Category Archives: Documentation

Palmetto GBA expands Probe & Educate initiative

Home health agencies in the 16 states served by Palmetto GBA Medicare Administrative Contractor could see a significant increase in the amount of records reviewed as part of an expanded Probe & Educate initiative.

Some agencies could be required to provide as many as 20-40 records on average instead of the five records requested for previous Probe & Educate reviews, according to Bobby Lolley, Executive Director of the Home Care Association of Florida.

“This review will be extensive, with 20-40 records on average being requested, not just another five records like in previous rounds,” Lolley said in an email to HCAF forum members this week.

Agencies subject to the significantly increased record requests are those which received denials of two or more records reviewed in an earlier round of the Probe & Educate initiative.  Some of those agencies did not receive specific instruction they were expecting from the MAC as part of the process because the Probe & Educate initiative was suspended earlier this year.

Lolley said all agencies in Round 2 can be subject to further review, even those agencies which did not complete Round 1 and receive one-on-one education from the MAC before that round was suspended.

Lolley said Palmetto provided the following  statement to a home health coalition request for clarification about agencies which did not receive one-on-one instruction : “Providers are being progressed if they did not request education on or before their due date. We have a number of providers that missed their deadline to request education, so yes, there is a chance that they have been progressed before they are receiving their education.“

Focus on the F2F

“Mac reviewers will be looking at the claims to ensure that agencies are in compliance with Medicare eligibility and payment requirements,“ said J’non Griffin, owner of Home Health Solutions.  “In Round 1, a substantial number of agencies had problems with the Face-to-Face.”

Additional concerns included a lack of specific orders for therapy and services, omissions and inconsistencies in documentation, but the Face-to-Face was one of the most troublesome areas for agencies, she said.

“Agencies which have not yet received training in the Face-to-Face should make doing so a priority,” J’non said.

J’non will offer an online audio training session titled “Make the Face-to-Face Count” next Thursday, July 13, reviewing valid and invalid F2F items pulled from actual charts, and discussing specific methodologies.  For details, click here.

Hospice agencies may be interested in an online audio training program titled “Improving Hospice Documentation,” presented by HHS Special Projects Director Heather Calhoun on Tuesday, July 11.  For details, click here. 

The 16 states in the Palmetto GBA area include Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, Illinois, Indiana, Ohio, Oklahoma, North Carolina, South Carolina, Tennessee, and Texas.

How your home health agency can avoid ADRs

EDITOR’S NOTE: This article is reprinted from the July issue of The Absolute Agency, a free monthly best practices guide for home health agencies published by Home Health Solutions. Click here if you’d like to subscribe.

You’ve read and re-read your claim before submitting it, and you have all the documentation in place – but there it is: the dreaded request for additional documentation.

First of all, don’t panic.

 An ADR does not necessarily mean your agency has done anything wrong. Many things outside your agency’s control can trigger these requests, including probes or edits that are service-specific, provider-specific, beneficiary-specific or diagnosis driven. In many cases the OASIS will trigger a frequently-abused HIPPS code.

If you really have done your homework, evaluating and scoring your patients according to Medicare’s own definitions and supplementing the OASIS with high quality clinical notes and assessments, your ADR experience is likely to be much less stressful.

You may simply need to do a better job of connecting the dots for the MAC reviewer by providing information that was inadvertently omitted, or pointing out documentation the busy reviewer overlooked.

 “Try to look at any ADR as a learning experience that can sharpen your documentation skills, identify weaknesses in your operation and shore up your processes to protect against future ADRs,” advises J’non Griffin, owner of Home Health Solutions.

   Sometimes, of course, it’s more than the luck of the draw that attracts ADRs. Agencies make mistakes. OASIS scores aren’t well supported, or call into question the patient’s homebound status, phraseology is vague or subjective rather than clinical, and it’s difficult to tell what’s actually going on with the patient’s condition.

When the agency has not clearly documented from the beginning, attempting to sort through the confusion can turn into a time-consuming bout of evidence-collecting and careful explanation.

J’non and the HHS team have helped agencies of all sizes across the country successfully respond to ADRs, and they have identified a few of the Red Flags likely to capture the notice of MACs. The good news is that agencies can address many of these risk areas before submitting claims just by carefully reviewing documentation.

“There’s no magic deterrent to protect any agency, but you can take steps to insulate yourself by being aware of certain triggers and becoming proactive about avoiding these errors or improving documentation in these areas,” J’non says.


