Plan for Next Visit: Is this the key to prevent medical necessity denials?

Medical review audits are in full swing. Home health agencies may receive documentation requests for records from a Medicare Administrative Contractor (MAC), Target Probe & Educate (TPE), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and/or United Program Integrity Contractor (UPIC). Regardless of the type of home health audit, denials for ‘not reasonable and necessary’ services have always ranked as one of the top reasons.

Most recently, RAC audits have continued the trend but, more specifically, identifying not reasonable and necessary services due to the lack of a specific plan for next visit.  Let’s look at the regulations for reasonable and necessary services.

Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, 40.1.1 – General Principles Governing Reasonable and Necessary Skilled Nursing Care. The clinical notes are expected to tell the story of the patient’s achievement towards their goals as outlined in the Plan of Care.  The notes will serve to demonstrate why a skilled service is needed.

What does this mean?

• The home health clinical notes must document not only the skilled service provided on the visit, but the plan for the next visit based on the rationale of prior results.
• The rationale explains in detail the need for skilled service considering the patient’s overall medical condition and experiences.
• Clinical notes should provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions, such as “continue with POC,” “observation and assessment,” or “teach medications” are not acceptable.

What to do now?

• Educate staff on the need to tell the story, not just at the beginning, but on every visit note in order to prevent medical necessity denials. Each visit note should stand alone with a clear picture of the skill performed and why the next visit is medically necessary. Medical Reviewers only have the documentation in the record to determine whether the care provided meets Medicare regulation.
• Educate staff on the need to document the issues identified during the visit and the follow-up/plan for the next visit.
• Perform medical record review for medical necessity.
  • Is the skill for the visit clearly identified?
  • Is there a specific reason additional skilled services are needed?
  • Is the plan for next visit specific and related to the patient’s condition?
  • Was the plan followed at the next visit?
• Consider partnering with a consulting firm to ensure your documentation will hold up to all the audits that may come your way.

About the Author

Dawn Cheek, Director of Clinical Consulting

Dawn Cheek is a Clinical Consulting Director at McBee. She is involved with home health, hospice, and hospital engagements and has been a healthcare consultant for 13 years. She has performed Medicare compliance reviews and related chart reviews for home health agencies, hospices, and hospitals. Her nursing background, coupled with her leadership experience, allows her to effectively monitor operational process and agency compliance