We asked respondents to AHCC’s 2021 Home Care Coding & Compliance Industry Survey about their biggest documentation concerns. Here’s a preview of some of the results, along with some comments from AHCC board Chair, Diana (Dee) Kornetti, Chair, MA, PT, HCS-D, HCS-C, COS-C, COO, Kornetti & Krafft Health Care Solutions.
Q: 52% of respondents say they have an established documentation improvement plan, but 15% say they don’t have a program and 14% say they don’t know if they have a program. These numbers are just about the same as last year. How do those statistics map up to what you’re seeing in the industry?
A: I think it is more about the quality and actual utilization of the program (if one is present). It is hard to figure out if any documentation improvement program is working until it is tested. And this usually happens one of two ways: 1) external auditing of documentation occurs, or 2) organization drives objective outside assessment of current documentation.
Either way, evaluation of the program and the resultant documentation that it has (in theory) produced, is ─ or should be ─ an annual event for every home health organization.
Now, as we look to the eventual end of the pandemic health emergency classification, and a gradual ramping back up of the auditing activities for the industry, there is no better time than the present to look at the existing program or work with experts (in and outside your organization) to build a valid documentation improvement program.
Q: The top four documentation issues respondents reported in 2020 were:
- Physician documentation doesn’t provide needed detail to assign acceptable codes (58%)
- Documentation includes clinical details that would support a diagnosis that is not MD confirmed (45%)
- Documentation is not submitted timely (42%)
- Clinician documentation doesn’t provide needed detail to assign acceptable diagnosis codes. (41%)
In 2021 the top four were:
- Physician documentation doesn’t provide needed detail to assign acceptable diagnosis codes (46%)
- Documentation is not submitted timely (33%)
- Clinician documentation doesn’t provide needed detail to assign acceptable diagnosis codes. (33%)
- Documentation includes clinical details that would support a diagnosis that is not MD confirmed (28%)
The top concerns are the same, but we saw some drop in the number of respondents who report these as concerns. What’s the one piece of advice you’d give to folks for addressing these top pain points?
A: Continue to push for intake and front line clinician education. Intake personnel should have clear guidance and training on when a referral is “complete” and what elements are required to move it on to scheduling of the patient.
Front line clinicians should be trained on how to review the referral for that information that is critical for inclusion in their admission/SOC (as well as discipline-specific evaluations) to establish a coordinated and cohesive record of care. Use of a template for clinicians to complete admission/evaluation narrative content is a great tool to achieve standardization of content, regardless of clinician or discipline.
Q: While 49% of respondents reported that coders in their agency know and follow a compliant query process that uses open ended questions that do not lead a physician towards a desired diagnosis, 31% say this isn’t a requirement of their query process. What do you think about those findings?
A: I think this reflects a level of ambiguity in the coding community that should drive clear guidance and training to assist credentialed coders with becoming competent in the query process.