Tag Archives: documentation

Think like an auditor

imageSeven times on a single day last week, Home Health Solutions Director of Appeals and Special Projects Heather Calhoun opened a case file and looked for proof of medical necessity.
Six of those seven times, she couldn’t find the proof she needed anywhere in the file before her.
“This is without question the No. 1 mistake I see agencies making in their day-to-day documentation, and the ramifications are enormous,” Heather says. “Without evidence that it’s needed, any care provided to a patient is not considered medically necessary and the agency may not be reimbursed for it.”
As home health agencies scramble to shore up the quality of their documentation practices under this month’s new wave of Centers for Medicare and Medicaid Services regulations, Heather and other HHS team leaders are working with agencies across the country.
Their goal is to teach home health care professionals how to think more like auditors — a skill that could be worth many thousands of dollars to an agency’s operational costs by preventing claims denials of specific services, visits or entire home health episodes of treatment.
“Documentation is an integral piece of the regulatory compliance required for agencies to succeed in today’s home health market,” HHS Owner J’non Griffin says. “We are working with agencies of all sizes to help them develop quality initiatives for meeting their regulatory burden.”

What auditors look for

To stand up to scrutiny, an agency’s documentation must be thorough. It will need to establish cause and intent for each aspect of care. That means agencies must record their delivery of patient care in clear and brief detail, beginning with the initial referral by a physician.
It isn’t enough just to note each pill, each dressing and each service provided to the patient; documentation must also show a comprehensive care plan coordinated among caregivers, with care goals specific to the patient.
But many agencies aren’t meeting all those requirements. Staffs busy with the delivery of patient care can get distracted from properly completing files — and HHS team members find that some of the same errors, omissions and inconsistencies show up routinely in the records of agencies of all sizes.

“Proper documentation is imperative for agencies,”  HHS Quality Assurance Manager Holly Kolitz says.  Even with time constraints and many competing demands,  agencies will need self-policing to  avoid costly errors and make sure documentation makes the grade.

 

Red Flag Checklist

     The HHS team has compiled the following checklist of some of the most common red flags almost guaranteed to catch the attention of auditors:
INCOMPLETE DOCUMENTATION:
— Missing physician orders
(Agencies need physician orders for each service, medication and treatment, including each change made to a patient’s medicine or treatment.)
— No evidence face-to-face physician requirement met
— No evidence of coordination of services
— No evidence of routine re-evaluation of patient care needs
— No explanation included for missed visits
— No documentation showing the physician was notified of a missed visit and why
ERRORS
– Careless mistakes due to lack of adequate proofreading 
INCONSISTENCIES: 
– OASIS, clinical notes, progress summaries, etc. fail to align, or in some cases even directly contradict each other.
— Clinicians provide conflicting information in their reports

“If a wound starts out being identified as one type of wound at the beginning of treatment, but is repeatedly identified in later documents as a different type of wound, auditors are certainly going to notice,” Holly says. “The legitimate question to be raised is whether we even know what kind of wound we’re dealing with.”
Agencies must provide documentation showing the initial diagnosis was changed or maintain uniformity throughout the treatment records, cross-checking to make certain later records support the wound identification in OASIS.
One of the most common mistakes Heather sees agencies make involves discrepancies in reporting between nurses and therapists.  A nurse, for example, may provide a highly functional score for a patient, because the nurse isn’t necessarily evaluating the same criteria as a  therapist. When a therapist evaluates the quality of the same patient’s gait,  stride or ease of transition from chair to walker, and reports lower functionality, the resulting discrepancy can become a red flag.

“Sometimes, it’s the simple mistakes that bog things down,” Holly adds. “Agencies can sometimes miss the obvious in recording details, and the results can create real issues.”
From copying a medical code wrong to identifying the wrong site for an injection or mistakenly substituting “right” for “left” on a record of a limb amputation, careless errors can sometimes cost an agency thousands of dollars.
The HHS team strongly recommends self-evaluation  in agencies, with frequent reviews of all documentation for accuracy.

One other area likely to generate red flags in an agency’s documentation is a lack of specificity. Tomorrow’s post will focus on strategies to better capture the important details needed for quality documentation.

