Home Health & Hospice Week

Be sure to cover all your technical bases, too.

The physician face-to-face encounter re-quirement may account for the lion’s share of home health agency claims denials these days, but longstanding denial reasons are still important too.

HHH Medicare Administrative Contractor Palmetto GBA recently denied an extremely high rate of claims for F2F under two therapy-focused probes (see related story, p. 50). But the MAC also made a steady stream of denials based on medical necessity and technical requirements such as physicians’ dated signatures and missing OASIS.

Under the probes of 2CGK* and 1BGP* claims, Palmetto regions saw up to 6 percent of de-nials due to codes 5A041 and 5F041 — "Information Provided Does Not Support the Medical Necessity for This Service," the MAC says on its website.

These results reflect what’s happening to agencies around the nation. "Many episodes are being denied for lack of adequate documentation of medical necessity," notes clinical consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. "This continues to be a huge issue, especially due to many of the software programs that require only a checkbox with no requirement to include a narrative."

Often there is no clear indication in the visit documentation of the actual skill provided on each visit by the nurse or therapist, Laff warns. "Our industry has gotten very lazy and haphazard with documentation, believing that the computer should be able to auto-populate information to support medical necessity and skill," she cautions. "There are many excellent ways an intelligent, intuitive software program can assist with clinical documentation," she allows. But clinical documentation should consider and include assessment information from multiple sources — "not just what has been entered into a database."

"Clinical notes need to be more than just checkboxes," agrees Judy Adams with Adams Home Care Consulting in Asheville, N.C. Docu-mentation must "explain what the patient has ac-complished along with clear evidence of a skilled service provided," Adams tells Eli.

Bottom line: HHAs must be teaching and encouraging their clinical staff to be critical thinkers, Laff exhorts. Then that thought process can lead to documentation that supports medical necessity. "We have developed a workforce with many clinicians who are not accustomed to thinking," she worries.

Even when clinicians do not over-rely on canned documentation provided by software, they can still run into problems based on reviewer subjectivity, notes clinical consultant Pam Warmack with Clinic Connections in Ruston, La. Medical necessity denials are more difficult to anticipate and defend than technical denials, Warmack notes. "So often two different reviewers may have a difference of opinion," she says. That’s when you see scenarios such as a RAC denying a claim for lack of medical necessity, then the MAC or QIO reversing the denial on appeal.

While they sometimes seem beside the point when you are focused on providing quality care to patients, you need to make certain you are covering all the technical bases — or you won’t get paid for your care at all. Under Palmetto’s probes, significant percentages of claims denials were due to technical problems such as failing to submit the OASIS that corresponds with the record; lack of a physician signature; and lack of a date to go with the physician signature.

At least the technical issues for denials "are easier to anticipate and deal with" than F2F and medical necessity problems, Warmack says.

Take These Steps To Support Your Claims

To head off denials related to medical necessity or technical pitfalls, heed this expert advice:

1. Don’t fly blind. "Always review the medical documentation" before sending in an ADR response, Warmack urges.

Require a review by the manager who is re-sponsible for the patient in question, Laff says. Use a specific agency review tool to ensure that no record is submitted for medical review without the manager (and senior-level staff) knowing exactly what was documented in the record to prevent surprises.

2. Set up ADR P&P. To make sure you review — and reply to — every records request appropriately, "agencies should have a designated clinical team to respond to ADRs," Laff advises. To avoid dropping the ball, develop a spreadsheet to track the receipt and due dates and document the dates the record was submitted to medical review, she suggests.

3. Nail down signatures. Review every order when it arrives, to be certain the physician’s signature is legible and dated legibly, Warmack offers. "If not, return it or get an attestation form or letter to substantiate the signature and date," she says.

4. Don’t let your records stand alone. Make it easier for medical reviewers to approve your claims by preparing a written summary of the eligibility, homebound status, and medical necessity to submit with the ADR, Warmack counsels.

Laff advises agencies to use a standardized template to pull together a summary describing why the patient was referred, what disciplines were involved, the number of visits by each discipline, a summary description of the care provided, and the patient’s response to the care (i.e., outcomes).

You can also make the reviewer's job easier, and your chances better, by submitting the record in correct chronological order with demographics and the correct MD orders on top, Laff adds.

5. Improve documentation. "Clinical staff need to document specifically to the care plan and the coverage criteria of the patient they are seeing," Adams says. If they aren’t doing that, you need to provide education to help them achieve that goal. That could range from one-on-one coaching to in-services for the whole staff.

Note: For a free copy of and link to Pal-metto’s probe results, e-mail editor Rebecca John-son at rebeccaj@eliresearch.com with "Palmetto probe results" in the subject line.