   Here are some of the trouble areas that can trigger an ADR for an agency:

– Contradictory answers on the OASIS
– Inadequate Face-to-Face documentation
– Multiple re-certifications
-Recertifying when there is no new or exacerbated diagnosis in the record
– Recertifying for a “later episode”
– Minor treatment changes that do not support medical necessity
– No evidence of a continuing need for skilled care
– Multiple episodes of observation and assessment of chronic con
– Repetitive education or education that does not address a knowledge deficit
– Discharges followed by re-admissions without any intervening change in the patient’s condition
– Inconsistencies in patient treatment



   When your agency has received an ADR, these tips may help you complete it in a timely and thorough manner:

  •  Look at the ADR due date and mark it on a calendar. With a limited response time, it is imperative to complete your information gathering tasks by the deadline. We recommend setting a target date for submitting your response prior to the actual due date to ensure timeliness.
  • Use a team approach to address the ADR. Nursing, therapy and medical records will likely need to work together to review and collect the data needed.
  • Carefully review the ADR and note each piece of requested documentation. There’s no better way than an old-fashioned checklist to make certain that you are addressing each request.
  •  Additional documentation which has not been requested may be provided to support payment of the claim. Signed and dated physician certifications, for example, may not be on the list of requested documentation in an ADR, but this is a foundational piece for establishing the validity of your claim.
  • On the other hand, do not make the mistake of overloading the reviewer with too much documentation. A file bulging with too much information, particularly information which was not requested, will not be happily received by an overloaded reviewer behind in his or her cases. Choose your evidence wisely, based on the strength it adds to your case.
  • Resist the urge to alter or attempt to correct any original documentation. Explain and supplement to make your case stronger.
  •  Assemble all documents in order of request. Your goal is to make the process as easy as possible for the reviewer, and providing the information in a manner that is easy to sort through will be helpful. Some agencies use page numbers specific to the particular case. Others identify documentation pages with highlighted text, or provide an index. There is no right or wrong way — but your submission must be easy for the reviewer to figure out.
  • Create a persuasive Cover Letter. This is arguably the most important part of your response. The Cover Letter will justify the care delivered by your agency and briefly tell the reviewer what supportive documentation is being submitted and how to easily find it. Don’t make the Cover Letter too long. It should briefly summarize the patient’s needs, the skilled services provided to meet those needs, and the patient’s response/progress. Make it as easy to read as possible. No one likes to read two pages of text unbroken by paragraphs! Use bulleted points, and consider adding some bold-faced titles to help the reviewer quickly scan the material. See how we have used bold-faced titles such as “Some ADR Triggers” and “Tips for Responding” here to break up the text? You may wish to do the same thing in your Cover Letter with helpful titles such as “What We’re Submitting” or “Skilled Services We Provided.”
  • Keep a copy of all documents submitted to the Contractor.


   ADRs are intimidating and time-consuming. Sometimes, the surest way to navigate an ADR is to turn to an experienced clinical consultant who can guide you through the process, make certain that you include all the key elements needed to support your claim.
The consultant can also show you how to make process improvements to reduce the risk of future ADRs or claim denials.
Home Health Solutions can provide the support you need to take the pain out of the ADR process. If you’d like more information about our ADR services, call us at 888-418-6970 or email:


CMS suspends pre-claim review rollout in Florida

That’s the word of the day for home health agencies in Florida, where there is industry-wide relief in the wake of a last-minute decision by the Centers for Medicare and Medicaid Services to suspend a pre-claim reviews rollout.
The rollout was set to begin Oct. 1,  but home health industry advocates and state lawmakers have lobbied hard to postpone the program, saying agencies are not prepared to meet the extra burden of preparing and submitting pre-claims.
Opponents pointed to a disastrous six weeks of initial efforts in Illinois, the first state to be included in the pre-claim demonstration, where very few pre-claims were approved on first submission.
The Home Care Association of Florida  was among the industry advocacy groups cautioning that patients needing home care were at risk as agencies scrambled to meet the pre-claims review burden. HCAF officials expressed relief Monday over the decision by CMS to grant agencies additional time.
No new timeline has been provided for the PCR demonstration in Florida or in other states which were previously scheduled to become part of the PCR demonstration over the next few months. Texas, Michigan and Massachusetts were on track to become part of the demonstration by Jan. 1.
CMS has indicated it will provide a 30-day notice before resuming the demonstration.  The demonstration already underway in Illinois is not included in the suspension, and will continue.
   In making the announcement, CMS acknowledged that problems experienced during the initial rollout in Illinois showed additional education will be needed before the demonstration can proceed.

Illinois non-affirmations

In Illinois, the demonstration that rolled out Aug. 1 has been marked by widespread non-affirmations, with an estimated 80 percent of first submissions failing to meet approval.
A large number of non-affirmations were based on the failure of agencies in Illinois to establish homebound status of the patient and medical necessity for home health services.
The National Association of Home Care and Hospice has fought the PCR demonstration, citing numerous problems with electronic submissions. NAHC’s Vice President for Law Bill Dombi called it “a complete mess.”

Use the reprieve to get prepared

“This delay gives home health agencies some much-needed time to better prepare for the pre-claims review demonstration,” says J’non Griffin, owner and president of Home Health Solutions LLC.
“But it is important to note that the process has only been postponed, and not canceled, so agencies will still need to prepare.”

Not sure where to start?

Home Health Solutions has a great DIY Kit to get your agency started, and it’s priced at just $25. Give us a call at 888-418-6970.
Many agencies are also considering outsourcing the preparation and submission of PCRs. Home Health Solutions is working with agencies who need PCR assistance, and will be glad to speak to you about how we can help your agency.


