Home Health & Hospice Week

If you don't thoroughly understand -- and document -- a patient's homebound status and skilled need, you could wind up furnishing her care for free.

In the third quarter of 2011, Palmetto GBA's number-one denial reason for home health agencies was "5AT10/5FT10 -- Documentation Does Not Support Homebound Status," the HHH Medicare Administrative Contractor reports in its December provider newsletter. "The services billed were not covered because the medical records submitted for review did not support homebound status," the MAC explains.

And the number-three denial reason was "5A041/5F041 -- Information Provided Does Not Support the Medical Necessity for All or Part of This Service," Palmetto adds. "The clinical documentation submitted for review did not support the medical necessity of the skilled services billed," the MAC details.

For example: "The submitted documentation may have indicated there was no longer a reasonable potential for change in the medical condition, or sufficient time had been allowed for teaching or observation of response to treatment," Palmetto continues.

"Unfortunately, so many of the denials are appropriate due to very poor documentation," says consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Further, "many agencies have not actually read and/or understood the [Centers for Medicare & Medicaid Services] coverage criteria and all home health regulations for payment."

Watch out: Due to a mixture of the Medicare requirements' vague nature and HHAs' poor charting practices in the prospective payment system years, it's easy for MACs to whack an agency with these two types of denials once the agency gets in the contractor's medical review crosshairs.

For instance, Lynn Olson, owner of Corpus Christi, Texas billing company Astrid Medical Services, saw a client that was under scrutiny for overutilization of outliers hit with homebound and medical necessity denials. "Don't do anything that will draw Palmetto's attention," Olson advises HHAs.

To avoid or appeal medical necessity and homebound denials, agencies "first must read the CMS HIM 11 coverage criteria to make sure they clearly understand the definitions of skilled home care services and the definition of homebound," Laff recommends. (See the coverage criteria in the Medicare Benefit Policy Manual, Chapter 7 at www.cms.gov/manuals/Downloads/bp102c07.pdf.)

HHAs must understand when their patients qualify for home care. (For Palmetto's list of acceptable reasons for skilled care, see story, p. 339.)

Use these tips for avoiding and appealing homebound and medical necessity denials:

• "Thoroughly audit the patient record without 'reading between the lines' and considering anything verbalized about the patient -- only considering what is documented," Laff counsels. The documentation alone must support the claim.
• The bene can leave the home if she is homebound. You just must "submit documentation that reflects that it is a taxing effort for the beneficiary to leave the home," Palmetto advises.
• Conduct an interview of the primary clinician if you decide to appeal. This will help you write a succinct summary for the appeal that highlightsreasons for medical necessity and homebound status. Your appeal summary should also include the total number of visits for each discipline provided, Laff adds.
• Don't neglect one requirement if the other is fulfilled. If the patient is homebound, they still must require skilled services and vice versa, Laff stresses.
• Focus on changes. Medicare is not a longterm care benefit, and Medicare contractors are on the look-out for patients who don't have skilled needs. One reason Palmetto cites for medical necessity denials is "the submitted documentation ... indicated there was no longer a reasonable potential for change in the medical condition."

"Look for documented evidence in the patient record reflecting changes in condition affecting the plan of care," Laff advises. "Do not rely on the addition of a simple over the counter medication i.e. ibuprofen, vitamins, etc. -- to support a significant clinical change in condition."

In particular, when the skilled need is observation and assessment, be sure to document those changes carefully. "If the patient has remained stable and all medical conditions are well controlled, it may be determined that the patient's condition is not volatile and therefore continued skilled services  were not reasonable or medically necessary," Laff cautions.