Examples of Sufficient Documentation Incorporated Into a

6.2.6 - Examples of Sufficient Documentation Incorporated Into a Physician’s Medical Record (Rev. 603, Issued: 07-21-15, Effective: 08-11-15, Implementation: 08-11-15) To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and, per §1814(a)(2)(C) and §1835(a)(2)(A) of the Act: • Be confined to the home; • Need skilled services; • Be under the care of a physician; • Receive services under a plan of care established and reviewed by a physician; and • Have had a face-to-face encounter with a physician or allowed non-physician practitioner (NPP). EXAMPLE 1: Does the below submitted documentation support the certification statement stating that the patient meets the eligibility criteria for home health benefit certification? Yes. Records received by the reviewer for a HHA claim for dates of service starting on 4/15/2015: 1. Patient was admitted to the hospital with a right-sided femur fracture sustained from a fall requiring surgery. A discharge summary dated April 14, 2015, signed by the inpatient attending physician. Included in the summary was a description of the patient’s injury, DME required, non-weight-bearing status, and the name of and appointment date for the community orthopedic physician who would continue to follow-up with patient, and the notation of the order for home physical therapy for home safety evaluation, gait training and strengthening 2-3 times per week for 6 weeks to be delivered by an HHA. Meets requirements for a face-to-face encounter (occurred within the required timeframe, was performed by an allowed provider type, and related to the primary reason the patient requires home health). Identifies the need for skilled services and alludes to the fact that the patient is most likely homebound because of the non-weight-bearing status and the order for DME. Identifies physician who will be providing care while patient is receiving home health services. Plan of care established with physician orders. 2. HHA generated comprehensive assessment (admission OASIS) dated 04/15/2015 along with physical therapy progress notes. PT 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 HHA assessment with progress notes has been signed by the community orthopedic certifying physician. PT progress note further supports that patient is confined to the home. 3. The community orthopedic physician-signed certification statement for HH services for start of care date of April 15, 2015. Certification statement signed by certifying physician. 4. HHA generated plan of care, which specifies the type, frequency and goals for therapies. The plan of care includes the signature of the certifying physician. Supports that plan of care has been established and reviewed by the certifying physician. EXAMPLE TWO: Does the below submitted documentation support the certification statement stating that the patient meets the eligibility criteria for home health benefit certification? Yes. Records received by the reviewer for a HHA claim for dates of service starting on February 1, 2015: 1. Primary care physician progress note dated November 15, 2014. States reason for visit is patient has a non-healing left foot diabetic foot ulcer measuring 1 cm x1 cm x 0.5 cm. Patient instructed on wound care with hydroactive gel dressing to be changed every 3 days. Patient able to return demonstrate application of dressing without difficulties. Meets requirements for a face-to-face encounter (occurred within the required timeframe, was performed by an allowed provider type, and related to the primary reason the patient requires home health). 2. Clinical note in physician record states that patient called primary care physician (PCP) on January 30th stating that the wound has gotten larger and there is copious purulent drainage causing the dressing to be saturated. She states she is unable to adequately change the dressing and keep it in place because of the size of the wound and the amount of drainage. Patient just recovering from pneumonia and she says she is unable to come into the physician’s office because she cannot drive. PCP made referral to HHA for skilled nursing services to evaluate the wound. Identifies the need for skilled services. 3. HHA generated comprehensive assessment (admission OASIS) dated 02/01/2015 along with skilled nursing notes which includes wound measurements, condition of wound, and documentation of physician phone call to report findings and receipt of verbal orders for daily wound care for 3 weeks, monitor and teach on signs and symptoms of infection and initiation of oral antibiotics twice a day for 14 days. Nursing notes also states that the patient is significantly deconditioned, as a result of recent pneumonia, requires the use of a walker to ambulate from chair to bathroom with frequent stops to rest. HHA skilled nursing notes further support that patient needs skilled services to initiate new wound care regimen, monitor for infection and that the patient is confined to the home. Physician’s verbal orders for daily wound care establish the plan of care. 4. The primary care physician-signed certification statement for HH services for start of care date of February 1, 2015. Certification statement signed by certifying physician. 5. HHA generated plan of care, which specifies the wound care orders, frequency of skilled nursing visits and goals for home health services. The plan of care includes the signature of the certifying physician. Supports that plan of care has been established and reviewed by the certifying physician.