Home Health & Hospice Week

Does your certifying docs’ documentation contain these elements?

One of Illinois home health agencies’ complaints about the Pre-Claim Review demonstration in their state is vague and confusing nonaffirmation decisions.

In an apparent effort to address that criticism, HHH Medicare Administrative Contractor Palmetto GBA on Sept. 30 issued an article enumerating the types of information required for the physician’s “‘actual clinical note for the face-toface (F2F) encounter’, required for compliant home health physician certifications.”

“A clinical note has specific classes of information,” Palmetto explains in its article. The note for F2F “is no exception.”

Palmetto lists these “classes of information” required in the note:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Vital Signs (Vitals)
• Temperature (Temp)
• Heart Rate (HR)
• Respiratory Rate (RR)
• Blood Pressure (BP)
• Physical Examination (PE)
• Assessment
• Plan
• Discharge Condition
• Follow up

Important: “While not every class of information has to be included in the clinical note in order to meet the requirement, a compliant ‘actual clinical note’ would contain a combination of some of the classes of information listed above,” Palmetto allows in the article.

Note: See the article in the “Articles” section of Palmetto’s PCR page online at www.palmettogba.com (click on “Jurisdiction M Home Health and Hospice,” then click on “Home Health Pre-Claim Review” in the “Top Links” box).