Home Health Articles and Information


Mar 25, 2021 11:19:07 AM / by Kristi Bajer, BSN, RN, COS-C

Does your documentation show a skilled need?

Some HHA's are confused about documentation of the patient's skilled need.  After all, the physician sent an order-- and we follow doctor's orders right?  Well, yes....and no.  Of course, you must have an order to admit a patient, but just having an order does not prove the patient is appropriate for skilled home health. HHA's must know the scope of coverage for home health and practice within it. The documentation on your OASIS, therapy evaluations, and regular therapy and skilled nurse visit notes must show a skilled need.

When providing OASIS training, I always tell quality assurance staff to think of the OASIS as an insurance pre-authorization.  After all, Medicare is insurance.  The depth of the OASIS scores coupled with the patient's clinical grouping should be used to determine skilled need. It should also guide the HHA to the reasonable and necessary amount of skilled care to provide along with the discipline(s) needed, appropriate amount of utilization, and length of care expected by CMS for the patient.  Relying on clinicians subjective guess to plan disciplines, utilization and length of stay is a slippery slop.  CMS uses data for this and your agency should too (shameless OperaCare plug-- we make this easy!!).

Below we will discus the rationale for 3 different denials from CMS for "Beneficiary Did Not Require Skilled Services".  They are great examples of common mistakes I see HHA's making and should help your HHA to avoid them. (underlining mine)



"A beneficiary with multiple co-morbid medical conditions affecting her mobility was homebound. A physical therapy evaluation was indicated to assess the patient’s mobility and need for an assistive device and home exercise program. At that evaluation the patient had no pain, shortness of breath, fatigue, or weakness. Her memory deficit included a failure to recognize person, place, and lack of ability to recall events of the last 24 hours, with impaired decision making. The patient did not have capacity to respond to the cognitive aspect of physical therapy. She needed a repetitive exercise program, not continued physical therapy."

In my opinion there could be a double denial on this claim. The first is providing therapy for a patient with no pain, SOB, fatigue or weakness. There would be an expectation of some degree of at least one of these issues on the patient assessment.  The other reason is cognition.  All to often I see large amounts of  therapy provided to patients who cannot retain information or follow simple commands. This is not reasonable and necessary as stated above.  Since the patient cannot participate in a meaningful way or retain any information a repetitive exercise program would be more appropriate.


"A beneficiary with a history of stage III chronic kidney disease, gout, hypercholesterolemia, and hypertension was homebound. Services for evaluating and reassessing skilled physical therapy and skilled occupational therapy were needed. However, the medical records did not support that the beneficiary required any ongoing skilled physical therapy or skilled occupational therapy. There was no indication for skilled nursing services. The beneficiary’s conditions were within his normal limits and there was no history of recent changes to medications or treatments. He had caregiver assistance available for processing information with respect to education regarding medical conditions and medications. The medical records did not support that the beneficiary required skilled services beyond those services related to the evaluations and reassessments."

An accurate H&P from the referral source is essential in an audit.  This requirement can be  frustrating since the physicians' documentation is not in the HHA's control.  But it must be addressed.  Make sure your intake is reading the H&P and noting if the documentation states the condition(s) necessitating the referral are documented as "stable".  In effect, the referral source is making your claim non- billable.  Educate the referral source and ask for a correction or write an addendum for the physician to sign. Also watch out for M1100, its a most missed question.  Does the patient truly have around the clock care? Or is the clinician mistakenly charting that the living situation they are documenting happens around the clock?

Example :3

"A beneficiary in her first episode of care with comorbid medical conditions including severe depression, anxiety, and osteoarthritis was homebound. Her conditions were of longstanding and there was no history of recent injury. She had caregiver assistance available for processing information with respect to education regarding her medical conditions. The patient was not consistent with her home exercise program, refused to ambulate with staff by using her wheelchair to attend meals, and refused therapy at times. As a result, ongoing skilled nursing and physical therapy services were excessive and not medically necessary after the third visit."

Here is another claim that could be denied for two reasons.  First, there is nothing prompting the referral?  Remember just because the patient has a diagnosis does not mean they require care.  What has changed? Exacerbated? What is the patient unable to do or understand?  Secondly, the HHA charted non-compliance.  While honest charting is a must, providing care when continually  charting the patient is unwilling to participate in their own recovery is a red flag. It tells CMS your HHA provided care with no reasonable expectation for improvement or maintenance. This is not considered good use of taxpayer's money.


Tags: PDGM, Compliance, Home Health, Quality assurance, Home Health Care, audits

Kristi Bajer, BSN, RN, COS-C

Written by Kristi Bajer, BSN, RN, COS-C

Kristi Bajer BSN, RN, COS-C, brings over 10 years of real world experience as a clinician, director, and administrator in home health. She is a firm believer in diagnosis driven evidence-based care in home health. Currently, she assists agencies with external chart audits and Medicare appeals, as well as providing training and coaching on OperaCare implementation and building QAPI programs using data to drive success and protect agencies from government audits.