Ensure Quality Home Health Medical Necessity & Documentation

The year 2020 comes with considerable changes to home health with the roll out of Patient-Driven Groupings Model (PDGM) and the unexpected COVID-19 public health emergency (PHE). While COVID-19 guidelines fluctuate in many states, the Centers for Medicare and Medicaid Services are taking critical steps to resume surveys to ensure home health and hospice agencies are meeting regulatory compliance, providing patients with quality care and taking precautions to establish patient and staff safety.

With the resumption of these surveys, one phrase that should remain constant to everyone in the home health industry is “if it wasn’t documented, it wasn’t done.” The way home health services are documented may change with COVID-19 guidelines, but auditors will expect the same documentation standards – that it is clear, concise and timely. Inadequate medical necessity and face-to-face (F2F) documentation are the source of many denials, and auditors will look specifically for accurate F2F and medical necessity documentation that supports the skilled services provided to patients. According to Celerian Group Company (CGS), the April 2020 summary of results identified thirty-two (32%) of home health claims were denied due to lack of skilled services documentation.

Documenting Medical Necessity

Medical necessity is a term frequently used in home health, and a common question surrounding it regularly arises from clinicians: how is medical necessity documented to demonstrate compliance for every episode of care? Medical necessity refers to the criteria of being “medically necessary and reasonable,” which is individualized to a patient’s unique medical condition and needs. There is no cookie-cutter or template-based process for documenting medical necessity as each patient presents unique goals, intervention needs and outcomes. Every visit performed by all disciplines must have documentation for the visit to stand alone. This means that an auditor can review a randomly chosen visit note and should be able to identify the skilled service performed, the reason the skilled service is necessary and the patient’s response to the individualized care. Since the purpose of medical necessity is to capture the patient’s story, viewing it through the questions “what, when, why and how” can help create more accurate documentation.

What: Interventions addressed during the visit, including the patient/caregiver’s response to the performed interventions
When: Time spent providing care and demonstration of the patient’s progress towards achievement of desired outcomes (did the patient require extended time to perform/learn; if repetitive teaching is necessary, include a rationale – any variances from the expected outcomes)
Why: A description of the patient’s needs at the time of the visit and a clear description detailing why the patient requires the skill of a clinician (‘why me, why now’)
How: A description of how the interventions were performed (i.e. therapy exercises or wound care performed)

Additionally, medical necessity includes verifying the patient’s home bound status. Every visit performed must include documentation that substantiates the patient remains homebound. Avoid use of template-based verbiage when describing the patient’s homebound status. Copying any portion of the regulation as a blanket statement copied from the CMS language, such “taxing effort”, is vague and not complete. To avoid this, clinicians should explain in detail how the patient’s current condition makes leaving home medically contraindicated, as well as describe what effects are causing the considerable and taxing effort when leaving home.

The ‘why me, why now’ theory helps clinicians tell the story of care needed, provided, and its outcomes. Every visit note must clearly show why the patient requires the skill of the clinician with details explaining why the patient requires that specific skill(s) on that specific day.

It is important to avoid vague descriptions when documenting medical necessity. For example, documenting statements such as “patient tolerated treatment well” and “continue with plan of care” are not clear enough for auditors to gain the full picture of the patient’s response to the skilled care performed. Rather, documenting objective measurements of physical outcomes and/or details about the patient’s change behavior secondary to provided education is necessary. Inclusion of the patient/caregiver’s response to the care plan should be incorporated into each visit note as well.

Face-to-Face (F2F) Documentation

With the arrival of the COVID-19 PHE, guidelines have been created that allows the use of telehealth services for conducting F2F encounters. The PHE waiver requires use of two-way audio and visual equipment that allows for real-time communication for telehealth F2F encounters. Keep in mind that a copy of the F2F encounter note, regardless of where the encounter occurred (e.g. physician office visit, hospital, or telehealth visit) must be obtained by the home health agency.

If the patient is admitted to home health directly from the community, the certifying physician (or their allowed non-physician provider) must perform the F2F encounter. If the patient is admitted to home health from an acute or post-acute care facility and the F2F is performed by an allowed provider other than the certifying physician, the certifying physician must acknowledge that they reviewed the F2F encounter. This can be captured in various ways:

Include the F2F date on the plan of care
Obtain a separate attestation from the certifying physician attesting to the F2F date
Certifying physician’s dated co-signature on the F2F encounter note

A valid F2F requires four key elements:

Timely (90 days prior to the start of care date or within 30 days after the start of care date)
The complete encounter note, signed and dated by an allowed provider
Related to the primary reason services are rendered
Evidence of the patient’s homebound status

Common F2F deficiencies that result in denials focus around encounters that do not clearly address the reason the patient requires home health services. The F2F note must provide the physician’s comprehensive assessment documentation that supports the patient’s need for home health services. Providing clinical oversight of an agency’s F2F process will often circumvent a F2F deficiency and subsequent denial.

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