Documentation for effective patient care communication, medical review and risk

management .

2014 Rehab

Documentation Training

Documentation timeline guidance:

Form Part A/ Managed Care Part B/ Medicaid

Plan of care/

Evaluation

Day of evaluation

suggested: eval same day or

within 24 hrs of order

Day of evaluation

suggested: eval within 72 hrs of order

Updated plan of care

Recertification

Every 30 days (or more

often as needed)

Every 90 days (or more often

as needed)

Daily treatment notes

(logs)

Daily to show

minutes/days/mode to

support RUG

Daily to show

minutes/days/mode/

timed/untimed codes

Clinician Progress

report

Minimum every 10

treatments

Minimum every 10 treatments

DC Summary Best practice: within one

business day of DC

Completed by clinician or

under direction of clinician 3

days prior to DC. Best practice:

within one business day of DC

G-Code Reporting None Part B only

Initial POC, Progress Reports

Updated POC, Discharge

Therapy

Signatures

A signature log should be maintained in the facility

designating signature and legibly printed or typed

name/credentials to identify each author of documentation.

This log is sent with ADRs (Additional Development/

Documentation Requests.)

For non-electronic signatures, a manual signature & basic

credentials with date should be provided. The reviewer

must be able to determine who rendered the service and

who supervised the service of assistants.

MD supervision

Failing to show adequate proof of

physician supervision can result in

denials of therapy claims.

Timely signature/date on POC/updated

POC, MD progress notes, orders, and

certifications help to show appropriate

oversight and involvement. MD notes

that mention therapy progress are

especially beneficial.

Physician Signatures and Dates Digital & faxed signatures are

acceptable. Signature stamps

are not. (source: MM698)

Date received stamps are better

than no date at all

The physician (or NPP) MUST

approve the plan of care

(POC) within 30 days of the

initial treatment.

Best practice:

MD sign and date the

POC/Updated POC form as

proof of monitoring and

approval of the POC.

If MD signature is delayed,

track your attempts to obtain

the signature

MD Orders

When? Who can write?

Prior to eval giving

permission to eval & treat

After eval, clarifying POC w/

frequency & duration (daily

skilled need part A)

Upon change in plan of care

At d/c from therapy if resident

remaining in facility, listing

the date that therapy will

cease

Requirements may vary by state, but Medicare allows orders from physicians, nurse practitioners, clinical nurse specialists (not employed with facility); DO, or physician’s assistants.

Duration of Care Should I always list 30 days

as the therapy duration on my

plan of care and clarification order?

• No. List the actual expected duration of your treatment. For some

diagnoses, this may be 8 weeks or longer, depending on the severity

of the deficits and potential for improvement. Medical reviewers

must verify that “reasonable progress” occurs in a “generally

predictable period of time”—stating the expected duration

accurately helps to meet this expectation

• Remember, updated POC’s/recertifications should report the

remaining weeks left from the initial POC projection.

Example: POC –projected 10 weeks of therapy

First Recertification should project 6 weeks of therapy

Second Recertification should project 2 more weeks of therapy

MD supervision requirements for Medicare Part A

Certification/Recertification is required to verify daily skilled rehabilitation

• MD, PA, NP, and CNS who are not employed by the facility may sign the

certifications

• The initial certification must be obtained at the time of admission, or as soon

thereafter as is reasonable (within 3 days is generally acceptable). The routine

admission order and the signed therapy POC does not serve the certification

criteria for skilled care.

• The first recertification must be made no later than the 14th day and subsequent

recertifications must be made in intervals not exceeding 30 days from the last

dated physician signature.

Recertification statements must contain:

• Written record of the reasons for continued need for extended care services

• Estimated period of time required for the resident to remain in the facility –this

should match your projected therapy duration

• Discharge plans

MD Progress Reports to support

skilled rehabilitation Include updates on the rehab

course in progress notes:

What deficits are hindering return to

prior level of function (PLOF) that

require continued services?

Summarize rehab goals, progress & patient response to therapy.

