 42 CFR § 424.22 and current CMS guidance.
Under 42 CFR § 424.22, Medicare home health certification requires a documented face-to-face encounter, a signed plan of care, and a homebound clinical narrative. Florida is one of five Review Choice Demonstration (RCD) states, with CMS extending the demonstration in 2024 for an additional five years — in force through approximately 2029. The practical implication for the referring physician is greater documentation rigor at intake, not more visits and not additional post-episode EHR work.
Five terms every referring physician should be able to use precisely
The first miscommunication between a physician's office and a home health agency is almost always a vocabulary mismatch. These five terms anchor every RCD conversation.
- Review Choice Demonstration (RCD)
- A CMS pre- and post-payment review program for home health claims, currently operating in Florida, Illinois, Ohio, North Carolina, and Texas. Agencies select one of several review choices annually. RCD does not change the substantive coverage criteria in 42 CFR § 424.22 or in Chapter 7 of the Medicare Benefit Policy Manual; it changes when and how documentation is audited.
- Pre-Claim Review (PCR)
- Choice 1 of RCD. The home health agency submits documentation — including the face-to-face encounter note, the plan of care, and the homebound narrative — to the Medicare Administrative Contractor (Palmetto GBA in Florida) before the claim is paid. A provisional affirmation or non-affirmation is issued within ten business days. PCR is the default choice for most Florida home health agencies.
- Post-Payment Review (PPR)
- Choice 2 of RCD. Claims are paid first, then reviewed retrospectively. Non-affirmed claims are recouped. Agencies that demonstrate sustained PCR affirmation rates at or above the CMS threshold may elect Choice 4 (selective post-payment review) or Choice 5 (spot check).
- Face-to-face (F2F) encounter
- An encounter between the patient and the certifying physician or allowed non-physician practitioner that occurs within 90 days before or 30 days after the start of home health care, addresses the primary clinical reason home health is needed, and is documented in the clinical record (42 CFR § 424.22(a)(1)(v)). Telehealth encounters meeting CMS criteria qualify.
- Attestation form vs. clinical note
- The load-bearing physician confusion. A signed F2F attestation form alone — without an accompanying clinical progress note that contains the date of the encounter, the clinical findings, and the homebound justification — is not sufficient for CMS. RCD reviewers require both the attestation and the underlying signed clinical note. Most third-revision requests originate here.
Clean documentation from day one means no third-revision calls
Kassy Health’s clinical liaison team confirms receipt of every referral within four business hours and identifies missing F2F clinical-note elements before the Pre-Claim Review submission goes out. The goal is a first-submission affirmation — not a week of back-and-forth with your office.
Refer a Patient
The six things RCD requires from the referring physician
None of these are new requirements created by RCD. All are pre-existing obligations under 42 CFR § 424.22 and Chapter 7 of the Medicare Benefit Policy Manual that RCD now reviews more rigorously and earlier in the revenue cycle.
-
A qualifying face-to-face encounter in the 90-before / 30-after window
42 CFR § 424.22(a)(1)(v) requires that the certifying physician, an allowed non-physician practitioner, or the physician who cared for the patient during a recent acute or post-acute stay must conduct a face-to-face encounter related to the primary reason for home health within 90 days before, or 30 days after, the start of care. The encounter must be documented in a clinical note that names the date of the encounter, the clinical condition, and the relationship between the condition and the need for home health.
-
A signed plan of care — the CMS-485 or equivalent
Under 42 CFR § 484.60 and Chapter 7 of the Benefit Policy Manual, the plan of care must be established and reviewed by the certifying physician, must list the disciplines ordered and the visit frequency, must specify the goals of care, and must be signed and dated. Under RCD, a Pre-Claim Review submission without a signed plan of care will be non-affirmed.
-
The ordering physician's signature on the F2F clinical note — not only on the attestation form
This is the most common reason a Florida home health agency calls back for a third revision. The HHS Office of Inspector General has documented limited compliance with the home health face-to-face requirement, and CMS contractor guidance has repeatedly emphasized that the underlying clinical progress note containing the F2F findings must carry the ordering physician's signature and date. An attestation form is administrative; the clinical note is the substantive document RCD reviewers rely on.