How home health agencies can meet the pre-claim reviews burden

Do you know the two primary risk areas?
Here’s a look at what’s being rejected —
and four things agencies need to do

This article first appeared in the September issue of SOLUTIONS,  a monthly e-newsletter from Home Health Solutions LLC.  If you’d like to receive our free newsletter,  click here to subscribe. 

Six weeks into the first Medicare pre-claim review demonstration in Illinois, the rest of the home health field is watching, hawk-like, to assess the damage and determine industry-wide risk.
Uneasy curiosity hinges on three questions:
What’s being denied? How bad is it? How can agencies insulate themselves?
“As a whole, it’s not going well,” reports J’non Griffin, owner and president of Home Health Solutions LLC.
“One agency has reported getting no non-affirmations — and they say they are uploading 80 to 100 different pages to justify the care for each claim.
“The last figure I saw, though, was about an 80 percent non-affirmation rate overall on the first submission.”
J’non’s assessment is backed up by the National Association of Home Care and Hospice. Bill Dombi, NAHC’s Vice President for Law, has called the pre-claim demonstration in Illinois “a complete mess.”
Agencies have reported individual claims taking up to an hour each to submit.
Some say they are unable to stop and save partially uploaded submissions once the uploading process has begun.
Several agencies say they have repeatedly been told their submissions are illegible. Many say their documents were lost during transmission.
The number of disappearing documents prompted CMS at one point to advise agencies to rely on fax submissions rather than electronic.

What’s ahead?

Currently, NAHC is lobbying Congress to suspend the next rollouts planned in Florida, Texas, Michigan and Massachusetts between now and the first of the year. Florida legislators are taking the lead in the opposition, since Florida is next in line with an Oct. 1 rollout.
But the clock is ticking, and despite overwhelmingly negative reports from home health agencies in Illinois, attempts by lawmakers there to suspend the process, and current efforts of Florida lawmakers to delay the next round, it seems likely for now that the pre-claim demonstration will move forward.
How can agencies prepare?
“To successfully meet the new burden of pre-claim reviews, home health agencies need to get much faster, with fewer documentation errors and oversights, expedited turnarounds, and a thorough understanding of exactly what is expected of them,” J’non says.

(For more information about how agencies can successfully handle PCRs,  be sure to check out the detailed recommendations in J’non’s 4-Point Roadmap for PCR Success,  below. )

Is your agency ready?

Industry experts agree that agencies will almost certainly be forced to hire additional full-time employees to meet the burden of pre-claim reviews. Generally, they estimate that for every 100 to 350 patients an agency serves, an additional one-and-a-half FTEs (one RN and one clerical) could be required.
For many agencies, however, a faster and more cost-effective solution may be to outsource the preparation and submission of pre-claim reviews. Home Health Solutions is now working with agencies needing assistance with PCRs.
“Agencies are discovering, as the requirements placed upon them increase, that it often makes more sense financially to outsource coding, billing and many other services so that they can focus on patient care,” J’non says.

Going it alone?

For agencies choosing to navigate the PCR process on their own, J’non recommends purchasing a helpful tool from Home Health Solutions. Think of the PCR Do-It-Yourself Kit as a $25 compass to point your agency in the right direction to steer through all the necessary paperwork.  A checklist and staff tutorial are included.
To order,  call HHS at 888-418-6970.

Roadmap for PCR success


J’non also offers the detailed 4-Point Roadmap below to help agencies successfully prepare for the pre-claim review process:

Agencies must streamline their operations, with faster turnaround times for coding, for developing a Plan of Care and getting the physician to sign off on it, and for collecting all documents needed to submit the pre-claim review.
Efficient teamwork will be an essential part of streamlining operations, J’non says.
She recommends agencies:

  • Identify key staffers and their responsibilities, and make certain there is no confusion about who is responsible for each step in the process of completing documents and collecting necessary forms to submit and re-submit claims.
  • Develop a back-up system to avoid delays in the event a key staffer becomes unavailable.
  • Determine who will be responsible for follow-up, and how often.
  • Make certain the person submitting pre-claims has immediate access to all required documentation and billing information.
  • Review the process with the full staff, stressing the need for timeliness and accuracy. Put policies and procedures in writing for easy access to avoid confusion or delays.


Agencies in Illinois are reporting that a high proportion of pre-claim reviews are being rejected on the basis that the patient is not homebound or the care is not shown to be medically necessary.
J’non recommends agencies look closely at their supporting documentation to make certain they have correctly established both patient eligibility and medical necessity.
A few reminders about documenting homebound status:

  • To be considered homebound, the patient must be unable, due to illness or injury, to leave home without special equipment or assistance from another person. Be sure to document WHY the illness or injury requires special equipment or assistance.
  • Document the impact on the patient from any excursion outside the home, the reason for the trip, and the effort required to leave home.
  • Make certain Face-to-Face documentation specifies why the patient is homebound. The physician’s note must specifically address the reason the patient needs home health services.