Provide updates on the DC plan in relation to rehab course progression

Speak to the intensity of therapy services (RUG) —why is it warranted? Short

term stay goal, high functioning previously, progress hindered by less rehab

service, following standard clinical protocol for condition

Example Progress Note Patient continues PT and OT with right knee

ROM improvements from 78 degrees to 90

degrees with pain managed through

medication. Patient is ambulating with a

walker to meals, but demonstrates reduced

weight bearing through the right LE. Patient

able to dress/bathe upper body but requires

some assistance for lower body due to

difficulty bending over. Patient will need to

be independent in ambulation, stairs and self

care skills to return home due to spouse

being gone all day at work. Current

intensity of rehab appropriate & necessary to

advance independence and meet DC goals

Supervision of Assistants

Other requirements

Show clinical analysis (not just observations of pt. performance)

Provide update on goals

Reflect on any treatment approach modifications.

Assistants should document any supervisory contact that occurs via phone.

Follow state co-sign and clinical oversight guidelines.

10th visit progress reports

Co-signature requirement

KY PTA Co-sign DC summary if PTA contributes

KY OTA Co-sign DC summary if OTA contributes

IN PTA Daily phone contact if not on site, no cosigns required

IN OTA Co-sign progress notes & all medical record documentation

Indiana Supervision Basics

COTA: Co-sign by OT within 7 days for all

documentation that will be part of the medical record.

PTA: Unless PT onsite, must consult with PT at least

once each working day. If consult is not face to face,

each PT may only supervise 3 FTE PTAs; the PT

consult may be by phone.

Kentucky Supervision Basics

PTA: PT supervisory visit every 20 visits or 30 days. (Medicare

requirement still every 10 visits.) Must have a written plan of

supervision and supervise no more than 4 FTE PTAs at any time.

Supervision is defined as accessible by phone during working

hours. Must co-sign d/c summaries if PTA contributed (not required

to co-sign notes or treatment logs.) Should be rare occurrence for

PTA to write part B DC summary—PT has to have seen within 3

days prior

COTA: No less than 4 hrs of general supervision per month & no

less than 2 hrs of face to face supervision. Prorated for part time

COTAs. OT cannot supervise more than 3 FTE COTAs. OT must

maintain a supervision log. Co-sign POC and DC summary

documentation (if COTA contributed) within 14 days

Ohio Supervision Basics COTA: OT may supervise up to 4 full time OTAs and shall

determine the intervention plan that the OTA implements. This must take into consideration the clinical complexity of the patient, competency of the OTA, the OTA's level of training in the treatment technique, and whether continual reassessment of the patient/client's status is needed during treatment/intervention. Cosign all documentation

PTA: PT does not need to be on-site, but available at all times and able to physically respond in an emergency or planned absences; Supervising PT is accountable for the direction of the actions of the PTA. PT must interpret physician referrals; Provide initial patient evaluation, initial and ongoing treatment plans, periodic re-evaluation of the patient and adjustment of the plan of care. PT must complete discharge evaluations. Cosign all documentation

Diagnosis Codes ICD.9 diagnosis codes should describe

the condition(s) and symptoms that

support medical necessity of therapy.

Effective coding is the first level of

defense to succeed under automated

medical review.

Take the time to choose individualized

codes to paint the picture of why you

are getting involved. Make sure

priority codes are communicated so

that the biller includes them on the

claim to Medicare (UB-04).

Rehab: Primary Diagnosis

Hospital insurance

Reflect reason for

extension of hospital

care in ECF

Therapy V-code 1st

listed on claim (UB-

04) if rehab is primary

skilling service & DC

plan is rehab to home

Outpatient therapy

insurance

Primary is main

reason therapy is

needed (may or may

not match facility

primary)

Medicare A Medicare B

V Codes

Encounter V codes

describe circumstances

that influence health

status, but are not acute

illnesses.

V-codes should only be

used for Medicare Part

A residents d/c’ing out

of the facility

Therapy V57 Codes may only be used as primary; include supplementary code(s) to further describe condition

V57 codes include: V 57.89 Multiple therapies

involved V57.1-PT V57.21-OT V57.3-Speech language

therapy V57.81 orthotic training

Rehab Coding Examples

Part A: Admit for Rehab

to home

Part B: Fall in Facility

Primary:

V 57.89 Multiple therapies

Secondary:

V54.13 Aftercare of hip

fracture

Treatment:

719.7 Difficulty walking

719.45 Hip pain With other relevant diagnoses listed in

priority order

Primary:

