Recently, audits like Targeted Probe and Educate (TPE), UPIC, SMRC, and RAC have become more frequent, especially since the start of the year. A notable area of focus for home health agencies that wasn’t heavily scrutinized in the past is teaching episodes.
When a skilled nurse provides education to the patient or caregiver—whether it’s about a new medication, wound care, or another topic—issues are being identified in the documentation. These concerns often relate to what is being taught or how the patient or caregiver responds to the teaching.
Medical reviewers expect detailed documentation of what was specifically taught, not just a note that the patient received printed materials. They also want to see how the patient or caregiver responded to the education. Did they demonstrate understanding? Were they able to repeat or explain back 50% or 75% of the information? If the teaching wasn’t effective, what was the issue? Was it related to the communication or teaching approach, or was it due to the patient or caregiver’s ability to retain the information? Clearly identifying these factors is essential.
Looking ahead to future teaching, let’s suppose a visit occurred today and focused on medication education. Will a follow-up visit be necessary? If so, why? What specific topics will need further teaching, and what is the plan to address them?
Another key area medical reviewers have been focusing on recently is the plan for the next visit. Although this requirement has existed for years, reviewers are now being more particular about documentation. Without a clearly outlined plan, claims are being denied. Simply stating “see the Plan of Care” or “continue the Plan of Care” is not sufficient. You must specify the exact skilled interventions planned for the next visit. Be sure not to overlook this critical detail.
To recap teaching visits, ensure there’s a legitimate skilled item that requires instruction. For example, if the focus is on medications, they must be new within the past 30 days or recently changed. If the patient has been taking the same medication for 10 years without any adjustments, education wouldn’t be necessary.
After confirming that the teaching meets Medicare requirements, be sure to document exactly what was taught, how the patient or caregiver responded, and the plan for continuing the education.
Recently, there’s been increased emphasis on documenting why teaching attempts were unsuccessful or how many attempts were needed and why they didn’t fully succeed. It’s crucial to capture these details clearly. Clinicians must ensure their documentation provides enough information for a medical reviewer to easily understand the patient’s current care status from a single note.
Healthcare Provider Solutions can assist with your medical review needs or help improve your agency’s documentation, feel free to reach out. We’re here to help. Wishing you a fantastic week ahead!
If you need help improving your agency’s documentation, or assistance with any other medical review needs, HPS is here to help, please feel free to reach out to us.
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