Review, review, review. Agencies can’t do too many in-house reviews and self-evaluations as they attempt to shore up compliance risks, limit oversights and reduce errors.
In particular, J’non recommends agencies focus on:

  • Accurate completion of the OASIS, especially in preparation for C-2 revisions which take place Jan. 1. This data collection tool offers numerous areas where clinicians can become confused. The HHS team frequently sees agencies making mistakes as simple as entering dates in the wrong place on this form, erroneously establishing non-compliance.
  • Proper documentation of Face-to-Face Encounters. Make sure the physician has documented the date of the F2F Encounter and provided the reason home care is necessary. A clinical note from the physician will be required, not just a form, and the content of the note must address the reason the patient needs home health care.The signature of a nurse-practicioner or other provider on the F2F will not suffice unless it is a co-signature with the physician. Even if the nurse-practitioner performed the F2F, the certifying physician’s signature and date will be necessary. Review all F2F dates to make certain there are no discrepancies. Mismatched dates are automatically denied.
  • Collect all necessary information before submitting pre-claims
  • Attach the assigned pre-claim number to all final claims and resubmissions.
  • For re-certifications, be aware that the re-certification statement on the projected length of time the patient will need home care will need to be submitted separately from the Plan of Care.
  • Also note that the projected length of care will shorten each time the patient is re-certified unless there is a documented reason showing why that is not the case. In a recent workshop on pre-claims reviews, Palmetto representatives stated that the re-certification statement is expected reflect a shorter duration for each episode of home health care for which the patient is re-certified. The first re-certification projection, for example, might be six months, but the next re-certification projection would be only four months. Be sure to include supporting documentation showing the need for any change in the projected length of stay.


Agencies will need to shore up training in many areas in order to reduce compliance risks and achieve success in today’s challenging home health market, J’non says. In particular, she recommend OASIS training and F2F review to prepare agencies to better handle pre-claims reviews.
HHS offers online training for both in its online store, with 8 CEUs offered for the OASIS course.
Click here to shop the online store now.

Do your OASIS scores add up to what’s really going on?

OASIS Scores Add UpEditor’s note: This article originally appeared in the July 25 issue of The Monday Fix, a free weekly email from Home Health Solutions featuring home health coding and OASIS tips.  Click here to subscribe.

In the complex world of home health, where boundaries and guideposts are almost constantly revised and re-interpreted, an agency’s success may well revolve around one crucial skill: the ability to accurately use the data collection tool known as OASIS.
The Outcome and Assessment Information Set (OASIS) is emerging as a critical performance measure for the field in general and for individual agencies.
“It’s hard to overestimate the importance of this data set,” says J’non Griffin, owner of Home Health Solutions LLC. The OASIS affects patient outcomes, reimbursement, STAR ratings, Value Based Purchasing and an agency’s bottom line.
And that’s just in its existing form.
Come Jan. 1, OASIS will ratchet things up a notch. The Centers for Medicare and Medicaid Services (CMS) implements a revised version of OASIS on the first day of 2017, and the new version known as OASIS C-2 will feature the first quality measures from the Impact Act of 2014.
This Act established some standardized measures for easier reporting and sharing of data between skilled nursing facilities, long-term care hospitals, inpatient rehabilitation facilities and home health. The goal is to facilitate coordinated care and improve patient outcomes, providing better post-acute care for Medicare beneficiaries.
Among other data, C-2 items will capture standardized reports of skin integrity, a patient’s functional status and cognitive function, medication reconciliation, incidence of major falls, transfer of health information and care preferences during a patient’s transition from one facility to another.
This is important information for the home health field, J’non says.      “The overall goal is to collect data necessary to create a vital picture of what’s actually going on in home health care,” she says.
Agencies are tasked with the same goal on an individual level as they complete the OASIS for each patient. But that goal can easily be hindered by hurrying through the process, looking at it as simply additional forms to be filled out, or – perhaps most damaging — limiting its scope by failing to understand the nature and reach of the information it seeks to collect.

The big picture from the details

Accuracy in reporting is requisite for proper use of OASIS to collect necessary information, yet many clinicians struggle to correctly capture  the information.
It’s quicker and easier to create a superficial account, relying on a cursory overview or a patient’s information alone.  But that can be misleading, and J’non believes agencies must train their clinicians to look at how all the information about a patient works together to create a cohesive report.
In some cases, clinicians must look beyond the narrow focus of the question at hand to consider other circumstances which may affect the answer, and carefully weigh what a patient tells them against the realities of a diagnosis by the physician, risk assessments, environmental evidence and more.
Sheena Meeker, a quality review mentor on the HHS team, offers the following example of how it may be necessary to carefully consider all aspects of a patient’s circumstances to make sure OASIS scores add up to a true reflection of what is going on.

Your patient is a 92-year-old male who lives alone in a single-story family home. His daughter assists with some errands, and occasionally meals at home. When you assess your patient’s ambulation status, you note the patient is a high fall risk, and uses walls and furniture to navigate through his home. He has a 2-handed walker in the home which he states he uses more than half the time for ambulation.  His medications are located on the kitchen counter, and he spends more than half his time in the living room. The patient states there is no problem with remembering to take his medications and he does not need any help. You are able to confirm this with his daughter.

