Kenyon HomeCare ConsultingWill Poor Home Health Documentation Be Your Final Nemesis? - Kenyon HomeCare Consulting (206) 721-5091

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Will Poor Home Health Documentation Be Your Final Nemesis?

This is the second in a series of articles discussing the 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, changes must be made now!

Hands down, home health documentation is at the top of ICD-10 concern list and the most often sited infractions found by surveyors. Three years ago, consultants and coding experts around the country begin beating their drums encouraging ICD-10 staff education. Now 2 quarters in, we are seeing the consequences of not attending to these documentation requirements.home health documentation

Kenyon Consulting associates working specifically with coding clients are reporting that many clinicians continue to document in the “old way” using generalities. The new ICD-10 requirements demand documentation consists of measurable data supporting the homecare diagnosis(s). This focused documentation explains the reason for the current episode of care, supports the care plan and addresses client goals.

Home Health Documentation Examples Identified by Palmetto 

The CMS payment contractor Palmetto has given two examples of specific documentation concerns leading to episode denials. Both cases fall under “management of a care plan” specifically for visits to change catheters or fill medication boxes.

Catheter changes. Clinical record documentation did not support:

  • Homebound status
  • Why the patient is unable to go into the physician’s office for catheter change
  • A viable homebound reason is NOT unavailable or unaffordable transportation

Medication Box Refills. Documentation failed to show:

  • Meds were frequently missed or taken incorrectly
  • Critical outcomes occurred requiring a nurse to follow up
  • No reliable, competent caregiver available to fill med box
  • Why pharmacy prefilled or bubble pack meds is not an alternative. A nurse is required to monitor missed or incorrectly taken meds, provide education and follow-up to prevent complications

Home Health Documentation Issues Now With Steeper Consequences   

Long standing areas of documentation distress cited often by surveyors, surrounds patient change of condition and aide supervision.  When a change of condition occurs, reimbursement denials are most frequently issued because the documentation failed to show:

  • Inadequate communicate with the physician regarding change in condition
  • Supporting data describing the change
  • Specifically what the clinician did/will be doing to address the change
  • Measurable outcomes of care goals
  • Increased number of visits to meet goals

Meeting the Medicare requirement of the clinician documenting aide supervision at least every 14 days, is an ongoing problem. With ICD-10, documentation requirements are broader, and have greater consequences. The supervising clinician must document:

  • Dates of any missed aide visits
  • Whether replacement was sent or the visit was rescheduled on a different day
  • Areas where aide did not follow the plan of care, specifically what was done or not done
  • What the clinician did to correct the situation
  • Physician was notified of missed visits or failure to follow care plan of care and what was done to resolve the problem

Some of the home health documentation requirements mentioned above are new but many are standards of practice long in place under the old coding system. In order for your organization to be successful, staff must be educated on appropriate documentation! Education leads to adequate supporting documentation, resulting in complete ICD-10 coding specificity allowing for timely and maximum episodic payments.

If you organization is experiencing documentation issues, contact Kenyon HomeCare Consulting today! We will help with onsite documentation education or by providing agency specific webinars.

Stay tuned for the 3rd series article, Making the Case for Recertification examining the expanded documentation requirements for recertifying home health.

Category: ICD Coding

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