How to Survive Audits by Documenting Medical Necessity in Home Healthcare

 In Home Health, Industry Voices, News, Regulatory, Webinars
On June 22nd, Jennifer Warfield from partner PPS Plus presented in the DeVero webinar series. This is a recap of that webinar. To view the webinar in its’ entirety, go to the webinar page.

Additional documentation requests (ADR) are the norm today – everyone in home health gets them. Perhaps the best defense of documentation requests from payers (specifically Medicare) might be a stout offense that boast an aggressive strategy of documenting every procedure at the point of care and providing specific details of the patient health plan. But even when taking an aggressive approach to defending services provided — with detailed documentation — of the patient experience, there still may be some instances when home health administrators must take action.

To do so, however, it may be worthwhile to understand exactly what some top reason for denial of payment are throughout the first quarter of 2017.

For CGS-processed claims, they list their top denials as: skilled nursing services were not medically necessary; physician’s certification was invalid since the required face-to-face (F2F) encounter was missing/incomplete/untimely; requested documentation was not received/or not received timely; documentation did not show that therapy services were reasonable or necessary; and initial certification was missing/incomplete/invalid, therefore, the recertification episode is denied.

For PGBA-processed claims, they list their top denials as: requested records were not submitted; F2F encounter requirements were not met; Health Insurance Prospective Payment System (HIPPS) code change because of partial denial of therapy; no plan of care or certification; info provided does not support the medical necessity for therapy services; and unable to determine medical necessity of HIPPS code billed as appropriate, OASIS not submitted

For NGS-processed claims, they list their top denials as: documentation submitted does not support homebound status; medical necessity not supported as OASIS not submitted; skilled observation was not needed from the start of care; skilled nursing services were not medically necessary; requested documentation not received/received untimely.

There are still many, many other reasons for denial of claims. Some of these include:

  • OASIS data might conflict with what was billed.
  • Skilled nurse visits are not covered because documentation indicated more visits were provided than were reasonable and necessary.
  • Physician’s plan of care or certification present and is signed but not dated: Documentation submitted did not include the physicians signed certification or recertification. Electronic signatures ensure compliance with this standard.
  • No plan of care or certification – no POC established and approved by a physician; all pages must be included; care plans are omitted from ADRs and/or the wrong plan of care may be submitted because agencies are working against a deadline. Even if not signed and dated then it’s not a valid note.
  • Unable to determine medical necessity HIPPS code billed as appropriate OASIS not submitted: Home health administrator did not submit the OASIS for the HIPPS code billed on claim.
  • F2F encounter requirements not met: These charts can be scrutinized – documentation not submitted with ADR; homebound status not adequate; reason for skilled services not adequate; clinical data not found in patients acute/post-acute records.
  • Information provided does not support medical necessity for this service: Clinical documentation submitted for review did not support the medical necessity of the skilled services billed – nothing listed during the therapy visits do not support the documentation.
  • Auto deny – requested records not submitted: Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity – there’s no reason for this if services are provided.

Home health administrators must review claims and must have a process in place to review end of episodes so they are clean for billing. This doesn’t mean you must quality assess (QA) 100 percent of the charts you process, but establish some sort of protocol that ensures members of your QA team review end of episodes before they are billed. In the case of responding to ADRs, they should be sent with sign receipt request so you are able to track the documents, so that you can see when the documents arrived at the claims processor and who there signed for them.

Administrators also should ensure that education is provided to staff during orientation and annually on the coverage guidelines for clinicians so they understand what is expected to recertify a patient for care.

Also, it’s important to understand that your caregivers should not be allowed to turn in late paperwork. Notes that are completed long after the visit are rarely accurate, and these notes are reviewed in the event of an audit. Each visit note for all disciplines must stand alone and provide needed.

Who’s looking at your documentation?

Recovery audit contractors are looking specifically for inappropriate payments, payment for non-covered services, duplicate service and for medical necessity of care. These contractors can review payments made from Medicare to a home health agency as far back as three years and if they find anything inappropriate, they are likely to keep an eye on your organization. They are paid to recover money for Medicare and they can be diligent, so you must be as well.

Zone Program Integrity Contractors are of most concern for home health and their focus is on detecting and preventing Medicare fraud and abuse.

Regional Home Health Intermediary per home health regions. Their focus is to ensure that services provided meet requirements for reasonable and necessary visits.

