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When EMRs Fail to Communicate

Virtually every home health agency uses an Electronic Medical Record (EMR) to generate clinical documentation and meet certification requirements. There is no shortage of available EMRs for agencies to choose, and most tout their ease of use and support for a smooth billing process. However, some aspects deemed not important during EMR selection may pop up as issues when subject to CMS Medical Review activity.

Given that CMS requires compliance with Code of Federal Regulations (CFR), Internet-Only Manual (IOM), and Local Coverage Determinations (LCD) for payment, it would seem that EMRs would carefully review these and incorporate them into their systems. This is not always the case.

One significant example relates to the home health certification requirements. There are five of these, spelled out in the Medicare Benefit Policy Manual (MBPM), IOM Pub. 100-02, Chapter 7, Section 30.5.1 bp102c07 with a helpful supporting document of MedLearnMatters SE 1436.

The item that most causes issues under Medical Review (Targeted Probe & Educate, Unified Program Integrity audit, Supplemental Medical Review Contractor review, Recovery Audit Contractor review, or Comprehensive Error Rate Testing review) relates to certification of the face-to-face encounter.

Many EMRs use verbiage on the Home Health Certification and Plan of Care (commonly called a “485”) that: “I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. This patient is under my care, and I have authorized the services on this plan of care and will periodically review the plan.”

As far as this goes, this part of the certification attestation is valid. However, so far there is no certification of the face-to-face encounter.

Many EMRs continue with such statements as “I certify that the above named patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me had, or will have, a Face-to-Face encounter that meets the face-to-face encounter requirements.” [emphasis added]

Here is the rub. CMS requires that before certifying a need for home health service that an encounter occur between patient and an allowed practitioner. The encounter does not need to happen prior to home health admission (can be up to 30 days after admission) but it MUST BE before the allowed practitioner certifies and attests that the plan of care developed meets the patient needs, and that the content of encounter was related to the primary reason for home health service.

In other words, the EMR that places the words “or will have”, or “will occur” in relation to the timing of the face-to-face encounter is setting up the agency for denials. There is NO ALLOWABLE situation where certification for home health can occur—the Plan of Care being signed by the physician/allowed practitioner—prior to ALL components of certification being met. This includes that a valid, timely encounter DID occur: not WILL occur.

Without going into details on the many possibilities related to face-to-face and certification, just keep in mind that if the patient is NOT starting home health directly after discharge from an acute/post-acute care setting where the physician or allowed practitioner, with privileges, that cared for the patient in that setting is certifying the patient’s eligibility for the home health benefit, but will not be following the patient after discharge, then ALL components of the certification must be completed by the same physician/allowed practitioner.

If the required encounter was completed by a different allowed practitioner than your home health (Plan of Care/485) certifying physician and the example EMR verbiage is present there is a HIGH RISK of having the entire claim denied unless additional content is present in the record.

The point is: charting just what the EMR offers as templates does not guarantee a compliant chart.

Another example comes up around the CMS home health therapy reassessment requirement laid out in IOM Pub. 100-02, Chapter 7, Section 40.2.1. Specifically, the part that says “At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements. The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.” [emphasis added]

Nearly all EMRs for therapy reassessments have current findings listed on the visit notes and assessment. This documents the CURRENT status in such areas as muscle strength, balance, bed mobility, ambulation, endurance, and range of motion.

HOWEVER, many (bordering on most) EMRs do NOT have a clearly laid out COMPARISON of these current findings to prior assessment measurements. Some have a general statement such as “Progress Towards Therapy Goals” or “Indicate Summary of Functional Progress Towards Goals.”

While these may appear to generate compliance, notice that they are making comparison to GOALS and not PRIOR ASSESSMENT. Of course evaluation of restoration or progress towards goals is important: it’s just not the whole picture and not directly aligned with the specific CMS requirement.

This leaves therapists to enter a narrative of findings, and since the form itself is directing this narrative to chart to therapy GOAL status and not reassessment finding CHANGE from the prior assessment, it sets up the agency for non-compliant charting. Denials for this are also very common on Medicare Advantage claims, where the reviewer is attuned to checking this area of charting.

These are two of many examples that demonstrate that simply using an EMR will not ensure that the documentation generated will pass Medical Review scrutiny. Even such simple items as the format for staff electronic signatures on documents can generate denials, so the “other” aspects of your chosen EMR should be evaluated.

What to do? The answer is two pronged: training of staff on what needs to be documented in the record; and working with the EMR vendor to see what modifications are necessary to give your clinicians the best platform to chart compliant.

Many EMRs do not place staff in the best position to chart compliant, payable content. If so, then your clinicians are working harder, not smarter. In this stressed environment of home health that is an unneeded burden. Your EMR should facilitate communication: not generate denials.

So, to paraphrase a popular commercial: do you know what’s in your EMR?

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