Parkinson’s 332.0

Secondary/Treatment: 781.2

Abnormal Gait

781.0 Bradykinesia

With other relevant diagnosis listed in

priority order

Coding Tips

AVOID

• Acute codes for

cerebrovascular accidents,

myocardial infarctions, and

fractures

• Vague codes such as

“weakness” or codes

unrelated to why therapy is

involved

USE

• Always use the late-effect codes

• Specific complexities that directly and significantly impacts the rate of recovery

Supporting Treatment diagnosis:

• Shortness of breath 786.05 • Abnormal posture 781.92 • Overweight 278.02 • Dizziness 780.4 • Edema 782.3 • Low vision 369.20 • Feeding difficulties 783.3 • Urge incontinence 788.31 • Impulsiveness 799.23 • Tremors 781.0 • Pain in limb 729.5

Diagnosis: basis for therapy plan

ICD.9 code

Onset date

Test values

Subjective complaints

Expected outcomes

Clinical observations

Objective measures

Clinical Compliance

Establishing Medical Necessity

Providing Medical History impacting current function

Showing Prior Level of Function

Establishing Current Baseline

Justifying Skilled Services

Medical Necessity Establishing Medical Necessity at Evaluation

includes defining why skilled therapy is needed now by showing…

• Recent change in condition/function that warrants an

evaluation . (what new events have caused new changes that

require a skilled clinician to become involved)

Identifying the prior level of function as compared to the

current level of function with objective measurements

• Defining the positive expectation for improvement using

skilled interventions.

Current Referral

Summary statement of the recent functional change.

Examples:

Recent complaints of left wrist & hand pain hindering functional hand use

Recent falls and mobility declines

Impaired ability to chew meats on regular diet and pocketing food

Avoid stand alone statements such as “ recent hospital

stay,” “MD orders,” or “patient request” that aren’t

supported with a functional change summary.

Examples of Non-Covered Services • Services that are diversional, for general flexibility/conditioning, do not

require the professional, sophisticated skills of a therapist to perform.

• Where a patient suffers a transient and easily reversible loss or reduction in

function which could reasonably be expected to improve spontaneously as the

patient gradually resumes normal activities

• Services in the presence of limited cognition that is so severe that an increase

in function is very unlikely; however, services may be covered:

– to establish & teach a caregiver safety, compensatory strategies, & implementation of a

maintenance program.

– therapy may be reasonable if there are meaningful goals even when they cant comprehend

instructions or remember –e.g. balance or safe transfers. (And goals established based on

the formalized testing score)

– when there is potential to recover lost cognitive abilities-e.g. new CVA

• Prepackaged, non individualized programs such as pre-op joint classes that

have pre-set objectives for all attendees and do not require a therapist’s

unique skill

• Services in the presence of non-cooperation by patient or caregiver

Defining “significant” change

Significant Insignificant

Clear, objective functional change compared to PLOF

Requiring significantly more staff assist or time fed by staff now, fed self last month,

transfers AX2 --was AX1

Risk level is higher Falls, skin, weight loss, contracture

Especially significant--changes that will show up on the MDS from last to current assessment

Return from brief hospital

stay with deconditioning

that will likely improve

without therapy

Dependent 80% with

transfers declines to

dependent 90%

Non-ambulatory resident

requests gait training

Medical History & Complexities Impacting Prognosis:

History & Complexities Living situation/support

Current and past diagnoses &

surgeries impacting current

function

Clinical complexity

clarification (co-morbidities

that will impact prognosis &

rate of progress)

Medications of concern

Info on past rehab experience

Residence/ living

arrangements

Social support

D/C plan/community

involvement

Routine/activities

Prior level of Function (PLOF) Best documented function within last 3-6 months .

MDS & nursing doc should corroborate our PLOF statement. Reviewers want proof of PLOF outside of therapy notes

Therapy documentation should show a

measurable contrast between prior level of

function (PLOF) and current function to justify

rehab involvement.

Typically, long term goals should not be set higher

than the PLOF.

Clarify activity level & involvement

Were they going to the dining room independently?

Managing housework?

Involved in the community?

You may only set

goals for tasks w/an

established recent

change from PLOF

to current level of

function.