How would you score M1860?

a. (0) -Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device)

b. (1) -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.

c. (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.

d. (3) – Able to walk only with the supervision or assistance of another person at all times.

RATIONALE: Even though the patient uses a walker more than half the time, safe ambulation for this patient requires at least supervision due to a high fall risk score. Safety of the patient is the key consideration in this case, and the high fall risk score directly impacts the correct response here.

How would you answer M2020?

a. (3) Unable to take medication unless administered by another person.

b. (1) Able to take medication(s) at the correct times if:(a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart

c. (0) Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.

d. (2) Able to take medication(s) at the correct times if given reminders by another person at the appropriate times

RATIONALE: Since the patient spends the majority of his time in the living room and his meds are in the kitchen – AND he requires assist or supervision for safety with ambulation – this would require someone to assist with medications for safety. The patient’s safety is again the key consideration, and impacts the correct answer.
This example illustrates how easy it can be for inexperienced, untrained and/or rushed clinicians to inadvertently mark the wrong answers on M1860 and/or M2020. The best protection against these kinds of accuracy errors is ongoing training, according to J’non.

What is your agency doing to prepare?   

Smart home health agencies are gearing up for the implementation of C-2 by using the next few months to carefully review how well their clinicians are using OASIS, and provide the training needed to shore up weaknesses, J’non says.
Who should agencies target for OASIS C-2 training?
“Everyone,” J’non says.
She is currently finishing up a brand new recording from HHS offering C-2 training, and will make it available via the HHS online store in the next few days.
In today’s fluid home care climate, where regulations and requirements shift rapidly and the only thing certain is the likelihood of more change soon, J’non  says agencies can’t afford to look at training as “over and done.”
Being serious about providing excellent care means getting serious about providing ongoing training and support to clinicians.

Click here to browse the HHS online store to see which online courses are available to help your agency. 

More changes ahead for home health this fall

summer shoreup art for solutions 2

What’s on your summer calendar?
Priorities should be internal audits,
reviews and self-assessments

Editor’s note: This post first appeared in a longer article in the June 9 issue of SOLUTIONS,  the monthly e-newsletter from Home Health Solutions LLC. Click here if you’d like to subscribe to SOLUTIONS.

Summertime, and the livin’ is easy. Unless, of course, you’re in the home health field.

From backyard barbecues to long and lazy afternoons at the beach, this is the time of year when leisure time is foremost in our hearts and minds. But this summer, smart home health agencies are looking beyond the distractions of summer to the fall, when the change of season will usher in a new round of major adjustments.

Home health agencies in Illinois won’t even have to wait until fall; the Centers for Medicare and Medicaid Services (CMS) announced last week  that it will move forward with preauthorization requirements despite opposition from the home health industry. CMS will roll out the first preauthorization program in Illinois Aug. 1.

Four more states will follow throughout the fall and winter, with Florida scheduled for Oct. 1, Texas for Dec. 1, and both Michigan and Massachusetts for Jan. 1.

Rollouts in those states will require home health agencies to perform prior authorization before processing claims for services. The procedure would be similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration, which CMS implemented in 2012. It requires prior authorization for scooters and power wheelchairs within seven states where fraud and errors have been prevalent in the past.

Nationwide, this autumn was already shaping up to bring a round of new challenges to home health agencies. In October, when CMS removes a three-year partial code freeze, some 2,500 changes are expected to become part of the ICD-10-CM classification set. At least 1,900 new codes will be added, 351 codes will be revised and 313 codes will be deleted. The tabular list will change as well.

A few Excludes Notes will shift and some others will disappear completely in this first reworking of the code set since its implementation at the start of 2016.

Exactly how these changes in codes will impact the home health field still isn’t clear, as the complete list of revisions has not yet been provided.


Be prepared; coding guidelines are likely to change frequently during the adaptation process to the revisions.

Guidelines already change so often with new interpretations that it can be difficult for coders to keep pace. Major re-interpretations just in the past couple of months had coders scrambling this spring to rethink the way diagnoses and comorbidities can now be linked, and how certain heart failure diagnoses can now be coded without further specification by the attending physician.

Many areas of ICD-10 implemented this year have given rise to questions, and as those issues are reviewed and addressed, coding guidance will continue to evolve rapidly with new interpretations and even reversals. It is crucial for agencies and the coders they employ to stay abreast of every change to reduce compliance risks.    And the changes in the ICD-10 set are just Round 1. On the heels of those changes, the Outcome and Assessment Set generally known by its acronym, OASIS, will undergo its own revisions. OASIS C-2 is scheduled for implementation Jan. 1, 2017, and will add new items, renumber some items, and make other changes in how data is collected.

How can home health agencies and home health coders prepare for all these major changes beginning Aug.1 and continuing through early 2017?

“There’s never been a more critical time to shore up your agency’s operation,” advises J’non Griffin, owner of Home Health Solutions LLC.

Addressing and correcting existing compliance risks this summer will better position agencies to handle problems likely to occur during the adaptation process in the fall, reduce the likelihood of home health professionals feeling overwhelmed by constant change, and provide an extra layer of insulation against potential losses due to claims denials, according to J’non.

