Seven 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:
— 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
– Careless mistakes due to lack of adequate proofreading
– 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