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Presented By:Melinda A. Gaboury, COS-CChief Executive OfficerHealthcare Provider Solutions, Inc.healthcareprovidersolutions.com

Home Health Eligibility Requirements

• Meets eligibility for home health– Homebound

– Under a POC certified by a physician

– Medicare participating agency

– Requires intermittent nursing or PT, SLP,or a continuing need for OT

• Face-to-face encounter for the SOC

• Medical necessity

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Home Health POC Documentation Requirements

• All diagnoses

• Mental status

• Services, supplies, and equipmentneeded

• Frequency of visits to be made

• Prognosis

• Rehab potential

• Functional limitations

Home Health POC Documentation Requirements

• Activities permitted

• Nutritional requirements

• All medications and treatments

• Safety measures to protect againstinjury

• Instructions for timely discharge or referral

• Any additional items needed

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Skilled Nursing Documentation

Home Health SN Documentation Requirements

• Requires skills of a registered nurse

• Necessary to treat illness

• Complexity

• Intermittent– “Skilled nursing care that is either provided or needed

on fewer than seven days each week or less than eight hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable)”

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Home Health SN Documentation Requirements

• Is the patient appropriate for homehealth nursing?

• Why does this patient need skillednursing services now?– Records need to support need for beginning

or continuing services

– Has patient received treatment for this same condition previously?

• Does not disqualify from treatment

Home Health SN Observation & Assessment Requirements

Reasonable potential for change in a patient’s condition

Coverage for up to 3 weeks or so long as there remains a reasonable potential for complication or further acute episode

Once condition stabilized, must discharge

O&A by SN is NOT reasonable and necessary when fluctuating signs and symptoms are chronic and have not required a change in prescribed treatment.

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Medical Necessity for HH SN Teaching

The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught.

Appropriate to the patient's functional loss, illness, or injury.

How to manage the treatment regimen

Where after a reasonable period of time, the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record.

Medical Necessity for HH SN Teaching Determining the number of visits:

Initial teaching: consider the complexity of the activity to be taught and the unique abilities of the patient.

Reinforcement: assess the patient's retained knowledge and anticipated learning progress.

Re-teaching: change in the procedure or condition, or where the patient, family, or caregiver is not properly carrying out the task.

Must document the reason that re-teaching or retraining is required and patient/caregiver response.

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Home Health SN Teaching Activities

Examples of SN teaching and training :

Medication administration & management New diagnosis, treatment, medication Management of medical gases (Oxygen) Wound care New ostomy care & management Self-catheterization Tube feedings IV care, management, administration Bowel or bladder training

Home Health SN Teaching Activities

Examples of SN teaching and training activities:

Techniques for ADLs, use of adaptive devices Transfer techniques Proper body alignment, positioning, skin care Use of prescribed assistive devices Prosthesis care and gait training Use and care of braces, splints and orthotics Therapeutic diet Medication side effects and contraindications Care and application of special dressings

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Medical Necessity for HH SN Direct Care

Wound Care

NOTE: While a wound might not require skilled nursing care, the wound may still require skilled monitoring for signs and symptoms of infection or complication or skilled teaching of wound care to the patient or caregiver.

Coverage or denial based on all of the documented clinical findings. The plan of care must contain the specific instructions for the treatment of the wound.

The size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented.

Document to Support the Focus of CarePaint the Picture with the Initial Clinical Summary

Can be used for the agency's F2F addendum to support the medical necessity for HH services and homebound status

Should be concise and patient-specific

Include reason for referral for HH services Give overview of related treatments, new and

changed medications, hospitalizations, surgeries, tests, recent emergency care

State the primary focus of care (primary diagnosis) for HH services; prioritize secondary diagnoses

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Document to Support the Focus of Care

Paint the Picture with the Initial Clinical Summary

Support medical necessity Identify patient/caregiver deficits to be addressed,

new diagnoses or exacerbation of condition, new or changed medications or treatments, specific needs for teaching, observation, or direct care

Include patient and caregiver availability, ability, and willingness to participate and/or perform

Identify safety issues, risks, non-compliance, or any other obstacles to care

Include assessment findings supporting homebound Required assistance, normal inability to leave

home, considerable and taxing effort

Document to Support the Focus of CareThe 60-day and Recertification Clinical Summary

Maintain proof of sending to the physician

Synopsis of the care provided Supports necessity for services provided Disciplines remaining active Clinical findings related to reportable vital signs Labs and specimens and overview of results Wound description, measurements, healing status Catheter changes, ostomy care and/or IV needs Includes planned updates to the POC Progress towards reaching prior goals Clinical assessment findings supporting homebound

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Document to Support the Focus of CareSkilled Nursing Visit Documentation

Every Skilled Nursing visit note should include:

Clinical assessment Response/changes in behavior to previous services Detailed rationale explaining need for services The complexity of the service to be performed Skilled services provided during the current visit Patient/caregiver’s response to skilled services Plan for next visit based on rationale of prior results Any other pertinent characteristics of patient/home Specific objective & measurable progress achieved

Document to Support the Focus of CareSkilled Nursing Visit Documentation

CMS clearly states generalized documentation does not support the need for skilled care. Terminology such as:

‘Patient tolerated treatment well’ ‘Caregiver instructed in medication management’, or ‘Continue with POC’ are vague or subjective and

should not be used.

“Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.”https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

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Document to Support the Focus of CareAvoid Under– or Over-Documentation

A descriptive, patient & visit-specific narrative that contains the above mentioned CMS requirements is imperative in each visit note.

“Cloned” or “copy-pasted” narratives were identified by the OIG as targeted areas of concern in EMR records.

Denials are likely when only “check-boxes” are utilized.

Fraud charges could result if the electronic record is over-documented and misrepresents services that were actually provided.

F2F FINAL RULE 2015 Update

Final Decision: We are finalizing our proposal to eliminatethe face-to-face encounter narrative as part of thecertification of patient eligibility for the Medicare homehealth benefit, effective for episodes beginning on or afterJanuary 1, 2015. The certifying physician will still berequired to certify that a face-to-face patient encounter,which is related to the primary reason the patient requireshome health services, occurred no more than 90 days priorto the home health start of care date or within 30 days ofthe start of the home health care and was performed by aphysician or allowed non-physician practitioner as definedin §424.22(a)(1)(v)(A), and to document the date of theencounter as part of the certification of eligibility.

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For instances where the physician is ordering skilled nursing visitsfor management and evaluation of the patient's care plan, thephysician will still be required to include a brief narrative thatdescribes the clinical justification of this need as part of thecertification/re-certification of eligibility as outlined in§424.22(a)(1)(i) and §424.22(b)(2).

In determining whether the patient is or was eligible to receiveservices under the Medicare home health benefit at the start ofcare, we will require documentation in the certifying physician’smedical records and/or the acute /post-acute care facility’smedical records (if the patient was directly admitted to homehealth) to be used as the basis for certification of home healtheligibility. We will require the documentation to be provided uponrequest to the home health agency, review entities, and/or CMS.Criteria for patient eligibility are described at §424.22(a)(1) and§424 22(b)

F2F FINAL RULE 2015 Update

HHAs should obtain as much documentation from the certifyingphysician’s medical records and/or the acute/post-acute care facility’smedical records (if the patient was directly admitted to home health)as they deem necessary to assure themselves that the Medicare homehealth patient eligibility criteria have been met and must be able toprovide it to CMS and its review entities upon request. If thedocumentation used as the basis for the certification of eligibility is notsufficient to demonstrate that the patient is or was eligible to receiveservices under the Medicare home health benefit, payment will not berendered for home health services provided.Therefore, in order to determine when documentation of a patient’sface-to-face encounter is required under sections1814(a)(2)(C) and 1835 (a)(2)(A) of the Act, we proposed to clarify thatthe face-to-face encounter requirement is applicable for certifications(not recertifications), rather than initial episodes. A certification(versus recertification) is considered to be any time that a new SOCOASIS is completed to initiate care.

F2F FINAL RULE 2015 Update

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Question: What happens if the face-to-face encounter is completedduring the 90-day period prior to the start of care (SOC) and then thepatient's condition changes?

*Answer: In situations when a physician orders home health care forthe patient based on a new condition that was not evident during avisit within the 90 days prior to start of care (SOC), the certifyingphysician or an allowed non-physician practitioner (NPP) must seethe patient again within 30 days after admission. Specifically, if apatient saw the certifying physician or NPP within the 90 days priorto SOC, another encounter would be needed if the patient’scondition had changed to the extent that standards of practicewould indicate that the physician or a non-physician practitionershould examine the patient in order to establish an effectivetreatment plan.

2015 FINAL HH Regulation

Make sure that you are clear……IF the agency supplements the visit note or discharge summary with additional information from the comprehensive assessment to support homebound status and the need for skilled services, this must be sent to the physician to sign and date, making it a part of the medical record of the patient.Lastly, please understand that the home health agency MUST obtain the visit note and/or discharge summary and this document MUST contain the first three criteria: 1) a visit date that falls in the required timeframe for the F2F; 2) the reason for the visit is related to the primary reason for homecare; and 3) the visit was performed by an allowed provider type.

F2F FINAL RULE 2015 Update

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In the Calendar Year (CY) 2012 Home Health (HH) ProspectivePayment System (PPS) proposed rule published on July 12, 2011,CMS proposed their intent to provide clarification to the BenefitPolicy Manual language regarding the definition of "confined tothe home". In the CY 2012 HH PPS final rule published onNovember 4, 2011 (FR 76 68599-68600), CMS finalized thatproposal. In order to clarify the definition, CMS is amending itspolicy manual as follows:

Homebound Definition

For purposes of the statute, an individual shall be considered “confined to thehome” (homebound) if the following two criteria are met:

Criteria-One:The patient must either:Because of illness or injury, need the aid of supportive devices such ascrutches, canes, wheelchairs, and walkers; the use of special transportation;or the assistance of another person in order to leave their place of residenceORHave a condition such that leaving his or her home is medicallycontraindicated.