PLOF Example:

Mrs. Jones was living alone in an assisted living (AL) apartment.

She completed showers every other morning independently using a

shower bench, she was also able to dress, groom, and toilet herself

independently. She was able to ambulate in her apartment and to

the main dining room (200 ft.) with no AD, but used a rollator

walker to ambulate longer distances especially when visiting her

sister who lives in the same AL on the second floor (approx.

distance of 2,000 feet). She has assistance from AL for

laundry/cleaning, she eats 3 meals/day in the dining room, does not

drive, but does manage her own medications. She enjoys attending

her card club every Tuesday night and her daughter picks her up

every Sunday to go to church.

Helpful facility resources

PLOF/admission form → for new admissions,

transfer from ALF etc.

Significant change form → long term resident

w/recent change

Documentation Example Current Referral: Mrs. Jones suffered 2 falls in the bathroom at night last week in her apartment and was taken to the hospital where she was treated for CHF and altered mental status change. Her daughter reports a gradual decline in cognition and memory for about 3 months and is interfering with her ability to carry out activities of daily living. She presents with a significant decline by now requiring physical assistance for functional transfers compared to being independent and needs constant supervision and verbal cues for sequencing and safety during self care tasks.

Hx/Complexities: CHF, recent falls, cognitive changes, and OA

Impressions: She presents with decreased strength requiring assist to transition from a sitting to standing position, impaired balance seen by LOB backwards during toilet transfers and also demonstrates stooped posture. She does not use appropriate safety techniques during transfers (did not turn on bathroom light, did not lock w/c, did not use grab bar,..). While getting dressed, she was threading both legs into the same pant leg, forgot to put on her underwear, and was unable to locate her shoes requiring cognitive assistance.

Skilled Justification: Mrs. Jones requires skilled OT services to formally assess her current cognitive status, implement compensatory strategies based on her current cognitive level to increase her independence with self care tasks, improve the use of safety techniques, provide progressive strengthening to reduce physical assist with functional transfers, and improve her balance and posture to prevent future falls.

Potential for Achieving Goals

Patient Goals

• Try to use their own words

Example:

“I want to be able to walk to my

sisters again and get dressed without

it taking so long.”

Potential for Achieving Goals

• Try to paint a picture

Example:

Patient wants to rehab back to AL as

soon as possible and is projected to

meet goals in 4 weeks with intensive

6 days/week therapy services to

return to her PLOF. She has strong

family support and consistent

physician supervision.

Initial Assessment/Current Level of Function:

Establishing Baseline:

Summarize the objective current functional findings that apply to your

goals such as level of assistance required with mobility tasks, ADLs, level

of pain, activity tolerance, etc.

Provide the objective data at evaluation that you will need to refer to later,

in order to show functional progress

After reporting the patients current functional status for a particular area,

also state the underlying impairments explaining why they are at that

level. Example:

LB Dressing: Min/Extensive assist 20%

Underlying impairments: LOB when standing,

decreased flexibility to reach feet easily, sits too

close to edge of seat increasing fall risk, and is

unable to gather clothing items due to current

activity tolerance level.

Establishing Baseline through objective clinical components

• Why can’t the patient ambulate safely?

• Due to his narrow BOS of 2” compared to the norm of 3” and his slow cadence of 60 steps/minute compared to norm of 81‐125 steps/minute.

I Independent No assist required

MI Modified Independent Independent using adaptive equipment

S Supervision Safety/cognition require therapist to facilitate task

CGA Contact Guard Assist

=MDS limited assist

Guided maneuvering or other hands on, non-weight

bearing assistance

Min Minimal

=MDS extensive assist

1-25% physical assist and/or weight bearing support

Mod Moderate

=MDS extensive assist

26-50% physical assist and/or weight bearing

support

Max Maximal

=MDS extensive assist

51-75% physical assist and/or weight bearing

support

D Dependent 76-100% physical assist and/or weight bearing

support

Assist levels

Including %s in functional assist measures helps to show

measurable progress on future documents when progress occurs

between assist levels

Establishing Effective Baselines To Show Progress Later

Pt. seated in standard w/c with sling seat upholstery (no pressure relieving device in place) creating increased LE adduction & internal rotation of bilateral femurs 25˚. No

footrests in place and feet are unsupported 3” from floor with hip flexion angle 110˚

