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Avoid These Home Health Documentation Pitfalls

Many in the home health industry struggle with incomplete and error-filled documentation. Improper documentation can impact crucial aspects of your home health business — from staff retention to patient satisfaction to your bottom line. 

To keep your finances in order and avoid legal issues, you must prevent these common home health documentation errors.

Rushing staff orientation on charting standards

The home health industry has undergone paradigm shifts in the past two years, and with documentation at the center. As agencies adjust to the relatively new Patient-Driven Groupings Model (PDGM), home health clinicians must be trained on the kind of detailed ICD-10 coding that supports all their documentation. 

 It can be tempting to rely on your clinician’s existing training and avoid the arduous task of in-depth documentation training. But, ICD-10 coding is complex, rigorous, and intricately linked to your bottom line. Setting guidelines based on these regulations — along with other industry standards and your company’s values — can help ensure your team has their i’s dotted and their t’s crossed. 

Missing minor errors that can have major consequences

According to the Celerian Group Company, a Medicare Administrative Contractor, many of the most common documentation mistakes in home health are minor (read: easily avoidable) errors. They list the most common minor errors and omissions as:

  • Mathematical or computational mistakes
  • Transposed procedure or diagnostic codes
  • Transposed beneficiary Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Incorrect data items, such as the use of a modifier or date of service

Share these trouble spots with your clinicians to ensure that they pay close attention to areas where common — but completely avoidable — errors compromise your business.

Over-reliance on templated information

A considerable advantage of EMRs is that they prepopulate many common data entry tasks. However, you don’t want your clinicians to rely so heavily on templated data that they forget to think outside the checkboxes. 

To maintain your quality of care, encourage clinicians to document events and circumstances that may be outside of your traditional intake forms and charts. This will not only ensure you have a clean line of sight into how all your patients are doing. It will also help you be prepared in the event of an audit or legal case.

Failing to keep up-to-date on changing standards

To make matters more complicated, the definition of proper when it comes to home health documentation is often shifting. It’s crucial that, as a business leader, you remain up-to-date on often-changing Medicare, insurance, and legal regulations. 

Follow top industry publications, such as HomeCare Magazine, Home Health Care News, and Modern Healthcare, to ensure you’re in the know. Staying connected with colleagues through industry organizations like National Association for Home Care & Hospice can help you keep informed as well. 

Siloing data

Outside of what data you collect, how you collect, manage, and store your data can impact the strength of your documentation. 

If you have a clunky interface between your clinician’s EMR or other documentation system and your CMS, it doesn’t just cause inconvenience. It can impact patient satisfaction, make it more challenging to create continuity of care, and even lead to more readmissions. 

By having a single, unified system, you can create the kind of systemic follow-up that helps ensure your patients always get the best quality of care. This can increase patient engagement and reduce readmissions. 

What’s more, an interoperable system can give you a big-picture view of your entire organization, providing insight into every aspect of your business, from what communication channel is most successful for prospects to what your top referral sources are.

Want more info on how an interoperable system can improve your bottom line in home health? Schedule a demo today.

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