Home Health Coding and OASIS Expert

Published on Thu Feb 12, 2015 PDF

Key: Your documentation should corroborate the physician’s.

The new face-to-face requirement means more work and less reimbursement certainty for many home health agencies. But if you’re proactive, your OASIS documentation can help patch up gaps in physician documentation.

Know What’s Required

“The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain information that justifies the referral for Medicare home health services,” explained the Centers for Medicare & Medicaid Services’ Medical Officer Cindy Simpson during the December National Provider Call, “Certifying Patients for the Medicare Home Health Benefit.”

This includes documentation that substantiates the patient’s:

1. Need for the skilled services; and
2. Substantiates homebound status;

In addition, Simpson explained that the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:

3. Occurred within the required timeframe,
4. Was related to the primary reason the patient requires home health services; and
5. Was performed by an allowed provider type (physician or allowed non-physician practitioner).

The good news: The HHA information the doc incorporates into her record can still tackle the tough part — showing homebound status and skilled need. The documentation from the physician or from the facility may be “lacking,” noted CMS’s Randy Throndset in the call. Examples given in the call showed “some gaps … in what was there.” But information provided by the HHA can “fit with what the physician or facility was providing and … substantiate the eligibility,” he told an agency in the question-and-answer portion of the call.

While information from the HHA can be incorporated into the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient, keep in mind that the info “must be corroborated by other medical record entries and align with the time period in which services were rendered,” CMS stressed in the presentation.

Also, “the certifying physician must review and sign off on anything incorporated into the patient’s medical record that is used to support the certification of patient eligibility (that is, agree with the material by signing and dating the entry),” according to the slides for the call.

Consider this F2F Scenario

The importance of your OASIS assessments will only increase under this rule. In one of the documentation examples, Simpson illustrated how an OASIS document could fill in the gaps of a physician record that doesn’t quite spell out the patient’s homebound status.

For example: In a sample scenario, Simpson shared a hospital discharge summary and two pages of the comprehensive assessment from the corresponding OASIS for a patient who was referred to home health following a total left knee arthroplasty.

Note: Find the documents Simpson refers to here: www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-12-16-Home-Health-Benefit.html. Open the “Examples” zip file and follow along with both “Example 4” documents.

The sample discharge summary includes the following F2F-related information:

1. Need for the skilled services: The following two sentences in the discharge condition section supported the need for skilled services, Simpson said. “Mr. Smith is to be discharged to home with home health services, physical therapy and nursing visits, ordered. PT is needed to restore the ability to walk without support. ” Short-term skilled nursing is needed to monitor for signs of decompensation and teaching of Lovenox injections.

2. Homebound status: The patient’s total left knee arthroplasty is documented under the procedures section of the discharge summary, and the discharge condition section describes the need for physical therapy. But “even though you could probably guess why the patient is homebound, it does not appear to be stated in this discharge summary,” Simpson pointed out.

3. Required timeframe: The discharge date covers this requirement.

4. Related to the primary reason for home care: The same note in the discharge condition section demonstrates that this encounter was related to primary reason for home care. Plus, the procedures section documents the patient’s left knee arthroplasty and need for physical therapy.

5. Performed by an allowed provider: The note has been signed and dated by an allowed provider type.

So far, the discharge summary has everything except documentation that demonstrates why the patient is homebound, Simpson said. “It hints at it, but doesn’t state it.” As a result, the reviewer may be left with the question “why doesn’t this patient go to outpatient therapy?”

For this last piece of required documentation, Simpson suggested turning to the excerpt from the comprehensive assessment.

The patient in this scenario has scored the following on the excerpted ADLs/IADLs:

(M1845) Toileting Hygiene: 1 — Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.

(M1850) Transferring: 1 — Able to transfer with minimal human assistance or with use of an assistive device.

(M1860) Ambulation/Locomotion: 2 — Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

In a comment following M1860, the clinician has written “Pt. with a shuffling gait and frequently trips while ambulating. Pt. requires a wheeled walker and requires frequent cueing to remind him to not shuffle when he walks and to look up to avoid environmental hazards. Unable to go up and down stairs without his daughter assisting him. Daughter states that patient needs 24/7 supervision and is only able to leave his home for doctor appointments and only when she and her husband assist him. Patient is an increased fall risk because of inability to safely navigate stairs, uneven sidewalks and curbs.”

The patient has scored “1s” and “2s” in the check boxes, but the most important part of this excerpt is the home health agency’s clinician’s written assessment, Simpson said. “We really value what you as clinicians working for the home health agencies do every day. And we really do appreciate when you document what you are doing. That is quite helpful to us.”

Important: “We can visualize this patient thanks to the wonderful comments written by this home health agency clinician,” Simpson pointed out.

Putting the techniques CMS outlined during the call into practice may prove challenging to HHAs, experts agree.

“The example from CMS seems to indicate they would like to have a ‘summary’ of the combined M1800 series following that piece of the assessment,” says Arlene Maxim, RN, founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. “This is interesting since, in my experience, I have seen no software where this type of comment section is built in.”

Incorporating HHA comments is a “wonderful idea, but it is going to be difficult to retrain the staff to create such a document using any (at least most) software available today,” Maxim says. “This type of ‘integration’ into the assessment is going to take some intense training of assessment clinicians.”

Don’t forget: The section from the example comprehensive assessment has been incorporated into the physician’s record and signed and dated by the patient’s physician. This indicates review and incorporation into the patient’s medical record.

Together, the section from the comprehensive assessment and the physician’s discharge summary corroborate each other, Simpson said. “The two fit together. The discharge summary states that PT is needed to restore the patient’s ability to walk without support and the section from the comprehensive assessment describes a supportive device — the wheeled walker.”

Resources. You can access the call’s audio recording, transcript, slides, and documentation examples online at www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-12-16-Home-Health-Benefit.html.