Discussion Guide: Documentation for House Calls-Discussion Guide for Documentation for House Calls course

Discussion Guide for Documentation for House Calls course
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The document from the Home Centered Care Institute outlines a comprehensive discussion guide intended for facilitating a group discussion on the topic, "Documentation for House Calls: Avoiding Negative Audit Outcomes." The guide aims to help participants understand and improve documentation practices to ensure positive audit outcomes.<br /><br />### Overview<br />- **Purpose**: Reinforce effective documentation practices in house call scenarios to prevent negative audit outcomes.<br />- **Audience**: Learners who have completed the aforementioned online education activity.<br />- **Duration**: 75 minutes.<br /><br />### Materials Needed:<br />- Hard copies of "Next Steps" handout.<br />- Case study handouts (Ralph, Betty, MJ).<br />- Superbill worksheets for each participant.<br />- Optional: Flipchart for capturing group comments and ideas.<br /><br />### Learning Objectives:<br />1. Explain “medical necessity” as defined by the Centers for Medicare & Medicaid Services (CMS).<br />2. Describe required documentation components for house call visits and avoid common mistakes.<br />3. Apply best practices for billing and coding to avoid raising red flags with auditors.<br /><br />### Agenda<br />1. **Introduction (5 min)**<br />   - Discuss importance of documenting medical necessity and relevant factors such as psychosocial issues.<br />2. **Define Medical Necessity (10 min)**<br />   - Detailed discussion of required elements: standards of practice, clinical appropriateness, necessity beyond convenience.<br />3. **Documentation Components (20 min)**<br />   - Discuss components such as Chief Complaint, History of Present Illness (HPI), Review of Systems, etc.<br />   - Interactive activity with smaller groups to discuss examples and challenges.<br />4. **Billing and Coding (10 min)**<br />   - Discuss training resources, examples of when to bill for time, and common red flags for auditors.<br />5. **Case Study Activity (20 min)**<br />   - Participants review case studies and use the Superbill worksheet to select appropriate codes.<br />   - Debrief with a group discussion on chosen answers.<br />6. **Debrief (5 min)**<br />   - Discuss potential improvements in documentation practices.<br />   - Review "Next Steps" and plan for implementation.<br /><br />### Case Studies<br />The document includes detailed case studies for three patients: Ralph, Betty, and MJ. Each case study is intended to:<br />- Provide real-world scenarios for practicing and applying documentation and coding guidelines.<br />- Cover medical history, current medications, and specific patient details.<br />- Highlight various challenges and discussion points for group learning.<br /><br />### Documentation Tips:<br />- Avoid "cloning" or copying notes across different visits.<br />- Ensure thorough documentation of all medical conditions and treatments discussed during visits.<br />- Account for time spent in counseling and coordination of care where relevant.<br /><br />### Answer Key:<br />The answer key provides the correct coding for each case study based on time, complexity, and services provided, ensuring participants understand the proper billing and coding practices.<br /><br />### Conclusion<br />This guide is designed to support healthcare practitioners in improving their documentation processes for house calls, ensuring they meet CMS requirements and avoid negative audit outcomes. The interactive elements such as case studies and group discussions are key to reinforcing the learning objectives.
Keywords
Home Centered Care Institute
house calls documentation
audit outcomes
medical necessity
CMS guidelines
billing and coding
case studies
documentation practices
Superbill worksheet
interactive learning