Home Health & Hospice Week

Make sure OASIS backs up your patients' homebound status.

Don't let your preoccupation with OASIS and coding result in slack homebound documentation, or you could be sorry -- very sorry.

Lifeline Health Care Group Inc. is sorry to the tune of $1.17 million for documentation lapses the HHS Office of InspectorGeneral recently found, and the lion's share of those lapses were for patients'home-bound status (see "OIG Slaps $1.2M Overpayment On HHA For Documentation Lapses").

Homebound status was one of the OIG's favorite home care punching bags in its latest report to Congress as well, with nearly $1.7 million in settlements reached for documentation problems featuring homebound (see Eli's HCW, Vol. XIII, No. 22).

HHAs "may see more and more denials due to homebound issues in the future," warns consultant Pam Warmack with Clinic Connections in Ruston, LA.

Home health agencies that are distracted with OASIS and coding requirements sometimes lose sight of the importance of clear homebound documentation, worries clinical consultant Judy Adams with the Larson-Allen Health Care Group based in Charlotte, NC.

These documentation lapses are part of a widespread trend, maintains clinical consultant Lynda Dilts-Benson with St. Petersburg, FL-based Reingruber& Co. Dilts-Benson "constantly" sees these types of documentation problems when she audits clients'charts, she says.

To make sure you don't lose thousands to homebound reviews, try these experts' tips:

1. Document regularly. First off, "a strong statement describing the patient's homebound status must be documented at the time of admission," Warmack recommends. Then document homebound status with every single visit note from every discipline, Dilts-Benson urges.

Avoid this common problem: Some agencies find that when they require homebound documentation at every visit, quality of the documentation decreases.

To combat this problem, Adams advises clinicians to complete a very comprehensive and detailed explanation of what makes the patient homebound at every assessment and reassessment time point.

2. Cue documentation. Prompting clinicians on forms to document homebound status is a great way to solicit necessary support, counsels clinical consultant Karen Vance with BKD in Springfield, MO.

"On the forms that leave it up to the clinician to remember to document homebound status, it happens less," Vance observes.

3. Avoid generic terms. Bad documentation is sometimes worse than no documentation at all. "I've seen boxes with 'homebound status' checked, 'yes,'" Vance relates. "This is not convincing."

Notes should be patient-specific, Dilts-Benson advises. For example, they should include descriptions of specific equipment needs, barriers in the patient's home and assistance requirements, among other factors.

Never: Simply listing "weakness" as the reason for homebound status isn't going to cut it, Adams contends. Records should include "clear statements of physical or mental functional limitations that demonstrate why the client has an inability to leave home or that show how leaving home requires a considerable and taxing effort," she stresses.

Always: "Imagine yourself verbally describing to a surveyor why the person is not able to leave the home without a lot of effort," and then use those descriptions, Vance recommends. That advice helps clinicians avoid "the routine phrases used over and over [that] may not aptly describe that patient."

4. Double-check OASIS. Homebound status "should absolutely support and be supported by what is coded in the OASIS," Dilts-Benson says.

If your patient's OASIS is all zeros and ones in the functional status domain (M0650 - M0700) and zero on M0490 (Dyspnea), you'd better have excellent documentation showing why she is homebound despite having virtually no functional limitations, Adams warns.

Often, clinicians document limitations in the medical record but fail to mark them on OASIS. For example, if you record that the patient has shortness of breath after walking 20 feet, you should make sure M0490 is marked "1," Dilts-Benson urges.

5. Explain apparent contradictions. If the agency has a comprehensive description of why the patient is homebound, reviewers will generally let homebound status stand -- unless they find blatant contradictions, Adams cautions.

And evidence that the patient regularly leaves the home can be such a contradiction. Therefore, you should explain any absences thoroughly, Dilts-Benson advises. Document "where they went and how much assistance they needed, as well as ... how often this happens," she says. Homebound regulations loosened up in 2002 to allow more absences from the home, but trips out still must require a considerable and taxing effort.

Try this: It's a smart idea to record not just how hard it is to leave the home, but the impact on patients' abilities when they return, Vance says. Document factors such as how long they have to rest after returning, what activities of daily living are affected or skipped due to fatigue, and what the absence does to their oxygen saturation levels, for example.

Be especially careful about documenting the reasons for missed visits, Warmack adds. "If a patient is frequently not home to receive ordered care, their homebound status may be questioned," she points out.

6. Compare notes. Reviewers are likely to question a patient's physical limitations if they are not backed up by the services aides provide, Warmack predicts. And every discipline's notes should support homebound status equally. "Agencies must read visit notes by every discipline visiting to ensure assessment findings do not contradict between disciplines," Warmack recommends. "This is often the case between nursing and physical therapy."

"Homebound status is always on the OIG's hot topic list for home care," warns Adams. "Because homebound is one of the qualifying criteria for Medicare home health services, agencies should always be prepared to have their records reviewed for clear evidence of the patient's homebound status," Adams tells Eli.