Documentation to Support Medical Necessity Documentation to support skilled services are as follows from CMS’s Medicare Benefit Policy Manual, Chapter 7. As is outlined in home health regulations, as part of the home health agency Conditions of Participation (CoPs), the clinical record of the patient/client must contain clinical notes. Additionally, in Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, “Home Health Agency Billing”, instructions specify that for each claim, agencies are required to report all services provided to the beneficiary during each episode, which includes reporting each visit in line-item detail. As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided. These clinical notes are also expected to provide important communication among all members of the home care team regarding the development, course and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole then, the clinical notes are expected to tell the story of the patient’s/client’s achievement towards his or 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: • The history and physical exam pertinent to the day’s visit, including the response or changes in behavior to previously administered skilled services, and the skilled services applied on the current visit. • The patient/client and/or caregiver’s response to the skilled services provided. • The plan for the next visit based on the rationale of prior results. • A detailed rationale that explains the need for the skilled service in light of the patient’s/client’s overall medical condition and experiences. • The complexity of the service to be performed. • Any other pertinent characteristics of the beneficiary or home. Clinical notes should be written so that they adequately describe the reaction of a patient/client to his or her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s/client’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care: • Patient/client tolerated treatment well. • Caregiver instructed in medication management. • Continue with the POC. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.
