If you are a Medicare-certified home health agency either responding to a bottomless pile of ADR requests, entering into the second round of Probe and Educate, or maybe even enduring a ZPIC pre-payment review, I suggest you take a step back and ask yourself one important question: "How are my clinicians doing their charting?"
Do they chart by checking boxes? Or are the records my agency submits for review filled with robust, data-rich, longitudinal charting? Are they charts that speak to each patient's unique individual story in direct correlation to the severity of the illness or injury being treated?
If you answered 'yes' to the first question and 'no' to the rest, you need to know about CMS's not-so-well-kept secret: CMS expects longitudinal charting. It has for many years now. However, like many CMS rules, it has been lying dormant, on the books but not enforced. This is changing, sooner than many will be ready for.
CMS has published a blueprint to aid in the development of longitudinal charting. I have shown it to hundreds of agencies over the past few years a the typical response has been, "CMS expects too much." Worse, the most common response is, "My EMR does not support that."
Way back in the MBPM 5-11-2015 update, CMS clearly communicated what longitudinal charting is, through the use of examples. Let's look at what follow-up notes should and should not say.
First, the should not's:
"Vague or subjective descriptions of the patient's care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:
These warnings tell us they really have been reading your charts. They are familiar with your practices and want to educate you with feedback from their medical review teams. If that doesn't work, they will use payment denials as an educational opportunity.
Now the should's:
"Clinical notes should be written such that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as 'next steps' to be taken. (Longitudinal Charting)"
Thus, the clinical notes are expected to tell the story of the patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a skilled service is needed. Therefore, the home health clinical notes must document as appropriate:
Following these bullet points in the order presented creates a longitudinal chart with each note building on the last, developing a clear demonstration of medical necessity for the services provided and outcomes obtained. On the other hand, tolerating clinical documentation laxity drastically increases the likelihood that a ZPIC letter will soon arrive on your desk. It could be the most expensive letter you ever open.
Michael McGowan is a former OASIS coordinator for CMS Region 9. He has been a Medicare payment denial appeals consultant and now is the CEO of OperaCare, a software/consulting company that helps home health agencies avoid payment denials, payment takebacks, ADRs and ZPIC audits.
©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org