-
A clinical narrative with diagnosis, prognosis, and homebound justification
The narrative must establish four elements: the primary diagnosis with an ICD-10 code that supports the case-mix grouping under the Patient-Driven Groupings Model; the current clinical instability or skilled need; a prognosis that supports the intermittent skilled care being ordered; and the medical reason the patient is confined to the home. Generic descriptors are insufficient. Observable, patient-specific findings are required.
-
Timely signature return — usually within the first few business days of the episode
Pre-Claim Review submissions must be made before the agency can be paid; in practice, this means the agency needs the signed plan of care and signed F2F clinical note within the first business week of the start of care. A 48- to 72-hour signature turnaround is the operating standard at most well-run Central Florida agencies. Delays propagate: a signature returned a week late routinely produces a downstream PCR non-affirmation and a second documentation cycle.
-
Replace "weak / SOB / deconditioned" with observable, patient-specific language
Conclusory descriptors are the most frequently flagged ADR finding for home health face-to-face notes. CMS contractor guidance specifically calls out "weak," "short of breath," and "deconditioned" as insufficient when used alone. The remedy is functional, observable language: the distance the patient can ambulate before fatigue, the assistive device required, the dyspnea threshold in feet or in flights of stairs, and the specific reason leaving the home requires the considerable and taxing effort described in the Benefit Policy Manual.
What CMS / RCD requires — and what a complete physician package looks like
The left column is the regulatory floor under 42 CFR § 424.22 and the Conditions of Participation at 42 CFR Part 484. The right column is what Kassy Health intake nurses request from referring physician offices in Central Florida so the Pre-Claim Review submission is right the first time.
How to write an RCD-defensible face-to-face narrative (five steps)
The goal is a short, observable, patient-specific clinical paragraph that survives Pre-Claim Review on the first submission. Five minutes of physician dictation here saves the agency, your office, and the patient an avoidable second-revision cycle.
-
Anchor the encounter date and the qualifying clinical reason
State the date of the encounter, the setting (office, hospital, telehealth), and the primary clinical reason home health is being ordered. 42 CFR § 424.22(a)(1)(v) requires the encounter to address the condition driving the home health need — not an unrelated routine visit.
-
State the primary diagnosis with ICD-10 specificity
Use the most specific ICD-10 code that supports the case-mix grouping under the Patient-Driven Groupings Model. Generic codes (e.g., R26.81, unspecified abnormalities of gait) frequently produce non-affirmation when used alone; pair them with the underlying clinical diagnosis (e.g., I50.32 chronic diastolic heart failure, or G20 Parkinson's disease).
-
Justify homebound status with observable, functional language
Replace conclusory descriptors with specifics: the distance the patient can walk, the assistive device used, the dyspnea threshold, and the medical reason leaving the home requires considerable and taxing effort. The two-part homebound test in Chapter 7, § 30.1.1 requires (a) a normal inability to leave the home and (b) that leaving requires a considerable and taxing effort — both must be supported by observable findings.
Example — anti-pattern (likely to be non-affirmed):"Patient is weak and short of breath with deconditioning following hospitalization. Homebound. Needs home health for safety."
Example — ADR-defensible:"Patient is ambulatory with a rolling walker, fatigues after approximately 20 feet, and requires standby assistance for shower transfers due to post-discharge orthostasis. Leaving the home for cardiology follow-up last week required two-person assist and a 90-minute recovery period. Homebound criteria are met: a normal inability to leave the home, and leaving requires a considerable and taxing effort."
-
Name the skilled disciplines and link each to a specific clinical goal
For each discipline ordered (skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social work, home health aide), state the clinical rationale and the measurable goal. Bare orders — "PT eval and treat" — are weaker on review than goal-anchored orders — "PT for gait training and fall reduction, goal independent ambulation 100 feet with rolling walker within 30 days."
-
Sign and date the clinical note itself
The single most common Pre-Claim Review non-affirmation is a signed attestation form without a signed underlying clinical note. Apply the ordering physician's signature and date to the progress note containing the F2F findings. If the encounter occurred at a different practice (hospital, post-acute facility), obtain a copy of that note with the attending's signature and include it with the certification packet.
