OASIS Alert

Published on Tue Nov 02, 2010 PDF

Focus on 8 crucial problem areas to secure your bottom line.

Auditors are hot on the trail of homebound patients who don't actually qualify for the status. If your patients' medical records fail to pass muster, your reimbursement will take a heavy hit -- no matter what your assessment says.

That's the situation many agencies are finding themselves in as they undergo reviews from Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs), and intermediaries.

Example: Recently, a Texas HHA saw a complete suspension of Medicare payments after Zone 4 ZPIC Health Integrity found six of 25 beneficiaries whose records it reviewed were not homebound.

State surveyors are also focusing on homebound criteria, industry veterans report.

Homebound criteria has been a long-standing issue for Medicare's home health benefit, notes attorney Marie Berliner with Lambeth & Berliner in Austin, Texas. That's because it's one of the few criteria patients must meet to qualify for home care services. In addition to being homebound, patients must require skilled care on an intermittent basis and the visits must be reasonable and necessary.

"From the beginning of home health, there has always been a requirement to clearly document what makes a patient homebound in the home health medical record," explains Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

Problem: Agencies have undergone fairly little medical review in recent years, notes consultant Pam Warmack with Clinic Connections in Ruston, La. "I fear providers have been lulled into a false sense of security as to the adequacy of homebound documentation," Warmack says. "On an almost daily basis, I am confronting my clients with the inadequacy of their description of the patient's homebound status."

"I don't see homebound documentation hardly at all anymore," worries consultant Sharon Litwin with 5 Star Consultants in Ballwin, Mo. Agencies used to document homebound criteria thoroughly. "Then the fiscal intermediary stayed away from this issue, and documentation got lax."

Industry experts are seeing these eight common problems with home care documentation:

1. Lack of details. "When I review clinical records, I find a lot of homebound status documentation that  ... provides insufficient detail," relates Chicago-based regulatory consultant Rebecca Friedman Zuber. Generic statements won't cut it with auditors, experts warn. "It is not enough to document, 'patient unable to leave home without assistance' and expect this to cover the homebound requirement," Warmack cautions.

2. Use of factors other than descriptions. Clinicians often point to a diagnosis code or a patient status description like "patient uses wheelchair" as the basis for the patient's homebound status. That's not good enough, Zuber warns.

These items don't address the criteria like a thorough patient description does, she says. (See related box, next page, for Medicare's homebound definition and criteria.)

3. Provider confusion over homebound definition. "The legal definition of homebound is a little bit wiggly," Berliner tells Eli. The definition does not use absolute measures or definitive physical conditions.

That has led some providers to be confused over what constitutes a homebound patient, Warmack reports. Many agencies have a "skewed concept of what qualifies a patient as homebound," she says. As a result, "patients are not always meeting the strict requirements defined within the Medicare Benefits Policy Manual."

For example: Some agencies think they can say to a patient, "You have to stay home for us to take care of you," Litwin says. "That isn't homebound," she warns. If patients can go out regularly and easily but stay home so they can be considered "homebound" and receive agency services, they don't truly meet the criteria.

4. Reliance on additional criteria. The homebound definition contains gray areas and that can be confusing.But adding your own artificial parameters doesn't help, says consultant and therapist Cindy Krafft with Fazzi Associates.

"I am noticing several electronic tools have made up their own criteria like "can't walk more than 10 feet" or "needs assistance of 2," Krafft tells Eli. "Then the note content does not support that restrictive of a statement, thus putting the care at risk" of denial and recoupment.

5. Checkboxes. E-tools have helped ease agencies' work flow, but that can be at the cost of adequate charting if agencies aren't careful.

"Far too often the clinicians rely on checkboxes to describe homebound, and this is simply not good enough," Warmack maintains. Records must contain more descriptive information than a brief generic statement.

"Clinicians, especially those who are using point of care systems, just check one of the standard boxes on the form like 'endurance' or 'limited mobility,' rather than including a statement that describes what makes the patient homebound," Adams worries.

7. Conflicting information within the record. One part of the patient's record may say she is homebound, but other parts may seem to contradict that statement.

For instance: "Information in the record seems to indicate the patient can come and go as they please,"

Adams frequently sees. Or "the patient is scored as fully independent in all of the activities of daily living and does not even use an assistive device," she says. In those instances, a detailed description of why the patient still meets the homebound requirement is necessary, or the ADLs need to be filled out correctly.

8. Unexplained trips. Under the homebound definition, trips away from home are OK as long as they are short and require considerable effort (see related box). But your documentation must support that.

Adams frequently sees "comments in the record about the patient not being home or going out to lunch without any explanation of why they were gone or description of what type of taxing effort it took to leave home," she says.

Expect Auditors To Ask Tricky Questions

The problems with agencies' homebound documentation may be exacerbated by auditors' and surveyors' interview styles on the issue, Berliner warns. Often they will call or visit beneficiaries and ask whether they are homebound, but neglect to mention that the question applies to the period a certain claim covers -- sometimes years before.

For example: Perhaps a patient received post-hip replacement surgery services a year ago, Berliner says. When the auditor calls, the patient says he leaves home frequently with little effort and the auditor concludes he isn't homebound, but that wasn't true during the claim period.

Auditors and surveyors also may draw the wrong conclusions when they simply ask whether a patient has left the home. The patient may explain that she leaves the home weekly for church or other reasons, but neglect to mention that her daughter must come to help her get to the car, that she uses a walker, that her daughter must load her oxygen tank in the car, etc., Berliner says.

Another problem: Auditors can get very inaccurate information when they question patients with dementia. "The patient may say they go out dancing every night," Berliner says. "But they're thinking about 1965."

Bottom line: When you start with a homebound definition that has gray areas, then auditors and patients each have their own ideas of what the definition involves, "you have a whole bunch of places where errors can take place," Berliner warns.