(vs. optimal 90 ˚.) Pt. with lateral trunk flexion to left approximately 30 degrees with

lateral trunk/axilla rubbing armrest increasing risk of skin breakdown. Braden Score is

12 (high risk of skin breakdown.) Left hemiplegic UE is fully flexed at elbow and wrist,

with hand fisted over adducted/opposed thumb. Gentle ROM of elbow, wrist, and hand

is painful as evidenced by pt. pulling away and groaning when ROM attempted. (will

provide objective ROM measures as able week 1.) Pain graded at 8/10 (severe) on

PAINAD with ROM attempts. Hygiene requires assist of 2 staff with increased

difficulty noted due to present posture & pain w/ subsequent resistance to activities

requiring movement of the left UE.

Patient is leaning in wheelchair

and fisting left hand. She has

become more combative with

care recently. Multiple

contractures noted.

Positioning Baseline continued

Using the positioning patient example, there are multiple factors listed that allow future progress to be objectively documented as the patient responds to skilled intervention

LE position

Base of support

Pressure reduction

ROM measurements

Improvement in hygiene and ease of nursing care

Reduced risk of skin breakdown

Pain reduction

Trunk stability/posture

UE position

Objective Evidence & Tests

HTS recommends completing a formalized test for each patient

If unable to complete the day of eval, set STGs accordingly & establish competencies for therapy assistants

Choose tests based on critical deficits identified at eval

Use of tests with interpretation shows your skill

CMS Benefit Policy Manual (Pub 100-02, 220.2) “The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for therapy.” “Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.”

Discipline specific formalized tests:

Occupational Therapy

• Allen Cognitive Lacing Screen (ACLS)

• Barthel Index

Physical Therapy

• Tinetti Balance and Gait

• Berg Balance Scale

• Timed Up and Go (TUG)

Speech Therapy

• Mann Assessment of Swallowing Ability (MASA)

• Swallowing Ability and Function Evaluation (SAFE)

• Functional Linguistic Communication Inventory (FLCI)

Test interpretation

Cognition tested using ACL protocol for RTI and

ACLS. Results indicate ACL score of 4.2.

Interpretations:

Pt requires 38% cognitive assistance & supervision to remove dangerous objects

outside of the visual field and to solve problems arising from minor changes in the

environment. She may reasonably be expected to spend a daily allowance, walk to

familiar locations in the neighborhood, or follow a simple, familiar bus route. 38%

minimum cognitive assistance is required to recognize and correct hazards in routine

activities. Research indicates pt. will benefit from striking visual cues and that there

is a reasonable expectation for achievement for MI with self care tasks. New learning

is expected for compensatory strategies & adapted routines using skilled techniques

appropriate for this cognitive level. These strategies will be incorporated into OT

treatment.

Progress Report Example

Skill: Analyzed functional cognition using ACLS protocol based on need for cues to follow hip precautions & to use walker. Findings indicating functioning at level 4.2. Incorporating striking visual cues in immediate environment in response to this result.

Continued Skill: Added goal –Pt. will respond to striking visual cues in room to comply with walker use with bed to BSC transfers 100% of the time 3 of 3 days. OT to analyze functional vision for reading posted reminders this week and will incorporate environmental compensations including consistent placement of AD, arrangement of bed position in relation to bathroom door and striking visual contrast adaptations to walker, call light mechanism and mobility aides.

Identifying impairments with baseline measures

Impairment Measure

Pain Pain scale, location, type, what improves/worsens?

Cognition Direction following, memory measures,

safety/judgment, ACL score (& other tests).

Strength/ROM Provide objective measurements based on MMT and

goniometric detail as needed. Name m.group and

specific impact on function

Sensation Light touch, monofilament, dermatome patterns,

proprioception

Neuromotor Tone (Ashworth), coordination, praxis, reflexes

Activity Tolerance Time in functional activity before rest required

Visual/Perceptual Low vision (acuity, print size for reading, visual field

range, etc.) stereognosis, MVPT

Skin Integrity Braden risk score, wound stage/type/description

Identifying impairments with baseline measures

Impairment Measure

Cardio-pulmonary

Status

O2 saturation levels, recovery rate after activity,

6min walk test (may modify to 2 mins), BORG,

perceived exertion etc.

