Here’s how to keep home health care records in tip-top shape

Our auditors review home health care facility documentation to verify services billed. They check for whether:

• Services were actually performed, billed and paid correctly.
• Care was reasonable and medically necessary.

Here’s a checklist for ensuring that your home health care records are correct and provide us with the information we need:

• Complete documentation as soon as possible after your visit or observation of the patient.
• Use legible handwriting on documents.
• Sign and date documents according to Blue Cross’ requirements.
• Be sure that patient records contain:
• Patient identification information
• The patient’s homebound status
• Signed and dated physician orders
• Pertinent medical and social history
• Physical assessment and medication reports
• Plan of treatment, care and evaluation
• Visit notes for all services provided with documentation to support the InterQual^® criteria application
• Ensure that treatment plans:
• Specify the particular service order
• Are signed and dated by the ordering physician within the patient’s certification recertification period
• Document verbal orders from the physician for changes in the plan of care. They must be documented, signed and dated on the date they are received.

None of the information in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.