Home Health & Hospice

Insider’s Scoop: Documenting medical necessity for teaching and training services

Homecare Insider, August 24, 2015

Editor’s note: This week’s Insider’s Scoop was adapted from one of HCPro’s newest home health titles, Documenting Medical Necessity: A Practical Guide for Home Health, written by Heather Calhoun, RN, BSN, HCS-D, COS-C. The complete manual provides down-to-earth, conversational documentation tips with dozens of example scenarios to help nurses understand medical necessity and document in a thorough manner that promotes the receipt of deserved reimbursement. For more information or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com

There is a lot of caregiver and patient teaching that occurs in the home. In fact, Medicare allows home health providers to educate clients on virtually any aspect of their condition or care as long as the need is identified at the time of admission and during each visit. More specifically, according to the Home Health Medicare Benefit Manual, skilled nursing visits for teaching and training are considered reasonable and necessary when these activities are appropriate to the patient’s functional loss, illness, or injury.
By extension, establishing the medical necessity of education in documentation mean the skilled nurse (SN) must identify what needs to be taught and provide evidence that the patient and/or caregiver has a knowledge deficit in this area.
To these ends, the clinician must set the stage for what services he or she plans to provide during the patient’s current 60-day episode, as well as rationale for the medical necessity of this care—practices that will decrease an agency’s number of Medicare denials based on lack of need.
In addition, routine notes must reinforce medical necessity and skill to ensure that Medicare continues to cover care. While clinicians may feel as if they are stating the obvious, spelling out every relevant aspect of a patient’s condition and care experience is an essential approach to home health documentation, as each note must stand alone in support of a patient’s need for delivered services.
Consider the following sample documentation, which justifies a patient’s need for teaching and training at the start of care (SOC) using vivid detail. 
Teaching and Training (SOC)
Patient has a history of a right side stroke that has left the patient with slurred speech, right hemi-paresis, and dysphagia, requiring a PEG tube. The patient is essentially bed confined and requires maximum assistance for transfers and all the patient’s activities of daily living. The daughter and niece will be the primary caregivers, living with the patient, as the patient can no longer live alone. The daughter will be caring for all the patient’s needs at night, and the niece will be caring for the patient’s daytime needs. The niece has had some education in PEG feeding, but the daughter has not been available for classes at the hospital to learn the increased needs of the patient. A referral was placed to the home health agency for skilled nursing and physical and speech therapy. The SN has arranged with the daughter and niece to perform the start of care (first visit) in the evening of the day of discharge from the hospital to admit and educate the caregivers on any needs that the patient has in the home.
SOC narrative
On the evening of admission, the daughter and niece are in the home with the patient, who has just arrived from the hospital a few hours ago. The patient is in a hospital bed and has bedside suction available, a Hoyer lift, and a wheelchair. The patient is on Jevity bolus feedings, 1 can 5 x day per PEG tube, with 250ml of free water, and the feedings were delivered the day before, along with all of the feeding supplies needed. The SN explained the needs of the patient to the caregivers, and they are willing to learn anything that is needed to care for the patient. Admission consents were signed, and the SN did a thorough head-to-toe assessment, with no skin breakdown noted, but has a reddened nonblanching area in her right heel. The SN applied moisturizer to the area and elevated the leg on a pillow, floating the heel to relieve pressure. The caregivers do not know how to turn and position the patient in the bed to prevent pressure ulcers and to make the patient comfortable. The patient currently has slight contracture to the right wrist and fingers. The patient was sent home with an arm splint applied to the wrist and fingers to prevent further contractures.
Due to the lack of knowledge of both caregivers on all aspects of care of a bedbound patient, the SN plans to educate them in these areas of pressure ulcer prevention, prevention of contracture, and turning/positioning the patient in the bed. The SN also will educate the caregivers on the use of the Hoyer lift for transfers to and from the wheelchair, as they do not know how to use this either. The SN assessed the niece’s ability to properly demonstrate bolus feeding per the PEG tube. The niece was able to prepare the area and obtain all the necessary supplies for PEG feeding. The niece had to have verbal cues to elevate the catheter tip syringe above the level of the stomach to aide in gravity, draining into the stomach. The niece also had the patient’s head flat when beginning feeding. The SN had to educate the niece and daughter to always elevate the level of the head at least to 45 degrees to prevent aspiration. Educate the caregivers on signs and symptoms of potential aspiration, such as wet cough, gurgling, spitting up milk or milk noted in the mouth, fever, and congestion. Taught caregivers that if this should happen, to stop the feeding and call the nurse immediately. The niece was able to demonstrate how to properly bolus feed the patient. The daughter noted to be very reluctant to perform this task for fear of doing it incorrectly. The nurse reassured her that the agency staff would be available for visits and for any questions that she has. The SN also left written instructions on each step to perform when feeding the patient per PEG.
The SN plans to return the following morning to educate the niece on giving medications through the tube and to troubleshoot potential tube complications. The patient has 3 new medications that the caregivers are not familiar with and will require education. Will also plan to educate on CVA etiology, along with fall prevention and management of pain. Physical therapy plan for evaluation due to patient with decrease in functional ability and speech therapy to assist with slurred speech and assess safety with swallowing and potential oral intake in the future. SN frequency will be daily x 4 days, 3wk1, 2wk3, 1w4, and then reevaluate for continued needs.