What is the Focus of Care?

by Keith Grunig

Nurse in Home Health Setting Performing OASIS Review

What is the Focus of Care in Home Health?

One of the most common things we hear from clients when there is a face to face but the primary diagnosis code is not PDGM compliant but there is a list of conditions that are listed out.  We will send a question back to the agency and ask "The Face to Face doesn't have a PDGM compliant code, but there is a list of codes.  The narrative is not clear on what the primary focus of care is, can you please help us understand what the focus of care is, or what the primary diagnosis is?"  The answer is usually something like "We're not the coder, you decide."   This happens in various forms a lot, and a lot of it is misunderstanding from the home health agency side.  The focus of care is an essential part of documentation to support medical necessity, home bound status, and ultimately if an agency will be paid or not for the episode.  

Simply put, the Focus of Care is stating why the patient is on service and what condition or conditions the agency will treat.  Most doctors, hospitals, SNFs, or other entities aren't worried about PDGM, let alone worry about what a PDGM compliant primary diagnosis and how it impacts the Face to Face (F2F) validity.  Therefore, it is essential that an agency clearly state what the focus of care is and how it is related to the F2F referral.  The Medicare Benefit Policy Manual states that the reason for referral on the F2F "Was related to the primary reason the patient requires home health services."   For a link to Chapter 7 of the Medicare Benefit Policy Manual click here.  The Medicare Benefit Policy Manual is essential for agencies to understand and have a thorough knowledge of.  It answers and spells out the conditions and requirements for agencies to follow for compliant claims.  

Face To Face

Face to Face continues to be the most common reason for denials.  For many, it is because the primary diagnosis doesn't match the F2F reason for referral.  For example, prior to PDGM being implemented, many practitioners used to use weakness as a reason for referral.  That would be the primary diagnosis and it was accepted by CMS.  Under PDGM, there is a whole long list of acceptable primary diagnosis codes.  If the code used as the primary diagnosis is not on the list, the agency will get paid $0.  Nothing.  It will likely be sent back to the agency prior to a denial, however.  The F2F document may be the most important document in the whole claim.  Without a valid and complete F2F, the claim will be denied.  

What does the F2F have to do with the Focus of Care?  Well, everything.  Remember that a lot of referring practitioners give referrals for issues that are not PDGM Compliant.  CMS wants agencies to move away from symptoms and focus more on underlying conditions.   Therefore, the F2F may say weakness, but the focus of care as told by a narrative from the nurse can tie the F2F to the reason for services.  The focus of care should address the reason for the weakness, thereby creating and validating the medical necessity.  If a F2F reflecting the focus of care can't be obtained, an addendum should be written for the practitioner to sign that ties the F2F with the focus of care.  If the underlying cause of weakness is dementia and the focus of care stems from dementia, then the F2F addendum could say "weakness due to dementia" and that should be sufficient to tie the F2F as the regulations say "Was related to the primary reason the patient requires home health services." (Medicare Benefit Policy Manual CH 7 pg. 29 4th paragraph second bullet point).  Ideally, in a perfect world, the F2F says dementia and if a new F2F can be obtained, then agency would obtain.  Our experience is that auditors do not like to look for notes that aren't clearly marked, and don't love addendums.  Additionally, auditors with contractors, Supplemental Medical Record Contractors called (SMRC) or Medicare Approved Contractors called (MACs) often don't understand the exact rules and can interpret rules and regulations erroneously or ignorantly.  

Home Care Answers has developed a narrative process that helps clinicians answer 4 questions in a narrative so that the clinician can best summarize what is happening with a patient.  We call it the 4 Way Test.  If a clinician answers the following four questions in the narrative, our findings are that auditors pass by (we've had one denial (1) ONE in the history of our company that can be attributed to Home Care Answers) with flying colors.  

4 Way Test- 

  • What is the primary focus of care (What are we here for- establishing medical necessity)?
  • How did the patient get there? (Underlying cause of issue- establishing medical necessity)
  • What are we going to do about it? (Establishes medical necessity and Reasonable and Prudent)
  • What can complicate the desired outcome (list comorbid conditions patient has that can impact the desired outcome) (Established medical necessity and reasonable and prudent care)

The following example of a summary statement effectively demonstrates the use of all four components of the 4-Way Tests.

“The patient is a 67 year old male that just underwent a total knee replacement due to degenerative arthritis of the knees. It is very likely that the patient will need the other knee replaced within the next few months. The patient has muscle weakness and gait problems that we will have PT work with, and nursing will assess the surgical wound for healing as well as draw labs in the form of pro-times w/INR r/t to the Coumadin use. We will also provide home health aide services for this patient to assist with ADL’s. See specific orders for further detail. The patient also has type II diabetes, hypertension, GERD, DJD, and is on medication for depression. All identified diagnoses will be monitored due to their inherent nature of potentially complicating the outcome”


Home Care Answers helps agencies rest assured by proactively helping agencies with documentation so that it is defensible.  With all of the headwinds agencies are facing, there should be no reason to not have a rock solid F2F process and focus of care statement to support the medical necessity so that agencies can deliver the care the patients need to continue to age in their home.  

To help learn how to have the best OASIS documentation, visit our blog OASIS Documentation for Dummies.  We want to help agencies help themselves to be successful.  

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