Home Health & Hospice Week

Pointer: Bulk up your observation and assessment support.

You may realize that proving medical necessity for skilled nursing visits is critical to obtaining your rightful reimbursement, but what can you do to actually achieve it?

Smart home health agencies should consider taking a number of steps to make sure this hot topic doesn’t doom their claims, including:

1. Get comprehensive with documentation. “Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services,” HHH Medicare Administrative Contractor Palmetto GBA offers in advice on how to avoid a SN medical necessity denial.

“The medical record documentation, including the Plan of Care and [OASIS], provide the basis” for the medical necessity determination, HHH MAC CGS notes in its Medically Necessary and Reasonable webpage.

“Include all records necessary to support the services for the dates requested,” directs HHH MAC National Government Services on its Responding To Post-Payment Review ADR webpage.

2. Go beyond the checkbox. Electronic records that provide a template for documentation can be a mixed blessing (see story, p. 222). “The checked box many times does not tell the whole story,” warns FORVIS consultant Angela Huff in Springfield, Missouri.

“Much like a recipe, those checked boxes can be more like ingredients that tell part of the story, but still need additional information provided to ensure the whole picture is provided so that the ‘recipe turns out’ as intended — in this case, in solid documentation regarding patient need and skill provided,” Huff advises. “The clinician has to provide the added descriptions and connections to pull the relevant assessment items together to tell the story of what they are seeing in the home and what interventions and skill they are providing as a result of the patient’s individual needs,” she continues. “A checkmark can’t always do that and stand alone enough to indicate the assessment items that point to what skills were needed any why,” she cautions.

“Reviewers may not be able to fit the pieces together correctly … without that solid context from the documenting clinician,” Huff warns. “That can lead to denials.”

3. Focus on data. “Coverage decisions are always based upon the objective clinical evidence of the beneficiary’s individual need for care,” CGS explains. Make sure your record includes that objective evidence.

4. Follow through. Don’t leave the patient’s story half told. “It is the home health agency’s responsibility to provide clear documentation of the medical necessity and reasonableness,” CGS stresses. “This includes: progress or lack of progress, medical condition, functional losses, and treatment goals,” the MAC details.

5. Sweat the small stuff. Technical details missing from a medical record can sink your claim. For example, “a legible signature and date signed is required on all documentation necessary to support orders and medical necessity,” Palmetto reminds providers.

“All services must include necessary signatures and credentials of professionals,” NGS tells agencies. And “the patient’s name must be included on each page (front and back where applicable),” the MAC says.

Plus: “The records submitted must be for correct dates of service for the claimed episode,” NGS adds.