In part I of our series, we’ve explored common reasons for denial in various claim environments. We also established that an important way to avoid denials is to implement solid processes of quality assessment (QA) measures as well as best practices for both administration and staff to ensure complete, thorough and timely claim submission.

In order to better understand how it all fits together, let’s dive in and get a better understanding of those reviewing our records as well as important factors to consider when ensuring documentation is accurate and as complete as possible.

Who’s looking at your documentation?

  • Recovery audit contractors are looking specifically for inappropriate payments, payment for non-covered services, duplicate service and for medical necessity of care. These contractors can review payments made from Medicare to a home health agency as far back as three years and if they find anything inappropriate, they are likely to keep an eye on your organization. They are paid to recover money for Medicare and they can be diligent, so you must be as well.
  • Zone Program Integrity Contractors are of most concern for home health and their focus is on detecting and preventing Medicare fraud and abuse.
  • Regional Home Health Intermediary per home health regions. Their focus is to ensure that services provided meet requirements for reasonable and necessary visits.

Documenting medical necessity

When documenting medical necessity, your clinical notes should include the following for every discipline: Assessment specific to the day of each visit; skilled services performed at each visit – if nothing skilled is done, the visit may not be paid; patient’s response to treatment rendered; plan for the next visit — if there is no plan, is a next visit necessary?

Remember, home health is not intended to be a lifelong event.

Avoid vague terms in your notes

When drafting patient notes, caregivers must avoid the innocuous and the non-detailed. For example, avoid the following: “Patient sitting up. Alert and oriented”; “patient with no new complaints”; “wound care performed”; “instructed on disease management and medication teaching”; “will continue with plan of care”;

Instead, be specific with patient notes. For example, dig in and provide detail so that the record best reflects the patient’s care and to ensure payment for services provides. Use the following: “Pain level since last visit has decreased from eight out of 10 to five out of 10”; “observed patient demonstration of insulin administration”; “patient reports coughing up thick green stuff”; “wound edges well approximating, no drainage noted”;

Plan of care specifics

The plan of care must be precise and patient centered. You must steer clear of cookie cutter interventions and goals, and you must rethink and revamp the POC if necessary. Instead of the plan being, “To teach on cardiac diet” write “instruct patient on rationale for following a cardiac diet, and foods allowed and not allowed on this cardiac diet.” Instead of writing “patient will understand the effects of Furosemide” write “to instruct patient on signs and symptoms on hyper or hypokalemia and when to report to health provider.”


A major red flag for an audit or a denied claim is when agencies list the majority of their POCs as “SN 1w9.” Frequencies of visits and care should be specific and include the details for how you are planning to discharge patients. Thus, you must focus on what services are needed, not availability of care.

Also, when providing documentation to support therapy, your orders must justify the evaluation; document orders beyond initial visit – sometimes it’s better to write exactly what they want you to do; number of visits projected; patient’s current functional status; objective tests and measurements; a review of relevant systems; progress toward goals – that’s our whole point; and provide a revision of interventions and goals when necessary.

Therapy specifics

When adding therapies, be sure that documentation demonstrates why the care is indicated. Provide guidance on the reason for evaluation. Next, be sure that the therapy plan of care is comprehensive, specific and documentation supports interventions and goals as planned.

However, you must always be wary of potential red flags — the less than obvious red flags than the one mentioned above. Detailed here are some of the most egregious examples of the worst offending red flags. These worst offenders are: if previous episodes of care are listed for the same issues; copy and paste of treatment for the patient; and providing no new diagnosis or issue details since a previous OASIS.

Keep in mind: If a patient is “re-certed” there should be different issues listed or better resolution to the problem. Re-certing a patient with same chronic conditions likely leads to a denial as will providing no definitive documentation of progress being made, care that is not reasonable and necessary, and numerous cancelled or missed visits by the patient.

Homebound or not?

When determining if a patient is homebound or not refer to the Medicare benefit policy manual definition. That’s the best place to start. Even with that, the homebound status should be documented at every visit. Caregivers must document whether assistive devices or assistance of another person is needed to leave home safely, and you can never assume that every patient that is homebound on admission is still homebound as care treatment commences. Additionally, your care team should question all patient absences and missed visits.

Reassessment of homebound status is legislated by 2011 federal regulations.

No matter the outcomes, every patient must have a plan for discharge even if they never will be discharged — we all need to know that there is a plan, as there may be the need for an early discharge for the patient reaching his or her goals early, or if the previous plan’s goals can never be met.

Stay tuned and join us for part III of our series, we’ll touch upon helpful information to help your organization properly address an ADR and provide even more information about audits in a helpful resource.

Entire blog post originally posted on DeVero, a Netsmart Solution’s blog on July 31, 2017.