She recommends agencies prioritize internal audits, quality reviews and other self-assessment measures between now and Labor Day.

“This summer is the time for agencies to take a proactive approach, identifying and addressing the need for quality clinical documentation and code specificity – and then follow up with extra training measures and education efforts in every area where there is any confusion or performance issue,” she says.

In many cases, it may prove more cost-effective and time-expedient for agencies to streamline operations by partnering with a consultant to develop and implement corrective measures, or to outsource some services.

Home Health Solutions is making it easier than ever to get help with a Summer Shore-Up Package, offering limited-time discounts on new services.

Now through Labor Day, the Summer Shore-Up Package from HHS will offer a 10 percent discount off any standard rate of new services. In addition, agencies contracting for coding services under the Summer Shore-Up Package will receive 5 free OASIS analyses with pre and post-HHRG (Human Health Resource Group) values.

“This discount reflects our sincere commitment to help agencies address areas where they may not be prepared to meet an additional round of challenges,” Jnon says. “We want to take some of the anxiety out of the equation for agencies, providing the guidance and services they need to achieve and maintain success in a fluid and challenging market.”

summer hore up coupon




5 Essentials for Your Agency’s F2F Documentation

Can you list the 5 Must-Haves to insulate your home health agency against claims denials based on insufficient Face-to-Face Encounter (F2F) documentation?
Do you know how to incorporate missing elements of the F2F into the medical record?
If you blinked uncomfortably, you’re not alone. These questions are making many home health professionals nervous in the wake of voluminous claims denials after reviews under the Center for Medicare and Medicaid Services “Probe and Educate” Strategy.
Quality Checklist Infographic smaller f2f“It was mind-boggling to  learn early in 2016 that an astonishing 508 of 595 initial claims reviewed under ‘Probe and Educate’ had been denied, ” recalls Home Health Solutions LLC owner and president J’non Griffin.
Over the next few weeks, as reasons for the denials were publicized, it became clear that one of the biggest problem areas for home health agencies consisted of missing, invalid or incomplete documentation for Face-to-Face Encounters (F2Fs) between home health patients and physicians.


The F2F is mandatory for a patient’s home health certification. It ensures that all orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition. CMS requires that it occur within a specific time frame and address specific information about the patient.
Many agencies relying on forms to capture F2F information discovered that the forms they were previously using omitted details necessary under new CMS requirements.  Agencies also ran into trouble by relying on a physician’s verbal acknowledgement that the F2F had occurred, documenting the encounter and asking the physician to sign.
Some agencies did not understand the distinction between a certifying physician and the primary care physician. Others had not adequately established the patient’s homebound status in records submitted.
Correct procedures for F2F documentation require a brief statement by the certifying physician describing the patient’s clinical condition during the encounter, supporting the patient’s homebound status and the need for skilled services.
While it sounds straightforward, obtaining correct documentation from the physician, complete with required dates and signatures, all in a manner meeting CMS expectations, has proved to be an ongoing challenge for home health agencies.


If your agency is struggling with the nuances of F2F requirements, a small investment in training could pay off with major reduction in the risk of claims denials.
Home Health Solutions has just released a recorded training session in which HHS Director of Special Projects and Appeals Heather Calhoun breaks down each component, explaining in detail the five objectives of F2F requirements and specifically how agencies can meet each objective.  During the 90-minute presentation, she outlines three specific ways an agency can incorporate missing elements of the F2F into the medical record, makes clear the homebound status requirements which must be met, and establishes the difference between certifying and primary care physicians.
“You’ll love Heather’s down-to-earth approach to training,” J’non promises. “She has the hands-on experience needed for true peer-to-peer mentoring that goes an extra measure beyond the typical classroom approach.  She delivers all the information you need to understand F2F requirements, and she does it with a practical and engaging style that you’ll appreciate.”

Click here to check out the F2F training program now available  in the HHS Online Store.


The HHS  infographic below provides a quick checklist of the 5 essentials which must be in your agency’s F2F documentation.  Each is explained in detail in the HHS training program.

Quality Checklist Infographic F2F Take 5


It’s impossible to please everyone all the time,  and your home health care or hospice agency is no different from any other business with regard to complaints.

In the home health care field, however, the scrutiny accompanying complaints is intense and multi-faceted, involving a lengthy list of both state and federal oversight.  Your agency may be reported to your state licensing and certification division,  entities responsible for accreditation, the U.S. Office of the Inspector General, the Office of Civil Rights — and the list goes on.

Since 2006, the U.S. Justice Department has taken a particular interest in hospice agencies, suing more than a dozen for fraud and scrutinizing many more.

Stringent accountability really is the only safeguard your agency has under such intense scrutiny. Proactive measures will help ensure that your agency handles complaints and grievances in a way that meets not only the Conditions of Participation imposed by the Centers for Medicare and Medicaid Services,  but any unannounced,  on-site  investigations by authorized entities of review.


