Medical Documentation Compliance

Home Health agencies have dealt with the ongoing level of scrutiny on medical documentation for many years. Leadership is relieved when no external home health care or medical coding audits have been implemented for their agency over the past few years and cringe at the thought of someone asking for charts. Others believe that no news is good news and not being selected means that everything must be OK. With ever-shrinking reimbursement, it is not enough to have a positive revenue stream. Agencies MUST protect that revenue against denial risk that has sometimes struck 3 years after the care was provided.

a female professional taking oasis coding notes at her computer
a female clinician reviewing oasis coding on her computer

Medical Coding Audits

To assess the status of the OASIS review/ Coding process, it is critical to assess patient records to identify both strengths and opportunities. The most efficient and effective way to establish a baseline is by participating in a medical coding audit conducted by credentialed documentation compliance experts focused on compliance with the most current official guidance.

The most effective way to determine accuracy is to conduct an audit of a sample of OASIS timepoints that have been reviewed and are deemed complete. Key points related to this audit are:

  • All auditors on the K&K Health Care Solutions team are externally credentialed for OASIS review and/or ICD-10 coding and only conduct work specific to that credential.
  • The medical documentation audits would be conducted off site with remote access to the electronic medical record (EMR) being granted to identified members of the K&K Health Care Solutions team.
  • The sample would be selected by the organization and represent work from a variety pf staff associated with the review process. We recommend this model to assess consistency across the group as a whole, but we can adjust based on the preferences of the organization.
  • The sample would focus on the timepoints of the Start of Care (SOC) as these are the more direct way to determine the accuracy of the review. If there are insufficient numbers of the SOC when the sample is collected, the Resumption of Care (ROC) can be added. Recertification timepoints are less than ideal for purposes of this project but can be included if no other timepoint is available.
  • K&K Health Care Solutions would recommend a minimum of 10 OASIS timepoints as a sample size. The agency can choose to request a higher number if needed.
  • The audit would focus on the following elements:
    • OASIS accuracy based on the most current official guidance and Q&As
    • Coding accuracy based on the most current official coding and reporting guidelines
  • Information would be collected and reported for each OASIS timepoint in the sample.
  • A summary report would be created to highlight both strengths and opportunities for the organization as a whole and for specific locations.
  • A one-hour conference call would be scheduled after the report has been submitted to discuss the findings and address any questions that remain.

Documentation Defensibility Audits

Medical documentation expectations are not the favorite topic for many clinicians and those who work to improve the situation may feel like it is falling on deaf ears. K&K Health Care Solutions provides specific documentation defensibility audits with detailed follow up plans and actionable tools. These resources have been proven to decrease risk and protect the revenue agencies have worked hard to secure.

K&K Health Care Solutions will review the clinical documentation contained in records following start of care (SOC), during course of care, and in preparation for recertification (RECERT) and/or discharge (DC).

Access to the records will be provided by the organization, in their entirety (inclusive of, but not limited to referral/F2F, OASIS, orders, communication and clinical visit notes) K&K will set up a Sync file and assist the organization with establishing an account for sharing of information in a HIPAA compliant process.

Findings will provide the agency with insights into the following areas:

  • Assessment of the care plan, including patient-centeredness of goal statements
  • Analysis of initial/reassessment evaluation(s) findings
  • Defensibility of each clinical visit completed in the medical record for the episode
  • Utilization of all appropriate disciplines
  • Timeliness of supervisory and reassessment visits (if applicable)

Key points related to this audit are:

  • The medical coding audit would be completed using the same sample provided for the OASIS and coding component of the project.
  • Findings will be integrated into the comprehensive report and included in the one hour conference call.
a woman in a suit working at a laptop for a documentation defensibility audit
a man searching through oasis documentation on his laptop
care plan icon

Targeted Probe and Educate (TPE)

When an agency finds themselves in round one of the targeted probe and educate process, what happens next can mean the end of the audit or a move to subsequent rounds. No matter what round the agency may find themselves in, K&K Health Care Solutions can provide a customized plan to assist in reducing risk going forward as well as dealing with appeals.

pre-bill icon

Denial Management

Despite their best efforts, agencies can find themselves in payment denial situations that consume a considerable number of resources – both human and financial. Successfully navigating the appeals process requires a level of understanding that K&K Health Care Solutions has repeatedly demonstrated as evidenced by successful redeterminations. Our goal is to assist agencies with the immediate issues by offering denial management in medical billing that is specific to a denial situation while building mechanisms to reduce future risk.