Documenting medical necessity

When documenting medical necessity, your clinical notes should include the following for every discipline: Assessment specific to the day of each visit; skilled services performed at each visit – if nothing skilled is done, the visit may not be paid; patient’s response to treatment rendered; plan for the next visit — if there is no plan, is a next visit necessary?

Remember, home health is not intended to be a lifelong event.

Avoid vague terms in your notes

When drafting patient notes, caregivers must avoid the innocuous and the non-detailed. For example, avoid the following: “Patient sitting up. Alert and oriented”; “patient with no new complaints”; “wound care performed”; “instructed on disease management and medication teaching”; “will continue with plan of care”;

Instead, be specific with patient notes. For example, dig in and provide detail so that the record best reflects the patient’s care and to ensure payment for services provides. Use the following: “Pain level since last visit has decreased from eight out of 10 to five out of 10”; “observed patient demonstration of insulin administration”; “patient reports coughing up thick green stuff”; “wound edges well approximating, no drainage noted”;

Plan of care specifics

The plan of care must be precise and patient centered. You must steer clear of cookie cutter interventions and goals, and you must rethink and revamp the POC if necessary. Instead of the plan being, “To teach on cardiac diet” write “instruct patient on rationale for following a cardiac diet, and foods allowed and not allowed on this cardiac diet.” Instead of writing “patient will understand the effects of Furosemide” write “to instruct patient on signs and symptoms on hyper or hypokalemia and when to report to health provider.”


A major red flag for an audit or a denied claim is when agencies list the majority of their POCs as “SN 1w9.” Frequencies of visits and care should be specific and include the details for how you are planning to discharge patients. Thus, you must focus on what services are needed, not availability of care.

Also, when providing documentation to support therapy, your orders must justify the evaluation; document orders beyond initial visit – sometimes it’s better to write exactly what they want you to do; number of visits projected; patient’s current functional status; objective tests and measurements; a review of relevant systems; progress toward goals – that’s our whole point; and provide a revision of interventions and goals when necessary.

Therapy specifics

When adding therapies, be sure that documentation demonstrates why the care is indicated. Provide guidance on the reason for evaluation. Next, be sure that the therapy plan of care is comprehensive, specific and documentation supports interventions and goals as planned.

However, you must always be wary of potential red flags — the less than obvious red flags than the one mentioned above. Detailed here are some of the most egregious examples of the worst offending red flags. These worst offenders are: if previous episodes of care are listed for the same issues; copy and paste of treatment for the patient; and providing no new diagnosis or issue details since a previous OASIS.

Keep in mind: If a patient is “re-certed” there should be different issues listed or better resolution to the problem. Re-certing a patient with same chronic conditions likely leads to a denial as will providing no definitive documentation of progress being made, care that is not reasonable and necessary, and numerous cancelled or missed visits by the patient.

Homebound or not?

When determining if a patient is homebound or not refer to the Medicare benefit policy manual definition. That’s the best place to start. Even with that, the homebound status should be documented at every visit. Caregivers must document whether assistive devices or assistance of another person is needed to leave home safely, and you can never assume that every patient that is homebound on admission is still homebound as care treatment commences. Additionally, your care team should question all patient absences and missed visits.

Reassessment of homebound status is legislated by 2011 federal regulations.

No matter the outcomes, every patient must have a plan for discharge even if they never will be discharged — we all need to know that there is a plan, as there may be the need for an early discharge for the patient reaching his or her goals early, or if the previous plan’s goals can never be met.

Responding to ADR

Even if you are aggressively proactive in your documentation and you take an aggressive strategy of documenting every procedure at the point of care and specific details of the patient health plan, you are almost guaranteed to receive an ADR request — they are the norm today. There are some instances when home health administrators must take action. In so doing, you must assign someone to monitor your direct data entry (DDE) every day. Do not ignore any requests received. Then use a checklist to be sure all required documentation is added and collected.

Include a copy of ADR letter; use a cover sheet and an index page in the response – don’t give the requestor the opportunity to find other potential issues. Don’t use Post-it notes or highlighters in the response. Include a clean copy of POC and secure attestation and addendums from physicians when needed. Include signature logs when needed and assure that everything is signed and dated.

Then put everything in chronological order and send everything at once. Remember, every record must be QA tested before being sent because, as the saying goes, “if you didn’t chart it you didn’t do it.”

Finally, in regard to ADRs, take a note of all correspondences and use these as an educational opportunity to develop a plan of correction.

Learn more

To learn more about audits and responding to ADRs, listen to a replay of our free webinar on the topic, “How to Survive Audits By Accurately Documenting Medical Necessity in Home Health” by clicking here:

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