Agency accountability begins with a set of well-defined policies and procedures regarding complaints and grievances,  according to Home Health Solutions owner and author J’non Griffin.

“The agency must be able to demonstrate that it takes complaints seriously, documenting each in a standard format, responding in a respectful and timely manner, and thoroughly investigating the complaint within a reasonable amount of time,” J’non says.

While it is important to note that different states may have varying requirements and time limitations for how complaints are reported, some general guidelines apply to all.

Policies should be in writing,  clearly spelled out, and the agency should not depart in any way from the procedures it has set forth, J’non says. In her new e-book, “Survey Ahead: Navigating the Guidelines,” J’non explains that one of the crucial points to be evaluated during Survey is how well an agency complies with its own stated procedures for grievance and complaint resolution.

All employees — including new hires — should be familiar with the agency’s complaint process, knowing exactly how and to whom complaints should be reported at the agency.  Identifying this person, and the process to be followed, should be a prominent part of the agency’s written policy. Reviewing the procedures at least annually with staff members will help ensure compliance.

Staff education efforts must also ensure that employees recognize and respect a patient’s cultural, psycho-social , spiritual and personal values, as well as understand the need to show respect for the patient’s property.


Language barriers and cultural differences account for many of the complaints lodged against home health agencies,  and can often be resolved or prevented with proper education and training.

While showing respect for a patient’s expectations of timely visits is not a specific right under the law, it is worth noting that failure to adhere to scheduled visits in a punctual manner also ranks among the most common and easily preventable complaints lodged against home health and hospice agencies.

Some of the other most common complaints against home health and hospice agencies include:
– Lack of notification from the office if a visit must be rescheduled due to the illness/absence of the clinician scheduled to make the visit.
– Confusing communication due to multiple caregivers
-Inconsistent quality of care provided
The patient has the legal right to voice grievances regarding treatment or care that he or she receives (or fails to receive) and/or for lack of respect for property . Agencies must advise patients of these rights in writing and provide the patient with the phone number for the home health reporting hotline in that particular state, its hours of operation and purpose.

It is important to document all steps taken toward resolution of a complaint, even if the complaint cannot be resolved.

“Even if the complaint or grievance was not possible to solve, surveyors will want to see documentation showing the actions that were attempted to resolve it — and the outcomes,” J’non says.


Here’s a quick checklist of 8 points which should be clearly spelled out in your agency’s complaint procedures and policies:

  1. Who in your agency is accountable for receiving,  documenting and resolving complaints?
  2. What is the time frame for documenting/reporting a complaint?
  3. What is the time frame for investigating the complaint?
  4. Does your agency have an intake form for standardizing the information-gathering aspect of documentation?
  5. Does your agency have a standardized means of documenting attempts to resolve the complaint?
  6. How are your employees made aware of your agency’s procedures for handling complaints?
  7. How often are your agency’s procedures reviewed, updated and re-shared with employees?
  8. How does your agency handle any variation from its own written procedures when reporting or investigating a complaint? Are sanctions outlined and enforced? 

If you’d like to read more about the specific items which will be evaluated at your agency during Survey,  “Survey Ahead” is now available on Amazon.  Click here to take a look.

No loose ends

Fans of puzzles know that solving one requires the creation of a particular kind of order, putting the pieces together in a logical way in to arrive at the correct solution.
Home health professionals perform similar tasks daily as they create orderly files made up of many different documents, from an initial referral by a physician to notes made by the nurse seeing a patient in the home. imageJust as a jigsaw puzzle is made up of interlocking pieces, with each piece depicting a small segment of the whole, the many different pieces of documentation that go into a patient’s file work together to create the larger picture of the patient’s health care experience with the agency.
And under new Centers for Medicare and Medicaid regulations that took effect this month, there can’t be any gaps in that picture.

A cohesive whole

One of the best, and simplest, ways for agencies to ensure that each step of the documentation process integrates seamlessly with all other pieces is to ask why an action is being taken or a procedure is being performed, according to J’non Griffin, owner of Home Health Solutions LLC.
Why was the care referenced in the documentation delivered? Was it medically necessary? Then agencies must show proof of that necessity.
Why was each visit made? Was it was part of the agency’s overall plan of care for the patient? Then visit notes should say so.
Approaching each piece of documentation with a goal of answering “why” will help knit together an interlocking summary of patient care and identify missing pieces that are likely to lead to costly claims denials.

Do all the pieces work in tandem?

Documentation must support the visit type and the visit type must support the plan of care. Notes made by clinicians in the home must clearly justify the visit and show the value as it relates to goals established in the plan of care.
“Quality documentation begins at the time of the patient’s initial referral to home health by a physician, and continues through each aspect of home care,” J’non says. “If each step is properly documented, the result will provide a comprehensive and cohesive file that will stand up to scrutiny.”
J’non and her team work with agencies of all sizes across the country to streamline operations, teaching agencies how to minimize compliance risk, untangle and make sense of regulatory changes and maintain quality patient care.

