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” each visit to ensure that the visit stands alone. 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 when home health services are considered “medically necessary and reasonable”. Outlined below are the general principles of 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:
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- 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;
- 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.
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Key Elements of Documenting Medical Necessity:
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- The history and physical exam is 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
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Terminology to Avoid When Documenting Medical Necessity:
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- 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
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Remember “if it wasn’t documented, it wasn’t done”. It is important that clinicians give themselves credit for the excellent care that they provide their home health patients.
Tips for Successful Documentation of Medical Necessity:
- Include Specific Details: Observed patient administer insulin injection; Patient with increased SOB and coughing up green sputum. This allows the auditor to visualize the patient, the patient’s needs and the need for skilled care. Always document any contact or communication with the patient physician or caregiver.
- 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.
- 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!
- Avoid Cookie Cutter Plan of Care (POC) and Documentation in General: All documentation including patient interventions must be patient specific and revised as indicated. 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
Need help with documentation? Contact Proactive!
Written By:
Nichole McClain, RN
Principal Consultant of Home Health Services