Medical review of home care charts, from many different organizations, has haunted home care agencies over the past couple of years. Lack of adequate Face to Face documentation has led to the highest percentage of denials. In addition, one of the top denial reasons, resulting from Additional Development Requests (ADR), Recovery Audits (RA) or Zone Program Integrity Contractor (ZPIC) reviews, is the lack of adequate medical necessity documentation!
Many agencies struggle with the Medical Necessity Denials and feel that the denial is vague. Below is a checklist that agencies should review and use as a guide when reviewing their charts:
Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:
- New onset or acute exacerbation of diagnosis (Include documentation to support signs and symptoms and the date of the new onset or acute exacerbation)
- New and/or changed prescription medications – New medications: those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications: those, which have a change in dosage, frequency, or route of administration within the last 60 days.
- Hospitalizations (include date and reason)
- Acute change in condition (Be specific and include changes in treatment plan as a result of changes in medical condition, e.g. physician contact, medication changes)
- Changes in caregiver status or an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action)
- Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy)
- Inherent complexity of services; therefore, the services can be safely and effectively provided only by a skilled professional
- Lack of knowledge or understanding of the beneficiary’s care, which requires initial skilled teaching and training of a beneficiary, the beneficiary’s family or caregiver on how to manage the beneficiary’s treatment regime
- Reinforcement of previous teaching when there is a change in the beneficiary’s physical location (i.e., discharged from hospital to home)
- Any type of re-teaching due to a significant change in a procedure, the beneficiary’s medical condition, when the beneficiary’s caregiver is not properly carrying out the task, or other reasons which may require skilled re-teaching and training activities
- The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate: (a) the beneficiary’s inability to self-inject and the non-availability of a willing/able caregiver, (b) the appropriate diagnosis to warrant administration of the medication, (c) laboratory results (if required to meet Medicare criteria), and (d) dosage of the medication.
- The need for foley/suprapubic catheter changes and/or assessment/instruction regarding complications
- The need for gastrostomy tube changes and/or assessment/instruction regarding complications
- The need for administration of IM/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice
- Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain
For more information, refer to:
CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 184.108.40.206, 220.127.116.11 and 18.104.22.168
CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 22.214.171.124