We have seen some key points that Medical Reviewers are beginning to deny if the expected documentation is not present.

There are several items that are required on individual visit notes. Clinicians get tired of hearing Medical Review discussions about “painting the picture” of the patient situation, but the Medical Reviewers do not have anything except documentation within the chart. They do not have the opportunity to interview the patient, and they do not have the clinician to ask questions, so all they have is your documentation.

As you go through the documentation of individual visit notes, documentation should be there to support the plan that is going to be provided to that patient. Specifically, the skilled service that is provided to the patient that day during that specific visit, the patient’s immediate response to the services that have been provided to the patient, and the requirement to document the plan for the next visit.

Even though Home Health documentation, EMR (Electronic Medical Record) systems have been immensely helpful, EMR documentation systems sometimes give clinicians the ability to simply use a checkbox or generic language. In many cases, with the plan for the next visit, we are allowed to mark a box that says, “see the plan of care” or “continue the plan of care.” This is NOT acceptable under Medical Review.  The requirements in the Medicare Benefit Policy manual specifically state that the agency is to document the actual plan of the care that is going to be provided and the skilled service that is going to be provided on the next visit.

In the last few weeks, there have been several denials in Home Health because there has not been adequate documentation to support the plan for the next visit. You might think, “are they really wanting to go down that road?” and the answer is yes, they are.

The documentation in the Medicare regulation is clear that it is required to document specifically what is planned for the next visit. In the past, Medical Reviewers have not picked that item to focus on, and now they are determined that they are going to focus on that whether we want them to or not.

Currently, there is a high volume of activity under Targeted Probe and Educate, UPIC Audits, SMRC Audits, etc. Be very meticulous about documentation to ensure that if a Medical Reviewer comes knocking at your door or e-mail, you are prepared with documentation that will support the care that you provide to your patients and will painlessly get through those medical reviews.

If you need assistance with a medical review or anything else mentioned in this Monday Minute, do not hesitate to let us know.