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Incorporating Home Health Agency Documentation into the Physician's Medical Record: Supporting Eligibility with Home Health Agency Clinician Notes

Did you know that home health agencies have an opportunity to use their clinician visit notes to help support eligibility for home health services?

CMS guidelines tell us that the home health agency's generated documentation for the patient, by itself, is not sufficient in demonstrating eligibility for Medicare home health services. Change Request 9119, Transmittal 92 which manualized policies discussed in the calendar year 2015 Home Health Prospective Payment System Final Rule published on November 6, 2014, states, "For medical review purposes, CMS requires documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) to be used as the basis for certification of patient eligibility."

However, CMS does provide an opportunity to have home health agency documentation incorporated into the physician medical record to support eligibility. Documentation used to support home health certification that was generated by the home health agency must be signed off by the certifying physician and incorporated into the medical record held by the physician or the acute/post-acute care facility's medical record. Section 6.2.6 of the Pub Manual 100-08 Medicare Program Integrity Manual provides examples of sufficient documentation incorporated into a physician's medical record. These examples include skilled nursing notes and physical therapy notes:

EXAMPLE 1: PT progress note helps support that patient is confined to the home:

Home health agency physical therapy progress note documents patient is non-weight bearing on right leg and requires use of a two-handed device to walk alone on a level surface, and requires assistance to negotiate stairs or steps or uneven surfaces. The home health agency assessment with progress notes has been signed by the community orthopedic certifying physician.

EXAMPLE 2: SN notes help to identify the need for skilled services:

Nursing notes states that the patient is significantly deconditioned, as a result of recent pneumonia, and requires the use of a walker to ambulate from chair to bathroom with frequent stops to rest. The home health agency skilled nursing note has been signed by the certifying physician.

Important Reminders:

  • The home health documentation being incorporated would be expected to corroborate or match and should not contradict the Certifying physician's documentation
  • A blanket form signed by the Certifying physician will not suffice to meet the regulations in lieu of signing off on the particular pages being incorporated

References:

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