Home Health & Hospice Week

Auditors are taking a magnifying glass to home health agency patients' homebound status, but you can retain your rightful Medicare reimbursement if you know the ropes.

Audits of HHA claims are on the rise from Zone Program Integrity Contractors, intermediaries, the HHS Office of Inspector General, and other authorities. And the homebound issue is often an easy target that denies an entire claim, or series of claims (see Eli's HCW, Vol. XIX, No. 38, p. 298). First: To shore up your homebound defensibility, you must examine your referrals to make sure patients really are homebound before you admit them. Ask yourself these key questions, TAG Marketing suggests in its homebound criteria flowchart -- Does the patient: leave home frequently for non-medical purposes? require assistance when leaving the home? require considerable and taxing effort when leaving the home? have a skilled nursing or therapy need?

If the answer to any of these questions is "no," stop the referral, says the TAG worksheet, which is designed for agencies to share with referring physicians.

If the patient is indeed homebound, then you need to focus on your documentation of that fact, experts agree. "Document, document, document," says consultant Sharon Litwin with 5 Star Consultants in Ballwin, Mo.

"If we focus on the definitions and document to support them, the risk would go down," says consultant and therapist Cindy Krafft with Fazzi Associates.

Follow these tips from the experts to improve your homebound documentation:

• Zero in on the definition's key phrases. Medicare sets out the homebound definition in its Medicare Benefit Policy Manual (see related box,this page). You'll want to target the phrases "general inability to leave home" and "leaving home requires considerable and taxing effort," recommends Chicago-based regulatory consultant Rebecca Friedman Zuber. "I urge agencies to focus their documentation on these two factors." Regarding absences, the core issues are "infrequent," "short duration," and "taxing effort," Krafft adds.

Plus: Don't get distracted with what-if scenarios. "Focus on the homebound status definition as is and not recent examples," Krafft advises. • Clinicians can never include enough details. Do not rely on boilerplate phrases and checkboxes to establish homebound status. "Press clinicians to include enough descriptive information that the documentation paints the picture of why these things are true," Zuber says of the factors that make a patient homebound.

Clinicians should be "very, very descriptive of the patient's homebound status," urges consultant Pam Warmack with Clinic Connections in Ruston, La. "The physical or mental/emotional disability which renders the patient homebound should be described in relation to a current illness or injury and validated with a diagnosis."

Bottom line: Medicare expects the home care clinician to document "how the patient's illness or injury prevents them from leaving home without a considerable and taxing effort," concludes Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

• Address the patient's trips. Don't just ignore your patients' absences from the home. You need to address them thoroughly in your documentation, experts urge.

Clinicians should ask patients how often they leave home, for what purposes, and who provides transportation, Warmack recommends. When the patients leave for nonmedical purposes, describe how long patients could tolerate being away from their homes and how frequently these absences occurred, she says.."The patient can leave home for medical care and to go to church or occasionally to go to the hairdresser," Adams allows. "However, there still is a need to document what type of effort it requires to leave home."

Every time: When you document homebound status, you should always "include information on how frequently the patient leaves home and what type of assistance and effort it takes to leave home," Adams adds.

• Document homebound status more frequently. Often, clinicians will document homebound  status at the beginning of a patient's episode( s), then forget about it. "Homebound status should be clearly established at least at every assessment time point," Adams maintains.

"I urge clinicians to document the patient's homebound status often -- perhaps even every visit -- in specific and descriptive terms," Zuber tells Eli.

• Restructure your charts. Auditors and surveyors will have an easier time finding documentation of homebound status if you set aside a separate place for it in your medical records, suggests attorney Marie Berliner with Lambeth & Berliner in Austin, Texas. You might want to flag a certain area of your paper or electronic chart where the clinician puts the homebound information.

And: It's not a bad idea to include Medicare's definition of homebound right there in the chart, Berliner tells Eli. It can help prompt your clinicians to document comprehensively and help auditors and surveyors remember what they are looking for, she says. "I think there are ... some denials going on because the review contractors really don't understand what homebound means, and so their interpretation can be too strict," Zuber says. "However, agencies' failure to provide more objective and descriptive documentation makes this possible."

• It's not too late to correct. Smart agencies will start looking at their own charts -- before reviewers do, Berliner says. HHAs may want to focus on homebound status for long-stay patients. Clinicians can input late entries when necessary, as long as they follow late entry guidelines such as identifying and dating the late entry.

Remember: If clinician's documentation comes under scrutiny by auditors or authorities, late entries will be questioned closely, legal experts note.

• Don't forget patients. In addition to addressing documentation issues, agencies may want to educate patients more thoroughly about the definition of homebound for Medicare purposes, Berliner  offers. Then if auditors or surveyors ask them questions, they can answer more accurately.

Note: TAG Marketing's homebound flow chart is at www.yourreferralconnection.com/download/TAG_PhysKit_Homebound.pdf, or e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "homebound flow chart" in the subject line for a free copy and link.