Home Health Medical Record Audit Form

Yes No N/A
Certification
Plan of Care
Is there a plan of care and
certification/re-certification
received with the
documentation submitted
for correct beneficiary?
Is the plan of care and
certification/re-certification
submitted legible? (If a
signed copy is not legible,
please also include a legible
unsigned copy.)
Does the plan of care and
certification/re-certification
submitted cover the dates
of service billed on the
claim?
Is the plan of care and/or
certification/re-certification
submitted legibly signed
and dated by the physician
prior to the date the claim
was billed to Medicare?
Fax stamp dates and
Received stamp dates are
not accepted as the
signature date.
Face to face
Is any required face to face
encounter documentation
submitted in the medical
record.
Is the face to face
encounter document for
the correct beneficiary?
Is the face to face
encounter document
submitted legible, have
physician signature and
date of encounter?
Does the actual encounter
visit note address the
primary reason home care
is being provided and not
simply include a diagnosis?
Does the face to face
encounter occur within 90
days prior to or 30 days
after the start of care date?

Is the face to face

encounter performed by a
physician or an allowed
non-physician practitioner
(NPP) and does the face to
face encounter document
include a date when the
physician or allowed non
physician practitioner (NPP)
performed the encounter?
Is the face to face
encounter signed and dated
by the certifying physician
or allowed non physician
practitioner prior to final
bill?
Is the date the physician or
allowed non physician
practitioner signed the face
to face encounter legible?
Does the documentation
include the clinical findings
that support the patients
need for skilled service and
homebound status?
Does the documentation
describe how the patient’s
clinical findings, as seen
during that encounter,
support the patients need
for skilled services?
If the face to face
encounter form indicated
to see attachment; is the
attachment submitted, and
labeled as an attachment?
 Is the additional
information submitted to
clarify the face to face
document signed and dated
before the claim was billed
to Medicare?
Nursing services
Management and evaluation
Is the physician narrative
for skilled management and
evaluation submitted in the
medical record?
Is the physician narrative
for skilled management and
evaluation legible and
signed by the physician,
and dated before the claim
was billed to Medicare?
Skilled Nursing
Is the order written on the
plan of care sufficient to
cover all skilled nursing
visits billed or covered by
an additional order?
Are the physician order(s)
signed, dated and legible?
Are the physician order(s)
dated after the claim was
billed to Medicare?
Does the physician order(s)
include specific
discipline(s), frequencies,
duration and specific
treatments for each
discipline?
Are the physician order(s)
for the PRN visit(s)
quantified and qualified?
Are the skilled nursing visits
for management and
evaluation of the patients
care plan reasonable and
necessary?

Is there a physician order,

to administer vitamin b12
to include frequency and
quantifying diagnosis?
OASIS

Is a copy of the OASIS

included in the
documentation submitted
to support the HIPPS billed?

Endpoint

Is the endpoint statement

submitted in the medical
record valid and realistic?

Therapy Services
Physical therapy
Does the order written on
the plan of care cover all
physical therapy visit(s)
billed or are there
additional orders?

Are the PT orders signed by

the physician, dated and
legible?

Do the PT orders signed by

the physician include
discipline, frequency and
duration?

Is the credential of the

person who performed the
initial physical therapy
assessment included?

Is the 30 day reassessment

visit documented in the
medical record?
In the initial physical
therapy evaluation, are the
short term goal(s) and/or
long term goal(s) stated in
objective, measurable
terms, and their expected
date of accomplishment as
required by the LCD active
for the dates of service
addressed?
 Does the plan of treatment
include specific functional
goals for therapy in
objective measurable
terms?
Occupational therapy
Does the order written on
the plan of care cover all
occupational therapy
visit(s) billed or are there
additional orders?
Are the occupational
therapy orders signed by
the physician, dated and
legible?

Do the occupational
therapy orders signed by
the physician include
discipline, frequency and
duration?

Is the credential of the

person who performed the
initial occupational therapy
assessment included?
Is the 30 day reassessment
visit documented in the
medical record?
In the initial occupational
therapy evaluation, are the
short term goal(s) and/or
long term goal(s) stated in
objective, measurable
terms, and their expected
date of accomplishment as
required by the LCD active
for the dates of service
addressed?
Does the plan of treatment
include specific functional
goals for therapy in
objective measurable
terms?

Speech Language Pathology

 Does the order written on
the plan of care cover all
Speech Language Pathology
visit(s) billed or are there
additional orders?

Are the Speech Language

Pathology orders signed by
the physician, dated and
legible?

Do the Speech Language

Pathology orders signed by
the physician include
discipline, frequency and
duration?

Is the credential of the

person who performed the
initial Speech Language
Pathology assessment
included?
Was the 30 day
reassessment visit
documented in the medical
record?
In the initial Speech
Language Pathology
evaluation, are the short
term goal(s) and/or long
term goal(s) stated in
objective, measurable
terms, and their expected
date of accomplishment as
required by the LCD active
for the dates of service
addressed?
Does the plan of treatment
include specific functional
goals for therapy in
objective measurable
terms?
Dependent Services
Medical Social Worker
Are the Medical Social
Worker visit(s) billed
Compliant with ordered
frequency/duration?
 Is documentation present
to cover medical social
worker visit(s)?
Does the assessment of the
social and emotional
factors related to the
patient’s illness, need for
care, response to treatment
and adjustment to care?

Do the service(s) performed

by the Medical Social
Worker related to obtaining
available community
resources to assist in
resolving the patient’s
problem?
Home Health Aide

Is documentation present
to agree with care plan for
each aide visit?

Are the home health aide

visit(s) reasonable and
necessary?

Is there documentation of
personal care provided by
the home health aide or are
the aide services an
extension of skilled services
– such as simple wound
care or therapy that has
been delegated?

Is the sole purpose of the

visit to provide
housekeeping services
only?

Homebound
 Is the criteria-one of the
homebound requirement
met? Criteria-one: the
patient must either:
because of illness or injury,
need for aid or supportive
devices such as crutches,
canes, wheelchairs, and
walkers; the use of special
transportation; or the
assistance of another
person in order to leave his
or her place of residence or
have a condition such that
leaving his or her home is
medically contraindicated?
*CMS has stated that
checkboxes and use of
general terms are not
adequate.
Is the criteria-two of the
homebound requirement
met? Criteria-two: there
must exist a normal
inability to leave home; and
leaving home must require
a considerable and taxing
effort? *CMS has stated
that checkboxes, and use of
general terms and re-
stating the requirement are
Insulin administration not adequate.
Is there a treatment order
to administer daily insulin
submitted in the medical
record?
Is the documentation of
why the patient can’t self-
inject insulin present in the
medical record?
Is there documentation of
why the patient’s caregiver
can’t/won’t administer
insulin present in the
medical record?
Are the results of the most
recent HBA1C included in
the medical record ?
Does the plan of care
include the order to
monitor and report the
HBA1C levels quarterly (and
no less often than 120 days)
or indicate if these are
being performed by the
physician?
Are the HBA1C level results
greater than 120 days
apart?

Is skilled nurse visit(s)

reasonable and necessary?