Since the inception of the Home Health Prospective Payment System (PPS) in October 2000, there has been relentless scrutiny surrounding home Home Health therapy documentation associated with supporting medical necessity for Medicare Home Health charts.  Considering all the pressures of limited time, regulations, never-ending audits, and the denial of payments due to lack of medical necessity, therapists must refine their documentation skills to ensure they can support and justify the need for therapy home health services. Documentation is key to compliance, quality of care, patient satisfaction, care coordination and reimbursement. Understanding what auditors are looking for and how to prepare and respond to an audit will ensure success and reduce the risk for denial and further scrutiny.


The therapy evaluation must accomplish two things: 1) highlight the necessity for skilled therapy and 2) identify the areas to address in future treatments.

During the first encounter with the patient, the therapist will set the expectations for the rest of the “plan of care” and for all future visits. The patient’s medical history should be reviewed carefully as this will be the roadmap that will help you identify some of the major issues and what questions to ask the patient during the actual evaluation.

A thorough assessment of the patient’s prior level of function is key to supporting your short and long-term goals and helping to support the need for skilled services. The patient’s prior level of function must be specific and include objective measurable findings that paint a picture of the patient’s level of function prior to a recent exacerbation, illness, or injury.

Therapy evaluations need to be comprehensive to ensure an accurate baseline assessment is obtained using methods such as interview, observation, and a hands-on assessment. It must include assessment of functional skills, safety, home environment, accessibility, mobility, and patient/family issues that may impact treatment. A plan of care approval from the physician or provider must always be obtained prior to continuing care.

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Therapists must develop goals that are realistic, individualized, functional and address the patient’s functional deficits. The plan must include treatment goals that are objective, measurable and pertain directly to the patient’s illness or injury, and resultant impairments. Using the SMART (Specific, Measurable, Achievable, Relevant and Time Bound) goal model, ensures that goals and outcomes are patient centered and prioritized.

Engage the patient/caregiver in the development of the plan of care, including treatment goals. This will help to ensure there is commitment from the patient and that they are motivated to participate and cooperate with the treatment regimen. The plan of care must include the expected duration of therapy services and describe the course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function and established goals.


The qualified therapist’s documentation should support and demonstrate medical necessity of the skill provided. The skilled progress note should include patient education and training activities with details supporting specific skilled instructions, teaching, and training that was provided by the therapist.

The documentation should also include the patient’s response to treatment, using objective measurements and their progress toward therapy goals, in addition to their ongoing deficits that require continued skilled care. Documentation of the patient’s response to the therapy interventions and education must include the patient and/or caregiver’s ability to return demonstration, reflecting their understanding and recall of what was taught.

A specific and detailed plan for the next visit MUST be included in the daily visit. Generalized and vague descriptions such as “continue with plan of care” and repeated plans should be avoided to decrease the risk of claim denials. Documentation content should convey to an auditor the status of the patient and adherence to the ordered plan of care, with their progress toward goals in measurable terms.

A clear picture must be painted to tell the story of the patient and demonstrate the care trajectory. Ensure all communications with patient/caregiver, team members, physicians/providers are documented. Additionally, document any changes or abnormal findings that are reported, and all actions that were taken to address them.


The key to facilitating the appropriate delivery of care is communication with patient/caregivers, team members and providers. Communication plays a critical role in improving collaboration, quality of care, data accuracy, compliance and in addition to developing a comprehensive, accurate and cohesive medical record.

Not only is collaboration important for quality of care but it is imperative for agency’s quality outcome measures to exceed state and national averages. Public reporting programs such as Care Compare and Home Health Value Based Purchasing give consumers even more data for analysis in choosing a home health provider for their or their family’s healthcare needs.


Documentation should be completed in a timely manner. The longer the time between your visit and the documentation of the visit, the higher the risk that you may forget important details of your visit with the patient. Timely and accurate documentation is important to protect your patient, promote safety, and ensure the patient receives the right treatment at the right time.

Accurate and timely documentation is also important to protect the provider, avoid liability and justify the services that you have requested payment for.  When documentation is missing from the chart, does not support medical necessity, or is inaccurate, reimbursement may be adjusted, delayed, or even denied fully.

Agencies should consider implementation of a Clinical Documentation Improvement (CDI) program to assist in improving quality of care, compliance, and accurate reimbursement.  These reviews may be conducted in real time as the documentation is completed and/or retrospectively.  If retrospectively, the preference would be that they are reviewed prior to final claim billing.  Any findings during these reviews should be communicated and used for education throughout the agency.

These are the top recommendations for establishing the foundation of defensible documentation and creating the framework for efficient, accurate and quality documentation throughout your patient charts.  Healthcare Provider Solutions CHAP Certified consultants stand ready to assist in any way necessary to ensure that your documentation will pass any level of medical review. Contact us today.