Balance Berg, Tinetti, Functional reach test, # LOB episodes

during task, LOB recovery, protective reactions etc.

Gait Stride, step length, cadence compared to norms,

weight acceptance, heel strike, phase of

impairment, AE use, in addition to distance

Communication Expressive,/receptive language, processing speed,

yes/no response accuracy, non-verbal

communication, voice quality

Dysphagia MASA, state stage of swallow impairment and show

proof of physician involvement in plan of care per

local coverage decision

Justifying Skill

For the full duration of care

Justifying Skilled Services Why does this patient require the

sophisticated service of a therapist?

What has nursing already tried? What are you able to do that nursing/family cant?

What are the specific techniques, frames of reference, strategies you are using to support each unit billed?

Failing to continually justify why therapy is needed each week, can lead to therapy denials.

Justification strategies:

predictability & effective use of time

Show predictability—Plan a reasonable duration at SOC &

reflect the full expected duration on the POC & orders

Every treatment billed must count toward the end goal

Meet STGs each week to show steady progress

If a goal isn’t met in 2 weeks—show plan adjustments

Show evidence based practice—use formal tests, show

comparisons to norms, use specific strategies for that dx

Turn less skilled tasks over to nursing/restorative

incrementally—show that you are focused on higher level skills

during therapy week 3 & beyond

Effective Progress

Reports

CMS requires that progress reports be completed a minimum of every 10 treatments or 30 days (whichever comes first.) You may write a note more often, but not less often.

Remember that 1 good progress note could be better than numerous repetitive notes that do not reflect skill.

Progress Reports should be individualized so it could not be used for another patient. Avoid general statements by including detailed information.

CMS Benefit Policy Manual (Pub 100-02, 220.2) “The beginning of the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment.

Progress reports should contain… 1. A statement of current functional status related to the measurable objective in the goal.

2. If the goal was met, or need to continue, discontinue or modify.

3. Under the “Comments” section for each goal, provide specific detailed skilled interventions that show your skill and critical thinking used to address the goal to help make the progress report more individualized.

Ex: what AE was used, specific EC techniques, specific tactile

cues, what environmental modifications were made, what

specific compensatory strategies did you teach the patient to

use, what specific training technique was done with the

caregiver regarding transfers,….

Progress reports should contain… 4. Summary of skilled services provided in the past 10 treatments that correspond

to your billing. Documentation should support each code billed.

5. Pt. and Caregiver Training completed using specific details

Ex 1: Instructed caregivers in safe set up of w/c in bathroom for sliding board

transfer with placement of environmental markers for consistency across staff,

placing sliding board and proper handling technique to initiate the transfer when

moving toward non-hemiplegic side

6. Patient Response: Explanation of how the patient is responding to the

treatment interventions and describe how the therapy is evolving.

7. Continued Skill functional deficits & medical issues (complexities)

impacting therapy & the skilled services needed to address remaining

problems.

Effective use of Rehab Optima library

drop downs

Only choose relevant

skilled intervention

phrases

Avoid using repetitive

phrases

Examples:

• If AROM was marked WFL’s on POC, do not choose “functional activities to increase ROM”

• If FMC was marked intact for fasteners do not choose, “theraputty techniques to improve FMC”

• If patient has a low cognitive level do not choose, “energy conservation during ADL’s”

Examples:

“Dynamic standing balance training” and “progressive standing balance training”

“Progressive resistance exercises” and “therapeutic resistance exercises” and “therapeutic exercises for LE’s”

“Thermal gustatory stimulation to increase swallow initiation” and “thermal gustatory stim to increase swallow timing”

Goal Writing

POC should include one or more short term goals (STG) for each long term goal (LTG.)

Each STG should have a baseline measurement and a PLOF

LTGs should be set for the full duration of the plan

Set STGs to be reasonably achieved in 1-2 weeks.

Use %s to show incremental gains

Update STGs as you achieve them

Revise goals that are not progressing

Break down tasks into component skills

Goals must be functional and measurable

Reasonable expectation of progress

Goal progress is evident in the

documentation over the past 1-2 weeks

Patient is not yet at PLOF

Treatments are based on accepted

standards of care and evolving based

on patient’s response

What if they’re not progressing?

