Kenyon HomeCare ConsultingMaking The Case to Prevent Recertification Denials! - Kenyon HomeCare Consulting (206) 721-5091

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Making The Case to Prevent Recertification Denials!

This is the third in a series of articles discussing coding and home health documentation issues now occurring due to ICD-10. If your organization is to survive, be successful and receive payment for services rendered, recertification changes must be made now!

Under ICD-9 recertifications were fairly easy.  Clinicians generally covered the patient’s progress and asked for additional visits.  Under ICD-10 that will not fly!recertification

Preventing Recertification Denials

First, you need an order signed by the physician acknowledging the verbal order.  Second, the follow up written communication to the physician must document what is needed [number of visits by discipline, frequency, etc.] and why [goals not met, change in condition, etc.]. It is recommended the language in this communication mimic the 485.

Effective January 1, 2016, much more documentation is needed to support the need for the recertification.  As an example, if the primary diagnosis is diabetes, the lab values must be included, e.g. the current A1C, blood glucose ranges and insulin dosage changes occurring during the cert period.  The intermediaries are expecting communication between providers meaning home health clinical staff, must obtain this information from the physician.  A detailed written report of what occurred over the last 60 days including lab values, medication changes and clinical findings, supports the need for the recert. If a case is reviewed under an ADR, failure to provide this level of documentation will likely lead to recertification denial.

Measurable Goals, Comprehensive Documentation Equals Viable Recertification

Clinical staff must develop measurable goals and documentation must reflect the patient’s measurable progress toward those goals.  When therapists provide the only skilled service, they’re good at setting measurable goals and documenting to those goals, but their documentation issues center around medication profiles.  Therapists usually document when the patient is not taking prescribed meds but do not document what they did to correct the issue. Corrective actions include:

  • Referral to nursing for med follow up
  • Establishing a plan to assist patient to remember to take meds

Nurses excel in developing plans of care, but are poor in establishing, writing to and documenting measurable goals.  Examples of measurable goals include:

  • Number of feet the patient walks before becoming short of breath
  • Despite education, patient failed to weigh daily for X days leading to a X lb. weight gain

Failure to document adequately “painting the picture” of why the patient needs continued home visits, leads to recert denials!

The Recertification Bottom Line

More explicit measurable goal setting and comprehensive documentation to those goals is now an absolute requirement.  Discussion, exchange of information and data (lab values, changes in treatment) between the clinical staff and the physician must be documented. Clinical staff must build the reason for and “paint the picture” of why a recert is required to meet the patient’s established goals.  This means the latest recorded visit note must be obtained from the physician. If a physician visit hasn’t occurred since the face to face visit, we suggest using the latest 485 and building from there.  Additionally, document all symptoms and level of acuity making goals unattainable. Remember, to send this recertification documentation to the physician for their records.  And, finally, be sure the coding sequencing and severity match the other providers, or the entire episode could be “kicked out. “

If you are feeling overwhelmed, consider these requirements as best practice and what we should have been doing all along. But, because previous codes were not as explicit as ICD-10, we got away with skimming the surface on documentation.

If documentation is an issue for your agency, Kenyon HomeCare Consulting can help!  Our experienced QI staff is prepared to educate and improve your processes resulting in stellar documentation. Your recertifications will sail through and when ADRs come, complete documentation results in quick reimbursement.

Contact us to get more information about the ICD-10 Coding Plus or call us at 206-721-5091.

This article makes the case for measurable goals, comprehensive documentation and enhanced communication between providers to prevent home health recertification denials. See examples here.


Category: ICD Coding

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