Wednesday: The Mechanics Of Specificity 

Did you see our companion post on the four elements of quality documentation?  Read it here

 

Will your agency’s documentation stand up to scrutiny?

imageHome health agencies are heading into 2016 with some degree of apprehension about how well their documentation will stand up to scrutiny in a health market rife with regulatory risk.
Flawed documentation could threaten agencies with everything from legal issues to claims denials, and the compliance burden fattened up this month as new G Codes for home health and hospice took effect.
Curtailing risk requires not only an eagle eye approach to all records, but ongoing training efforts for staff whose notes are a crucial component in demonstrating quality care, according to J’non Griffin, owner of Home Health Solutions LLC.
“Agencies must sharpen their documentation skills, making certain their staff really understands how to capture critical information and integrate it with a cohesive, justifiable and well-defined care plan,” she says.
“At the same time, they’ll need to avoid the inconsistencies, omissions and errors that create red flags for auditors.”
Easier said than done? Maybe not. With the right focus on achieving quality, some guidance and a bit of practice, J’non believes, most agencies will successfully navigate these new complexities.
Home Health Solutions works with agencies of varying sizes to streamline operations and shore up bottom lines by identifying and improving weaknesses. Documentation is one of the areas where weaknesses are most likely to occur.
“Our clients often have unique needs and face different challenges, but when it comes to documentation errors, many of the same mistakes show up no matter how large or how small an agency is,” J’non says.

Four ways to clean up your documentation

With those recurring trends in mind, J’non and her HHS team members have identified four primary goals which any agency can use as a checklist in the pursuit of quality documentation:

1. Be defensive.

Your documentation is a legal record, and must stand up to examination by many sets of eyes.
“The quality of your documentation is the quality of care delivered to your patient,” says HHS Director of Appeals and Special a Projects  Heather Calhoun. “What is written there becomes the indisputable record of whether something was done, and why.”
The record will grow as your team members work from it and with it to develop and deliver patient care; each addition must not only be accurate and complete, for its integrity to be maintained, but must build on the other parts.
Eventually this record may well be seen not just by by auditors, but by licensing, accreditation and government reviewers — and could, in a case involving legal proceedings, even be viewed by judges or juries.
“It must be able to defend itself to each new pair of eyes as an error-free, easy-to-understand, complete record with all parts in place to show exactly how and why your agency provided quality patient care,” J’non says.

2. Be specific.

With auditors now able to pull out records of visits by type and ask specific questions, details have become more important than ever before.
Vague areas in records are the black holes of the home health field, costing agencies thousands of dollars, and must be bridged with clear, concise summaries showing cause, goals and intent as well as all specific actions taken.
“And the need for specificity begins at the very start of all care,” Heather says. Agencies must start each case by first establishing the medical necessity for care and continue to document each step in the process through the filter of why it was necessary.

3. Be realistic.

One of the most important skills agencies must master to meet new documentation requirements is goal-setting. Determining a realistic course of patient improvement within a 60-day window requires consideration of comorbidity and a comprehensive approach across all home health disciplines.
Holly Kolitz, HHS Quality Assurance Manager, describes the right approach as a careful balance of common sense and measurable achievement.
“Goal-setting is a very patient-specific process,” she says. “It’s very important to be realistic about what you can expect a particular patient to fully understand and achieve, as well as in selecting the parts of that process which must be captured in documentation.”

4. Be comprehensive.

Does your documentation work together to tell a comprehensive story about a patient, with each piece fitting together like an interlocking puzzle? The pieces must match on multiple levels, with each document both standing on its own merit AND integrating seamlessly with each of the other documents.
“This is critical to demonstrating cohesive continuity of care,” Heather says. “Inconsistencies in documentation can potentially cost agencies a great deal of money.”
In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

All this may sound like a tall order, but focusing on these four fundamental goals really can make a marked difference in the quality of your agency’s documentation procedures.
“And if your agency needs additional help to untangle new documentation requirements, HHS can provide the customized services you need to transition successfully into 2016,” J’non says.

Beginning tomorrow, the HHS team will take documentation practices a step further, breaking down each of the four fundamentals covered here with some specific strategies for each.

TUESDAY:  Think Like An Auditor (A Checklist of Common Mistakes)