Home Health Certification and Plan of Care Billing 101

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Medicare requires a home health certification and plan of care to be compliant and for reimbursement.

Creating the plan and its follow up can be complicated. The plan of care should match the documentation within the OASIS. It can take hours of time and energy to be compliant. Many agencies are looking for innovative ways to streamline their process.

In this post you will learn about how some agencies are navigating plan of care documentation while maintaining compliance.

Common Plan of Care Scenarios

In an effort to streamline processes and minimize costs, many aspects of healthcare are transactional.

While there has been a significant increase in the number of patients choosing home care, there has also been a significant staff shortage. One of the ways to compensate for staffing shortages is to outsource functions like coding, documentation review, billing, and collections. In an effort to meet the increasing needs of agencies, HealthRev Partners has been at the forefront of customizing services and analytics. But, protecting you and your agency is our number one goal. And we’re not willing to bend on that.

Other outsourcing partners may say “yes” when an answer should be “no” to protect their revenue or close a deal. If the right thing to do isn’t what you want to hear, are you willing to listen or even dig a little deeper? Just to give you an example, we recently had a question from a client that fell into a legal ’gray area.’ It was a great question, and we took responsibility to find the proper answer to serve the client to the best of our ability. The functions that came into question in this particular case were:

1. Locking of OASIS documentation in an EHR
2. Reviewing, approving, and signing the plan of care

So we reached out to NAHC, the National Association for Home Care & Hospice, and have recorded their response later in this blog.

First, let’s start with some basics.

Home Health Certification and Plan of Care Billing 101

Here’s a quick overview:

• What is a plan of care in home health?
• Forms and billing for plans of care so you make money.
• Frequently asked questions to nail it every time.

What is a plan of care in home health?

Medicare requires several pieces of documentation to be compliant and to pay claims. Home health agencies must have an order/certification that outlines the need for home health services. This order is based on the initial assessment and the plan for treatment (care). It’s important to complete these pieces of documentation and have the referring physician sign them as quickly as possible to start care and for timely filing.Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at § 484.2 as a physician assistant, nurse practitioner, or clinical nurse specialist as defined at this part.

In a plan of care (POC), Medicare is looking for individualized, patient-specific, measurable outcomes and goals.The first step to producing a POC is to complete the OASIS/Comprehensive Assessment. The OASIS is a standardized data set that captures things like the patient’s condition, clinical needs, living situation, functional status, and more. To learn more about completing an OASIS, click here.

From the OASIS, a home health agency can develop the POC. The POC outlines everything a patient needs from services that will be provided to medical equipment needed and expected results.

The POC must be consistent with findings in the OASIS/Comprehensive Assessment. It must be reviewed at least once every 60 days by the care team and referring physician.

How to Write a Plan of Care

Many home health agencies use the CMS-485 Form to serve as a plan of care and certification for home health services documentation.

Using the CMS-485 form is voluntary, but most agencies prefer it because it was specifically designed to assist the referring physician in documenting the Home Health Services Plan of Care/Certification to establish the Medicare beneficiary’s eligibility and need for home health services.

Each patient must receive an individualized written plan of care, and any revisions or additions must be approved by the certifying clinician.

To write a plan of care you need to include the following elements for each patient:

• All pertinent diagnoses
• The patient’s mental, psychosocial, and cognitive status
• The types of services, supplies, and equipment required
• The frequency and duration of visits to be made
• Prognosis
• Rehabilitation potentialFunctional limitations
• Activities permitted
• Nutritional requirements
• All medications and treatments
• Safety measures to protect against injury
• A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors
• Patient and caregiver education and training to facilitate timely discharge
• Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient
• Information related to any advanced directives
• Any additional items the HHA or physician may choose to includeAll patient care orders, including verbal orders, must be recorded in the plan of care

Difference Between Reviewers and Clinicians

The expectation is that a clinician who is building a Plan of Care has been directly involved in patient care. An outsourced reviewer has not seen the patient but is trained in reviewing documentation and offering recommendation to the clinician. The assessing clinician should make the judgment for approving those suggestions based on their direct contact with the patient.

Who Can Approve the Plan of Care?

• Approval of Plan of Care should be done by a clinician who has seen the patient.
• A clinician providing advice about the care of a patient must be licensed in the state as a clinical and comply with licensing rules.
• Anyone providing direct services must be an employee of the agency. The same training and employee qualifications would apply to a reviewer if they are acting as a clinician with an organization.
• There is liability associated with making clinical judgments and decisions about the care of the patient.
• The name on the order should not be solely the reviewer or outsourced partner since they have not laid eyes on the patient.

Making Changes to the Medical Record

• Reviewers or outsourced partners who have not seen the patient should not make changes to a medical record.
• A outsourced partners should not make changes to the Plan of Care, interventions and goals, functional limitations, and locator items. They can make recommendations.

Locking the OASIS

• Locking the OASIS is a technical function and can sometimes be set up within an EHR/EMR to auto lock.
• Because the function of locking the record is not clinical, a reviewer or outsourced partner can lock the documentation once it is approved by the clinician.

So Where Does That Leave an Outsourcing Partner?

As a service company, you have to be able to meet the needs of the client.

These functions can be time consuming, and it may seem like a good idea for outsourced partners to take these off of a client’s plate. But once again, we wanted to be sure.

Finding a trustworthy partner can make the difference in empowering your agency to maintain cash flow and grow while minimizing risk. HealthRev Partners is committed to doing the right thing, even if it’s not the popular answer.