Not meeting goals?

3 options:

Document modification of approaches, plan adjustments, training

Hindrances to reflecting skill:

No initial status for goals

Insufficient detail for goals

Clarifying detail for skilled

interventions lacking

Lists of treatment activities and

observations without info on

skilled facilitation

Skilled interventions not shown

to support every code billed

Unapproved abbreviations

No modification of approaches

based on clinical complexity

No test scores or detailed

measures to show objective

gains outside of goals

No test score interpretation

No implementation of new

approaches based on test

results

Goals not met, but no plan

adjustments

Untimely notes

Taking credit for progress 1. Go beyond observations of performance and state how you

facilitated progress.

2. Focus on measurable functional outcomes—not description of

activities used that could be perceived under review as non-

skilled (clothespin tree, balloon volleyball, ROM ladder)

3. Avoid activities that may seem rote or repetitive –medical

reviewers tend to find these services “maintenance therapy”

that could be performed by restorative.

CMS Benefit Policy Manual (chapter 8, 30.4.1.2)

“Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive

walking are appropriately provided by supportive personnel, e.g., aides or nursing

personnel, and do not require the skills of a physical therapist. Thus, such services are not

skilled physical therapy.”

Justification of Skilled Service Ex. 1

Instead of just documenting observations/assist levels, focus on the skilled intervention:

As a result of OT facilitation of task sequencing, training in one handed dressing techniques and the use of adaptive equipment, pt. completing UB ADL tasks with min assist improved from mod assist. Bathroom modifications including grab bar now enable pt. to step into tub with mod assist.

Justification of Skilled Service Ex. 2 Non-skilled:

Pt. tolerating 25 reps of LE exercise all planes with red T-band

Skilled:

Promoting improved postural-core stability for dynamic functional activity through progressive balance, proprioceptive, and bilateral integration challenges via reciprocal movement patterns based on PNF guidelines within limits of prescribed cardiac precautions.

Ongoing Justification Updated POC/Recertification

Assessment summary since last progress report

• Summarize the skilled interventions and pt./caregiver education provided in the last 10 treatment sessions. What has the patient accomplished over the previous documentation period that is directly related to your skilled intervention?

Assessment summary since Eval/SOC

Summarize the patient's progress since evaluation and discuss what deficits still remain and what skilled interventions are needed to overcome those deficits in the week(s) ahead? How are you adjusting your approaches based on the patient’s response?

Updated plan of care

Opportunity to show comprehensive analysis of progress, remaining deficits, how you are using test scores to guide intervention, how you are making adjustments based on patient response/clinical complexities, safe transition strategies

Audit Tips : ther-ex 97110 Generalized strength & endurance training is not considered skilled in the absence of clinical complexity. Focusing on functional application of skills is especially important after the 10th visit. Majority of treatment should focus on function vs. reps of exercise—reflect this in coding choices & notes.

“Documentation should describe new exercises added, or changes made to

the exercise program to help justify that the services are skilled.

Documentation must show that exercises are being transitioned as

clinically indicated to an independent or caregiver-assisted exercise

program (HEP)). An HEP is an integral part of the POC and should be

modified as the patient progresses during the course of treatment. It is

appropriate to transition portions of the treatment to an HEP as the patient

or caregiver master the techniques involved in the performance of the

exercise... Documentation must clearly support the need for continued

therapeutic exercise greater than 12-18 visits. “

Audit Tips : neuro 97112 Notes must reflect appropriate use of code with emphasis on balance, coordination, tone, proprioception or other neuro-muscular component skills

Supportive Documentation Recommendations for 97112

“Objective loss of ADLs, mobility, balance, coordination

deficits, hypo- and hypertonicity, posture and effect on function

Specific exercises/activities performed (including progression of

the activity), purpose of the exercises as related to function,

instruction given, and/or assistance needed, to support that the

skills of a therapist were required”—NGS LCD 7/11/11

Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.

Audit Tips : gait 97116

Supportive Documentation Recommendations for 97116

“Objective measurements of balance and gait distance, assistive

device used, amount of assistance required, gait deviations and

limitations being addressed, use of orthotic or prosthesis, need for

and description of verbal cueing , presence of complicating factors

(pain, balance deficits, gait deficits, stairs, architectural or safety

concerns) Specific gait training techniques used, instructions given,

and/or assistance needed, and the patient’s response to the

intervention, to demonstrate that the skills of a therapist were

required”—NGS LCD 7/11/11

Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.

