OASIS Alert

Published on Sat Oct 14, 2006 PDF

OASIS items can support homebound status.

One year later and denial rates for HAEJ1 claims are still sky high. Good documentation would cut the number in half.

In a review of 156 claims for the period from April through June showing a patient with the lowest clinical severity and little or no functional loss, regional home health intermediary Cahaba GBA denied 111 and reported a reimbursement denial rate of 61.93 percent. Lack of documentation of homebound status figured in 48 of these 111 denials.

Background: After completing a probe edit in April 2005, Cahaba began using a widespread edit for claims with a HIPPS code from the OASIS assessment showing a low clinicalseverity and high functional ability. Continuing analysis shows ongoing lack of documentation of homebound status combined with OASIS answers showing little reason to expect the patient to be homebound.

Don't Neglect Homebound Status

Nothing in the prospective payment system changed the fact that homebound status is essential to qualify a patient for the Medicare home health benefit, experts warn.

Despite a slight expansion in the reasons the Centers for Medicare & Medicaid Services says a patient may leave home without jeopardizing homebound status, when he does leave, it must require "a considerable and taxing effort," says consultant Terry Cichon with FR&R Healthcare Consulting in Deerfield, IL.

To prevent a claim denial after you have provided the care, focus on these five essentials:

1. Review homebound criteria. The beneficiary may leave home to receive medical care, attend religious services, participate in certain adult daycare programs, and attend unique functions such as weddings, graduations, funerals or family reunions. But if the patient does leave home "for any reason," your documentation must show the taxing effort required, Cahaba instructs.

2. Document repeatedly. On review, your intermediary uses your documentation to determine homebound status. Start at the beginning of the episode by noting the reasons the patient qualifies as homebound. Then as the patient progresses, document the continuing homebound status.

3. Use descriptions. Document homebound status with "clear, specific and measurable terms," Cahaba says.

Example: Instead of saying "tires easily," say "becomes short of breath after 10 feet," the RHHI suggests.

4. Explain missed visits. If a patient was not home when you went to visit, document why the patient wasn't home. If no explanation is given, the reviewer may find the patient not homebound, Cahaba warns.

5. Be sure OASIS answers and documentation match. Your intermediary is likely to question homebound status if the OASIS assessment shows the patient is independent in mobility items -- such as M0690 (Transferring) and M0700 (Ambulation/locomotion) -- and in activities of daily living.

This is especially true if the patient also scores low on M0420 (Frequency of pain interfering with patient's activity or movement) and M0490 (When is the patient dyspneic or noticeably short of breath?). In this situation, ask yourself what makes the patient homebound and document it clearly.