 Keep things realistic

Once OASIS data has been carefully collected and properly recorded, a case manager must evaluate and make use of that data to develop a realistic plan of care for a patient based on the assessment.
Clinical notes made in the field will then need to integrate seamlessly with that plan of care, not only fully supporting the visit type and acknowledging goals, but also measuring progress.
Notes will need to show clearly how the care plan is being executed with purpose at each visit.

Billing must be part of an agency’s comprehensive documentation as well. In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

Home Health Solutions team members understand the challenges facing home health care professionals as they try to adapt to the many regulatory changes implemented this month.
But implementation of the four strategies outlined in this week’s series of blog posts can make noticeable improvements in an agency’s compliance efforts and ensure that documentation will stand up to scrutiny in 2016.
“And if additional assistance is needed, we can provide the training and guidance needed to help agencies stay on track and focus on quality patient care this year,” J’non says.


The nitty-gritty of specificity

“Every picture tells a story, don’t it?” Rod Stewart sang to us in an old ’80s song based on a popular British idiom.
These days, a home health patient’s records need to tell a story, too — and it had better be a thorough one, reflecting a coordinated care plan and continuity of care, with realistic goals and outcomes, or the agency could risk costly claims denials.
imageUnder this month’s new Medicare and Medicaid regulations, home health agencies are responsible for much more detailed documentation throughout the home care delivery episode than ever before.
“Now that we’ve transitioned into IC-D10 coding, you really have to be much more specific,” says Holly Kolitz, Quality Assurance Manager for Home Health Solutions LLC. “Basically, you’re creating a little window of what happened while you were there.”
Holly and other HHS team members work with agencies of all sizes across the country to streamline operations, helping health care workers adapt to new regulatory requirements and avoid costly claims denials.
As part of that process, they train health care professionals in the mechanics of specificity: how to sift through the agency’s many, many interactions with and on behalf of a patient to glean the specific details which must be documented.

It’s a balance

Turns out there’s something of an art to capturing the nitty-gritty of patient care, especially in the notes recorded in the field by nurses and clinicians.
Too many useless details serve no real purpose, frustrating the peers, supervisors and auditors who review them. But too few details can create dreaded “black holes” of home health documentation, where failing to record what was said or done, and show cause for it, can wind up costing an agency thousands of dollars.
Finding the right balance between those two extremes is proving to be at least somewhat intimidating to most agencies. Their nurses and clinicians generally aren’t storytellers, scribes or court reporters; they’re caregivers.
And very busy caregivers, too.
“Today’s home health field is fast-paced,” Holly says. “A lot of expectations are placed on caregivers, and each home visit has to be a well-rounded visit. But proper documentation has become an imperative part of the process.”
How can caregivers identify and learn the pertinent details which must be included in their notes?

The 5 Ws

The Home Health Solutions team often starts its specificity training with a review of one of the oldest, simplest and most reliable formats for capturing information: a basic list known as “The 5 Ws.”
Five words beginning with W — Who, What, When, Where and Why — will capture almost every detail caregivers need to include in their files. A sixth word — How — adds more important information.
Simple? Yes, but many agencies struggle with reporting each of those six aspects of information, particularly with recording WHY something is being done, and later with capturing HOW it was done.

Tell me WHY

Applying the 5Ws begins the moment a patient is referred to the agency, with the WHO and WHEN aspects covered in the on-boarding and intake process.
But the information collection system often breaks down immediately afterward, as agencies fail to record WHY they are providing services to the patient in the first place.
Failure to include documentation showing medical necessity for home health services, including the initial referral by a physician, is the No. 1 documentation error most agencies make, according to Heather Calhoun, Director of Special Appeals and Project Management at Home Health Solutions.

Care goals and 5 Ws

As managers develop comprehensive care plans for patients, coordinating services between various types of caregivers and establishing realistic goals, application of the 5 Ws can once again make significant contributions to the quality of the patient file.
In developing the comprehensive plan, be sure to include WHY and HOW each service will be provided, with specific documentation showing its medical necessity.

In the field

The 5 WS must be captured in the field, too, as caregivers actually deliver the planned treatment and services, and record doing so.
Notes should reflect not only WHO delivered each treatment or service, WHERE and WHEN, but continue to refer to WHY. Ideally, the WHY portion of the clinician’s notes will refer to the comprehensive care goals set for the patient, as well as addressing any specific goals for that particular visit.
Finally, caregivers must record WHAT they do and HOW.
It isn’t enough, for example, for a caregiver to note that she taught her patient the purpose of a particular pill and its side effects. Quality notes will reflect why she reviewed this information with the patient, what information she shared and even how the patient reacted.
“The nurse would need to summarize in a paragraph what she told the patient to educate the patient on the importance of the medication and encourage the patient to be compliant in taking it,” Heather says.

New documentation standards may seem overwhelming to agencies, but the Home Health Solutions team is encouraging. Much of the attention to detail now required of caregivers hearkens back to quality practices drilled into nursing school students, they say, and will become second nature with practice.
If your agency needs staff training to better meet new regulations, Home Health Solutions offers a comprehensive array of customized modules and on-site services.

THURSDAY: Tying up all the loose ends in your agency’s paperwork