Documentation…What’s all the Fuss?

Documentation…What’s all the Fuss?

I was talking with my good friend Thelma Bowen about documentation in home care. Not just the importance of coding and OASIS answers (and these are important), but also the importance of supporting that coding and OASIS with the day to day documentation. I think that despite all of the brouhaha about the importance of patient specific, individualized documentation to support the need for Medicare covered home health services, many HHAs struggle mightily from trying to take this concept from struggling to implement to making it happen. Agency leaders have asked me more than once: “How perfect do we need to be?” I always answer: “I don’t know? How much of your payments do you want to keep?” The fact of the matter is that the most important thing for HHA agency to do is to think in the long term rather than reacting to what they hear about what Medicare and their contractors are doing now. Sure, they need to keep up with and adapt to changes but if they have not laid a solid foundation of compliance with regulations they are already behind and at risk. We all know that recovery auditors can and do go back three years in their efforts to recover payments. It is important for them to stop assuming that the fact that they survive surveys with no problems means they are not at risk for payment denial on review. Survey status has little to nothing to do with their risk for payment denial when their claims are pulled for Medical Review. I think that the HHAs need to objectively assess their risk and make changes going forward to ensure that they are not just responding to the latest thing that Medicare has approved for review.

These are the biggest problems/needs that I am currently seeing: (in no particular order)

1. Failure of clinicians to adequately support in writing the homebound status of the patient. I compare and contrast narrative, OASIS items, referral information and F2F to what the clinician has selected. I think that the HHAs should remove all homebound checkboxes and require a brief specific statement specific to the patient that is supported by the documentation.
2. Failure of clinicians to adequately identify the impact of the underlying conditions on the patient ability to progress and to meet goals. I think that all HHAs should add at every part of the comprehensive assessment the following statement: “How do the cardio/circulatory (or respiratory, elimination, etc) conditions impact on the home health plan of care?” and “What knowledge deficits have been identified that require the skills of a nurse to instruct.” This is because therapists and nurses generally do not do a good job of doing this.
3. Failure of therapists to add comments throughout the comprehensive assessment to support the impact of underlying conditions on the treatment plan. The guidance to surveyors includes the following statement: “For therapy-only cases, the comprehensive assessment should incorporate OASIS data items as well as other assessment data items the HHA currently collects for therapy patients, as opposed to simply adding them at the beginning or end.”
4. Failure of clinicians to promptly contact the physician/physician designee to confirm diagnoses that are not physician confirmed on the referral and that impact on the poc.
5. Failure of clinicians to promptly submit OASIS documentation so that any needed QA can be done within the five day window. Many errors would be corrected if this occurred.

Learn more on documentation, denials, compliance, proper coding and the largest survey deficiencies with an upcoming seminar for Home Health and Hospice featuring some of the leading consultants in the industry May 16 and 17 in Birmingham, AL. Enter a special promo code NURSE in honor of Nurse’s week May 6-12 for your discount.

Selman-Holman & Associates supports Home Health Solutions, LLC in its endeavors to educate homecare professionals in improving documentation. Contact us for more information on how to improve your documentation or click the link above to attend this comprehensive conference.

J’non Griffin, RN WCC, HCS-D, COS-C, BCHH-C, Guest Blogger

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