Why RCD is in force, what the data says, and where Florida fits
The Review Choice Demonstration replaced the earlier Pre-Claim Review demonstration and entered Florida operations in 2020 under CMS's Review Choice Demonstration for Home Health Services program, administered by Palmetto GBA. The demonstration was extended in 2024 for an additional five years, placing the current operating horizon at approximately 2029. Industry trade press described the renewal in operator-facing terms: Home Health Care News reported on the affirmation-rate dynamics and the operational cost of pre-claim review in its 2023 coverage, "'Applying Resources In Wrong Bucket': Home Health Providers See Review Choice Demonstration As Yet Another Burden."
The HHS Office of Inspector General, in its review of the home health face-to-face requirement, documented limited compliance among certifying physicians with the documentation standard in 42 CFR § 424.22. That finding is the empirical anchor behind both Pre-Claim Review (designed to catch the missing or non-compliant F2F before the claim is paid) and the persistent pattern of agency requests for revision that physicians experience in clinic.
Florida-specific advocacy is part of the public record. In 2024, members of Florida's congressional delegation wrote to CMS asking for a delay to the Florida implementation, citing — among other concerns — "limited ordering physician availability to provide necessary signatures." The letter was reported in HomeCare Magazine under the headline "Florida Reps Urge CMS to Delay Review Choice Demonstration in State." The signature-availability concern remains the central physician-side friction point five years into the demonstration.
The payment context matters for clinical decisions as well. MedPAC's March 2026 Report to the Congress, Chapter 8 (Home Health Services), recommended a 7 percent reduction to the CY 2027 home health base payment rate, citing what the Commission characterized as persistent overpayment relative to costs. CMS's response will be issued through the CY 2027 Home Health PPS rulemaking cycle. Combined with the Patient-Driven Groupings Model behavior adjustments finalized in the CY 2026 Home Health PPS Final Rule (CMS-1828-F), the operational environment is one in which documentation rigor, accurate ICD-10 coding on the plan of care, and clean RCD affirmation rates have measurable financial consequences for the agency. Indirectly, those consequences translate into how aggressively an agency must chase physician signatures.
The assessment instrument that the agency uses to drive the OASIS-tied case-mix calculation is OASIS-E2, effective April 1, 2026. OASIS-E2 added social determinants of health and patient-preference items but did not alter the face-to-face or homebound documentation standards. Industry policy commentary is increasingly published by the National Alliance for Care at Home, formed in 2024–2025 from the merger of the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO).
RCD questions Florida physicians actually ask
Eight questions Kassy Health's clinical liaison team hears most often from Central Florida referring physicians, hospitalists, and discharge planners.
RCD does not change the underlying documentation required by 42 CFR § 424.22 — the face-to-face encounter, the plan of care, the homebound narrative, and a signed clinical note were already required. RCD changes when that documentation is reviewed: at Pre-Claim Review before payment, or at Post-Payment Review after. The practical effect on the referring physician is that agencies request signatures and revisions more quickly and more rigorously. CMS extended the demonstration for an additional five years in 2024, so the topic remains in force through approximately 2029.
Under 42 CFR § 424.22(a)(1)(v), the certifying physician or an allowed non-physician practitioner must have an encounter related to the primary reason for home health within 90 days before, or 30 days after, the start of care. If the window has been missed, the home health agency cannot be paid for that episode. The remedy is to perform a qualifying encounter as soon as feasible and document the clinical reason home health remains medically necessary; in many cases the agency will need to restart the episode of care.
Yes. CMS allows the home health face-to-face encounter to be conducted via telehealth, provided the visit is conducted by the certifying physician or allowed non-physician practitioner, uses real-time audio and video, and addresses the primary reason home health is required. The same documentation requirements apply: a clinical note signed by the ordering provider, not only an attestation form. The telehealth flexibility was originally introduced during the COVID-19 public health emergency and was retained in subsequent CMS rulemaking; consult the current CY Home Health PPS Final Rule for the operative effective dates.
Yes, with limits. The face-to-face encounter may be performed by a nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant working in collaboration with or under the supervision of the certifying physician, or by the physician who cared for the patient during a recent acute or post-acute stay. The certifying physician — not the NPP — still signs the home health certification and the plan of care. The NPP-conducted F2F note must be communicated to and incorporated by the certifying physician.
A complete physician package supports timely Pre-Claim Review submission: the signed face-to-face clinical note (not only the attestation), the signed plan of care (CMS-485 or equivalent), the homebound narrative with functional descriptors, the primary diagnosis with ICD-10 code, and the ordering disciplines. Agencies are required to obtain a signed plan of care before billing; under RCD, the practical window for the physician signature is the first few business days of the episode. Kassy Health intake confirms within four business hours of receipt which document, if any, is still outstanding.