If the patient meets one of the Criteria-One conditions, then the patient mustALSO meet two additional requirements defined in Criteria-Two below.

Criteria-Two: There must exist a normal inability to leave home;

AND Leaving home must require a considerable and taxing effort.

Homebound Definition

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Homebound Documentation Examples of Taxing Effort

SOB experienced after ambulating 15 feet Unsteady gait makes leaving home unsafe w/o assistance Hip pain makes transferring into a vehicle very difficult Unable to leave home without constant supervision due to

memory loss and disorientation States he has not left home except for physician appts Requires a walker because of pain from recent TKR surgery Paralysis of left extremities makes the patient wheelchair

bound and requires assistance of caregiver to leave home Recent hospitalization for pneumonia has resulted in

significant weakness and debility CABG surgery has resulted in significant pain, SOB and

weakness Infected surgical wound results in significant pain

*

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*Therapy Clarifications*EFFECTIVE DATE APRIL 1, 2011

*Qualified therapist assess, establish goals and re-assess patient

*Measurable treatment goals be described in the:

* Initial Evaluation

*Plan of care

*Clinical record

*Methods used to assess a patient’s function include

*Objective measurement

*Successive comparison of measurements

*There must be objective measurement of progress toward goals and/or therapy effectiveness.

Therapy Clarifications

Evaluation and POC goals must include:

*Objective measures of function (e.g. swallow, bathing, dressing, walking, stairs, use of devices)

*Described correlation between

*Treatment for illness/injury to professional standards

*Measurable goals related to illness/injury

*Short and long term goals

*Specific target dates

Documentation Requirements

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*Common ADR denial Reasons:

*HHA did not submit the required reassessment(s) when responding to the ADR request

*Credentials missing*Illegible credential with signature*Illegible signature of the therapist *POC missing short and long term goals*Goals missing specific target dates*Objective measurement results are not documented*Reassessments are not being completed within the required timeframe

General Principles Governing Reasonable and Necessary PT, OT and ST services

The service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist.

The skilled services must be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury.

General exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy.

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Initial Therapy Assessment

For each therapy discipline, a qualified therapist (instead of an assistant) must assess and document the patient’s function using a method which includes objective measurements which correspond to the therapist’s discipline and POC goals.

Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must functionally assess the patient.

Therapy Reassessment (must be performed in conjunction with an ordered

therapy service)

At least once every 30 days, for each therapy discipline Performed by a qualified therapist (instead of an

assistant) Must provide an ordered therapy service, Must functionally reassess the patient Must compare the resultant measurement to prior

measurements Must document the effectiveness of therapy, or lack

thereof. The 30-day clock begins with the first therapy service (of

that discipline) and resets with each reassessment

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Therapy Visit Notes

The history and physical exam pertinent to the day’s visit (including the response or changes in behavior to previously administered skilled services)

The skilled services applied on the current visit Patient/caregiver’s immediate response to the skilled

services provided Plan for the next visit based on rationale of prior

results Vague or subjective descriptions of the patient’s care

should not be used. Patient tolerated treatment well Patient has improved muscle strength/ROM Continue with POC

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

Avoid Under– or Over-Documentation A descriptive, patient/visit-specific free-text narrative

that contains the above mentioned CMS requirements is imperative in each visit note to support medical necessity.

“Cloned” or “copy-pasted” narratives were identified by the OIG as targeted areas of concern in EMR records.

Denials are likely when only “check-boxes” are utilized.

Fraud charges could result if the electronic record is over-documented and misrepresents services that were actually provided.

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*Therapy Clarifications

Orders =PT 2w8

1

PT (1)

2 3 4

PTA (2)

5

6 7

PTA (3)

8 9 10

PTA (4)

11 12

13 14

PTA(5)

15 16 17

PTA(6)

18 19

20 21

PTA(7)

22 23 24

PTA(8)

25 26

27 28

PT (9)

29 30 31

PTA(10) Continue

* Therapy Clarifications continued…

Orders =PT 2w8

1 2

3 4

PTA (11)

5 6 7

PTA (12)

8 9

10 11

PTA(13)

12 13 14

PTA(14)

15 16

17 18

PTA(15)

19 20 21

PT(16)

22 23

24 25 26 27 28 29 30

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Questions

Melinda A. Gaboury

Chief Executive Officer

Healthcare Provider Solutions, Inc.

810 Royal Parkway, Suite 200

Nashville, TN 37214

615-399-7499 Phone

615-399-7790 Fax

info@healthcareprovidersolutions.com

www.healthcareprovidersolutions.com

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