The CMS Medicare Benefit Policy Manual outlines the conditions for Medicare home health coverage. The patient must be confined to the home, under the care of a physician, receiving services under a plan of care and in need of skilled nursing care, physical therapy or speech language pathology on an intermittent basis (or the patient must have a continuing need for occupation therapy).

In addition to these conditions, the services provided also must be reasonable and necessary. When a medical record is submitted to one of the Medicare contractors for review, the reviewer’s decision on whether care was reasonable and necessary is based on information reflected in the home health plan of care, the Outcome and Assessment Information Set (OASIS), and the medical record of the patient. 

The following list contains the most frequently seen reasons for denials and some of the causative factors:

The medical record does not support that the patient experienced a change or exacerbation in condition, or care was provided beyond what was reasonable and necessary.

The likelihood of this happening increases with each additional episode of care an agency provides. Agencies often fail to document clearly problems patients experience and/or describe why patients continue to need nursing or therapy intervention. Documentation typically contains continuing assessments that can appear to indicate that the only thing the agency is doing is watching the patient to ensure that no new problems occur. It is the responsibility of the agency to defend the reason why it is continuing to provide services to the patient.

Home health aide services were reasonable and necessary, but could not be paid, as there were no qualifying skilled services.

Home health aide services only may be provided if the patient requires nursing or therapy services. A qualifying service must continue for each episode of care. Representatives of many agencies are confused about the difference between a qualifying service and a skilled care visit, especially as it relates to blood draws. The home health agency may provide visits to obtain blood samples for therapeutic monitoring, but it is not a qualifying service for Medicare home health benefits, and in the absence of other skilled services, Medicare will not pay for this. The patient must continue to qualify for home health eligibility based on an eligible skilled need (nursing service for wound care, restorative therapy services, etc.) to allow agencies to continue billing for home health aide services. 

The therapy documentation does not support the need for therapy services.

Therapy documentation must describe why a therapist is needed and why a non-skilled professional cannot provide the care. The therapy notes typically describe what the patient did during the therapy session, but fail to include limitations of the patient that were addressed by the therapist. 

The therapy documentation does not support a decline in function, and the OASIS does not support a functional decline in ADLS (activities of daily living) or mobility.

Medicare requires that therapy evaluations include the patient’s prior and current level of functioning, and that the OASIS assessment conducted at the start of care includes a description of the patient’s ADL/IADL functioning prior to the current illness, exacerbation or injury (as well as their current functioning). In cases in which the therapy documentation indicates that the patient already needed supervision prior to the current illness or condition, and when the OASIS assessment indicates that the patient needed some help with ADLs, the agency must describe clearly why the physician and clinicians believed that care was needed to improve the patient’s condition and/or safety. 

Discrepancies in the medical record: The OASIS completed by the nurse at the start of care and the physical therapy documentation were found to have discrepancies, and due to the conflicts in the medical record, the medical necessity of skilled therapy services could not be supported.

This happens to home health agencies frequently when a nurse completes an OASIS assessment by choosing values indicating that the patient is able to function safely without help, but the therapist indicates that services were needed because the patient was unsafe ambulating (this could mean the nurse writing the OASIS assessment noted that the patient can walk with a cane or walker, for example). All clinicians involved in the care of a patient should discuss their findings with each other and ensure that they are consistent in their assessments or can explain any variations.      

A HIPPS code is downcoded due to OASIS items not matching paper copies in the record.

It is common practice for a home health agency to use a coder in the office to assign ICD-9-CM codes to diagnoses and to reorder the diagnoses documented in the OASIS assessments to meet coding guidelines. Many agencies also conduct audits on the OASIS assessments to determine if there are inconsistencies in the data. When either of these occurs, changes must be made to the OASIS assessments, which could impact the Health Insurance Prospective Payment System (HIPPS) rates for individual episodes. Due to the nature of the business, clinicians often are spread widely across geographic regions that may or may not be located near their offices. Because of this, agencies are allowed to speak with the clinicians filing OASIS assessments and to transcribe corrections made at the time of the review, later having the clinicians sign the corrected OASIS forms. Agencies must be very cautious to ensure that the corrected HIPPS is value-billed, and that when documentation is submitted for review, the corrected form is included and identified in the packet.

We must remember that auditors do not have the inside scoop on your patients; they do not have the opportunity to hear verbal reports provided by clinicians and must rely solely on the documentation. As an industry, we may be providing excellent care, but we also must provide excellent documentation to describe the need for care clearly.

About the Author

Bonny Kohr, RN, CHCE, HCS-D, is the manager of clinical services for FR &R Healthcare Consulting, Inc. She is a registered nurse, a certified homecare coding specialist and a certified homecare and hospice executive. Bonny worked 23 years in home health care, starting her career as a field staff nurse before becoming a clinical director and finally a chief operating officer.

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