Home Health & Hospice Week

How well do your patients’ records tell their story?

Wondering how to make sure your claims will pass muster with medical reviewers? A new tool from HHH Medicare Administrative Contractor Palmetto GBA might help.

Palmetto is issuing denials for face-to-face documentation at an alarming rate, but denials for the old-school trouble spot of medical necessity persist as well (see related story, p. 52). Here are items Palmet-to says it wants to see in the medical record when it conducts review, according to its website:

Documentation to support beneficiary is appropriate for Medicare Home Health Services (not an all-inclusive list)

• New onset or acute exacerbation of diagnosis

• Acute change in condition

• Changes in treatment plan as a result of changes in condition (i.e. physician’s contact, med changes)
• Changes in caregiver status
• Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes)
• Homebound status is supported
• Need for a skilled service is supported

Therapy Documentation

• Orders include frequency and duration
• ‘Eval and treat’ orders are followed up with specific interventions
• Measurable goals for each discipline
• Skilled care evident on each note
• Every note signed and dated
• Notes reflect progress towards goals
• Assessments completed
• Initial assessment contains assessment of function which objectively measures ADLs
• Reassessments performed timely to reassess the beneficiary and compare resultant measurement to prior measurements
• Assessments performed by therapist, not assistants
• Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals
• Physician orders have documentation that the intervention ordered took place

Nursing Documentation

• Daily skilled nurse visit orders contain frequencies with indication of end point
• If insulin administration is reason for service, documentation of why beneficiary or caregiver cannot administer
• Skilled care evident on each note
• Every note signed and dated
• Visits consistent with physician orders
• If teaching and training, clear documentation of tasks to be taught and progress toward beneficiary/caregiver accomplishing that task
• For observation and assessment, documentation of beneficiary status after 21 days
• Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals
• Physician orders have documentation that the intervention ordered took place.