Home Health & Hospice Week

Diagnosis alone doesn't cut it.

The Medicare requirement basing home health agency payment on your referral sources' documentation is maddening, but HHAs have to roll with it - at least for now.

History: HHAs cheered when the Centers for Medicare & Medicaid Services eliminated the much-hated physician narrative requirement for the face-to-face encounter in 2015. But, the requirement's replacement mandating certification and eligibility determinations to be based solely on referring physicians' and facilities' documentation may have been worse.

Having to rely on a third party's documentation for payment is extremely frustrating for agencies and unfair, they argue. But unless CMS makes the use of HHA documentation mandatory in this year's PPS rule (see story, p. 74), agencies just have to live with the requirement.

HHH Medicare Administrative Contractor Palmetto GBA lists these common examples of inadequate documentation from the physician:

• Diagnosis alone, such as osteoarthritis
• Recent procedures alone, such as total knee replacement
• Recent injuries alone, such as hip fracture
• Statement, "taxing effort to leave home" without specific clinical findings to indicate what makes the beneficiary homebound
• "Gait abnormality" without specific clinical findings
• "Weakness" without specific clinical findings.

Another problem: "CGS has observed many physician certifications do not contain a statement for documenting the date of the face to face encounter," the MAC noted in a January post to its website. The certifying physician must attest to five items (see box, p. 77), including "document[ing] the date of the encounter," CGS instructs.

Ensure Your Documentation Makes It Into The Physician Record

To overcome many of physicians' and facilities' documentation shortfalls, it's imperative for HHAs to get their supporting documentation signed into the physician's record, experts stress.

"Agencies can provide to physicians and referring facilities the documentation from agency assessments and plans of care," explains Beth Noyce with Noyce Consulting in Salt Lake City.

Having that documentation signed into the record can fix both technical and content problems.

For instance: On the technical side, "if the face-to-face encounter documentation provided by the physician isn't marked as such, the agency can label it as the face-to-face encounter document and provide a labeled copy to the referring facility or physician who performed the encounter," Noyce offers.

On the clinical side, "a therapy assessment shows more clearly that the patient's homebound status is valid, providing a copy to the physician or referring facility for the patient's record there meets criteria that physician or referring facility records must include enough information to show the patient qualifies to receive home health services," Noyce tells Eli.

In a separate article, CGS offers two more examples of when a clinical note would help support the cert:

Example 1: PT progress note helps support that patient is confined to the home. Home health agency physical therapy progress note documents patient is non-weight bearing on right leg and requires use of a two-handed device to walk alone on a level surface, and requires assistance to negotiate stairs or steps or uneven surfaces. The home health agency assessment with progress notes has been signed by the community orthopedic certifying physician.

Example 2: SN notes help to identify the need for skilled services. Nursing notes state that the patient is significantly deconditioned, as a result of recent pneumonia, and requires the use of a walker to ambulate from chair to bathroom with frequent stops to rest. The home health agency skilled nursing note has been signed by the certifying physician.

Note: For more cert documentation tips, see a future issue of Eli's Home Care Week. The CGS article on incorporating your documentation into the physician record is at www.cgsmedicare.com/hhh/pubs/news/2017/1117/cope5302.html.