AUDIT PROOF HOMEBOUND DOCUMENTATION

Audit proof homebound documentation

One of the most common causes of home health audit denials is failure to appropriately document homebound status. There are 3 timepoints at which homebound status must be appropriately documented to fulfill this requirement. They are...

  1. The F2F and corresponding H&P from the physician or NPP
  2. The OASIS and care plan
  3. All follow up visit notes until DC

But wait. We have to document homebound status over and over??  YES!

Setting the stage for admission with complete documentation on homebound status is essential. Connecting the functional deficit with a disease process is a good way to document this.  Fill in the blanks below to help document most home health scenarios...

 

Mr. Smith is homebound due to (weakness, unsteady gait, confusion, dementia, medical restriction, etc. ) as a result of (CVA, COPD, Alzheimer's, joint replacement, etc.) exacerbation and requires an (assistive device) and assistance from (caregiver) to ambulate safely and leave the home.

(homebound documentation requirements have two separate criteria, and can be found in The Medicare Benefits Policy Manual (MBPM) Chapter 7, 30.1.HERE)

 

Though states in the Review Choice Demonstration (RCD) have an added requirement for home health admission, I believe they have an advantage if they have chosen the pre-claim review (PCR) option. In PCR, homebound status documented in the F2F, OASIS assessment, care plan and physician certification statement are reviewed as well as documentation supporting; the patient is confined to home, has a normal inability to leave home, and leaving home is a considerable and taxing effort before patient affirmation. That said, these agencies have learned from trial and error how to document for compliance. They have also had the opportunity to resubmit until they got it right. Most agencies tell the same story, at first, they dealt with denials and needed to re-submit often, but they soon learned how to document to meet the homebound requirements and were able to teach referral sources as well.

In our work with agencies who are in home health audits or those for whom we complete mock audits, we find most agencies are doing a fair job of meeting the initial requirements. However, providing continued proof of homebound status is a point of failure even in PCR agencies. It is just as important to document homebound status throughout the episode of care to ensure compliant audit proof documentation as it is at admission. 

Here are a 3 examples of partial denies from CMS due to homebound status…

Scenario 1

…..records indicated that home health services were ordered to treat decreased mobility, intractable pain, and decreased ambulation. The beneficiary also had a surgical wound that had not healed. She lived alone at home, was dependent on someone else to dress her, and could only walk with another person present. Leaving the home would have required a considerable and taxing effort at the start of care. However, during the episode of care that started on October 24, 2015, her mobility status improved. Specifically, by November 20, 2015, she was able to walk 100 feet on all types of surfaces using a cane with supervision and could tolerate sitting and standing for up to 30 minutes. In addition, there was no evidence in the records that leaving the home required a considerable or taxing effort after November 20, 2015. The medical information does not support that she remained homebound after this date… https://oig.hhs.gov/oas/reports/region2/21701022.asp

Scenario 2

For another beneficiary, records showed that the patient was initially homebound after being treated for congestive heart failure and a hip fracture. He had some post-hospitalization debility in addition to his normal debility, had pressure ulcers on both heels, was limited to ambulating 20 feet with a rolling walker, and his residence had steps. The beneficiary’s condition improved over time and by a later date in the episode, the beneficiary was outside when the physical therapist arrived and had already wheeled himself to the corner of his street two times. At that point, leaving the home did not require a considerable or taxing effort. https://oig.hhs.gov/oas/reports/region5/51600055.pdf

Scenario 3

For another beneficiary, records showed that the patient was initially homebound, as she was thought to require care in the home setting due to needing a cane and the assistance of another person to ambulate, having significant weakness and being at an increased risk for falls due to polypharmacy, disease process, and numerous comorbidities. By a later date in the episode, she was able to transfer and ambulate 200 feet with a rolling walker without hands on assistance. She was residing in an accessible assisted living facility without mobility barriers. Leaving the home would no longer require a considerable or taxing effort. https://oig.hhs.gov/oas/reports/region1/11600500.pdf

 

All three of these examples started strong with homebound documentation. But as the patient improved, clinicians literally documented the patients no longer met CMS’ homebound criteria while continuing to provide care! If your agency is identified for audit, these trends can lead to large amounts of overpayments for claims billed “incorrectly”. Below are suggestions on how to improve homebound documentation throughout the episode in your agency...

  1. Review the two criteria CMS homebound requirements with staff
  2. Make sure the field staff understand the continued need for homebound status at every point of care--not just admission
  3. Have your clinicians answer the question “What is keeping this patient from going to outpatient therapy?” chart these functional limitations at every follow up visit to meet the homebound documentation requirement 
  4. Outline next steps for your clinicians when their patient no longer meets CMS homebound criteria
  5. Perform an internal audit for homebound status in your agency

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