The home health agency selects its review choice annually under CMS rules. Most Florida agencies are on Choice 1 (Pre-Claim Review) because the documented affirmation threshold provides operational stability; some agencies with sustained high affirmation rates move to Choice 2 (Post-Payment Review), Choice 4 (selective post-payment review), or Choice 5 (Spot Check). The agency can tell you which review choice it is on. From a referring physician's standpoint, the documentation standard under 42 CFR § 424.22 is the same under all choices.
Additional Documentation Requests (ADRs) and Pre-Claim Review non-affirmations frequently cite generic descriptors — "patient is weak," "short of breath," "deconditioned" — as insufficient. The HHS Office of Inspector General has documented limited compliance with the home health face-to-face requirement, and CMS contractor guidance specifically calls out conclusory language. The remedy is observable, patient-specific findings: distance ambulated, assistive device, dyspnea threshold, and the specific medical reason leaving the home requires a considerable and taxing effort.
RCD has been extended once and may be extended again. CMS announced in 2024 that the demonstration would continue for an additional five years, placing the current end date in approximately 2029. The demonstration is operated by Palmetto GBA in Florida, Illinois, Ohio, North Carolina, and Texas. Referring physicians should treat RCD documentation expectations as the ongoing operating standard for Florida home health, not a temporary intervention.
Sources cited on this page
Every regulatory and clinical claim above is linked inline and listed in full here. URLs were click-tested on 2026-05-13.
- Code of Federal Regulations. 42 CFR § 424.22 — Requirements for home health services. Office of the Federal Register, current edition. Accessed May 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-B/section-424.22
- Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 7 — Home Health Services. Pub. 100-02. Accessed May 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf
- Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services. Program landing page. Accessed May 2026. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/review-choice-demonstration-home-health-services
- Code of Federal Regulations. 42 CFR Part 484 — Home Health Conditions of Participation (including § 484.60 plan of care requirements). Accessed May 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-484
- Centers for Medicare & Medicaid Services. Calendar Year (CY) 2026 Home Health Prospective Payment System Final Rule (CMS-1828-F). Fact sheet, November 28, 2025. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-home-health-prospective-payment-system-final-rule-cms-1828-f
- Centers for Medicare & Medicaid Services. OASIS User Manuals (OASIS-E2 effective April 1, 2026). Accessed May 2026. https://www.cms.gov/medicare/quality/home-health/oasis-user-manuals
- HHS Office of Inspector General. Limited Compliance With Medicare's Home Health Face-To-Face Requirement. OIG report and podcast. Accessed May 2026. https://oig.hhs.gov/newsroom/oig-podcasts/limited-compliance-with-medicares-home-health-face-to-face-requirement/
- Medicare Payment Advisory Commission. March 2026 Report to the Congress: Medicare Payment Policy (Chapter 8 — Home Health Services; recommendation for 7 percent CY 2027 base-rate reduction). Accessed May 2026. https://www.medpac.gov/document/march-2026-report-to-the-congress-medicare-payment-policy/
- HomeCare Magazine. "Florida Reps Urge CMS to Delay Review Choice Demonstration in State." Reporting on a 2024 letter from Florida congressional representatives to CMS. https://www.homecaremag.com/news/florida-reps-urge-cms-delay-review-choice-demonstration-state
- Home Health Care News. "'Applying Resources In Wrong Bucket': Home Health Providers See Review Choice Demonstration As Yet Another Burden." June 2023. https://homehealthcarenews.com/2023/06/applying-resources-in-wrong-bucket-home-health-providers-see-review-choice-demonstration-as-yet-another-burden/
- American College of Physicians. Medicare Home Health Face-to-Face Encounter Requirement. Practice resource. Accessed May 2026. https://www.acponline.org/practice-career/business-resources/payment/medicare-payment-and-regulations-resources/medicare-home-health-face-to-face-encounter-requirement
- National Alliance for Care at Home. Industry policy resources. Accessed May 2026. https://allianceforcareathome.org/
For related reading, see the physician hub, refer a patient, how to choose a home health agency, what happens in the first week of home health, and skilled nursing services.