Medical Necessity: The Key to Successful Home Health Documentation

Medical Necessity: The Key to Successful Home Health Documentation

One of the top denial reasons for home health claims is “services were not medically necessary”. Many home health agencies face challenges related to documenting medical necessity for both nursing and therapy services. Clinicians must “paint the picture” of the care and services provided at each visit to ensure that medical necessity requirements are met. Failure for each note to individually support medical necessity can result in denial of those visits.

What is Home Health Medical Necessity?

Home Health medical necessity is established when home health services are supported as “medically necessary and reasonable”. Outlined below are the general principles governing reasonable and necessary skilled nursing care per the Medicare Benefit Policy Manual Chapter 7 – Home Health Services

40.1.1 – General Principles Governing Reasonable and Necessary Skilled Nursing Care

Skilled nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the services needed do not require skilled nursing care because they could safely and effectively be performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit.

Skilled nursing care is necessary only when:

(a) the particular patient’s special medical complications require the skills of a registered nurse or, when provided by regulation, a licensed practical nurse to perform a type of service that would otherwise be considered non-skilled;

(b) or (b) the needed services are of such complexity that the skills of a registered nurse or, when provided by regulation, a licensed practical nurse are required to furnish the services.

Key Elements of Documenting Medical Necessity:

• The history and physical exam as pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit
• The patient/caregiver’s response to the skilled services provided
• The plan for the next visit is based on the rationale of prior results
• A detailed rationale that explains the need for skilled service in light of the patient’s overall medical condition and experiences
• The complexity of the service to be performed
• Any other pertinent characteristics of the beneficiary or home

Terminology to Avoid When Documenting Medical Necessity:

• Patient tolerated treatment well
• Caregiver instructed in medication management
• Continue with POC
• Wound care performed
• Patient with no new complaints
• Instructed on med teaching
• Instructed on disease process

Remember “if it wasn’t documented, it wasn’t done”. It is important that clinicians give themselves credit for the excellent care being provided to home health patients.

Tips for Successful Documentation of Medical Necessity:

1. Include Specific Details: Observed patient administer insulin injection; Patient with increased SOB and coughing up green sputum. Providing details of the visit allows the auditor to understand the patient, the patient’s needs and the necessity for skilled care. Always document any contact or communication with the patient physician or caregiver.

2. Timely Documentation: Ensure that clinicians are completing documentation timely (per agency policy). It is recommended that as much documentation as possible be completed during the patient visit to ensure accuracy of the documentation.

3. Educate, Educate, Educate: Ensure your orientation program includes a focus on home health documentation and the requirements. Provide ongoing education through chart audits and following audits such as Target Probe and Educate (TPE). Specific, real-life examples are great education!

4. Avoid Cookie Cutter Plans of Care (POC) and Rote Documentation in General: All documentation including patient interventions must be patient specific. Avoid copy and paste and repeated statements that carry from note to note throughout the patient’s episode of care.

References: Medicare Benefit Policy Manual Chapter 7 – Home Health Services www.cms.gov/files/document/bp102c07pdf Contact Proactive to schedule a review of Home Health medical necessity documentation compliance or for assistance in managing Home Health ADRs and Appeals.

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