Audit Tips: cognitive therapy

Coverage for 97532 (cog skills) is

limited to the following conditions:

• 310.1 PERSONALITY CHANGE

DUE TO CONDITIONS

CLASSIFIED ELSEWHERE

• 310.8 OTHER SPECIFIED

NONPSYCHOTIC MENTAL

DISORDERS FOLLOWING

ORGANIC BRAIN DAMAGE

• 310.9 UNSPECIFIED

NONPSYCHOTIC MENTAL

DISORDER FOLLOWING

ORGANIC BRAIN DAMAGE

• 96125 cognitive testing (memory, reasoning, sensory processing, visual perceptual status, orientation, temporal and spatial organization, social pragmatics, decision-making & executive function)

• requires an extensive formal report to show test results and analysis of those results and is billed per hour of the therapist’s time

Providing handrolls, “carrots”, bed wedges, or prefab splints that do not require adaption/adjustment or other skill are not covered services

Monitoring a splint or other positioning program for more than a few days to analyze tolerance is not considered skilled.

Coverage

guidelines:

splints

Coverage guidelines:

wheelchairs

Positioning:

Issuing cushions, finding footrests etc. is not skilled unless complicating factors documented to justify

Provide detailed measurements & descriptions of problem areas to reflect medical necessity and show your skill

Then address the underlying issues impacting positioning first, BEFORE ordering equipment or modifying the w/c

W/C Management 97542

May only be billed for 3 days unless there are significant complexities and documentation supports the additional treatment

Coverage guidelines:

dysphagia

When billing 92610 swallow eval or 92526 swallow treatment the ICD.9 code for dysphagia must be present. These include:

438.82 Dysphagia cerebrovascular disease, 464.01 Acute laryngitis with obstruction, 464.51 supraglottitis unspecified with obstruction, 478.30 -478.34 codes related to paralysis of vocal cords, 478.6 edema of larynx, 507.0 pneumonitis due to inhalation of food or vomit, 787.20 dysphagia unspecified, 787.21 dysphagia oral phase, dysphagia oropharyngeal phase, 787.23 dysphagia pharyngeal phase, 787.24 dysphagia pharyngoesophageal phase, 787.29 other dysphagia

92526 is an untimed code and may be billed 1x per day.

97150 may be billed for group dysphagia treatment (revised summer 2011)

FMP development is covered for 2-4 visits to train caregivers; avoid excessive durations with unsupported skill (e.g. “monitoring” of diet consistency tolerance)

Nursing Documentation To Support Rehab

Nursing should document to show a change in status warranting a new therapy evaluation

Nursing should document weekly to support therapy services with a summary of progress, problems, & nursing carry-over interventions

Regular communication of the most pertinent info re: recent week’s therapies to nursing is important. Weekly rehab meeting and/or written communication forms are good tools

MDS coding should support not contradict the interdisciplinary team charting

Documentation shows skilled

need

Minutes are justified to support the

RUG

Justifying skilled stay & RUG level To support a Medicare A skilled stay, documentation must

show:

1. Clear skilled need

2. Minutes provided are reasonable & necessary for condition

(UTI and CVA are not the same intensity)

3. Treatment is evolving based on patient’s responses

Speaking to the Intensity

The RUG level achieved (RU, RV, RH) should support medical necessity through your documentation. Examples: • Specific MD protocol • Barriers to DC home • Community Involvement • Clinical Complexities • Acute Changes • Planned Short Stay • High level D/C expectation • Advancement of strategies • Split treatments /BID

Tips from past audits

Watch length of service

Services that were initially skilled,

may be denied as “maintenance

therapy” if duration is too long.

Meet & adjust goals each week

Avoid repetitive treatment notes

Very low level patients aren’t

supported for long durations

Use caution with :

PROM, distance of ambulation,

strengthening, monitoring equipment

Safe Transition

Effective Discharge Planning

Home Assessments

• Should be completed 7-10 days prior to DC

• Use a standard Home Visit Report

• Educate patient using the Safety Checklist

• Home assessments are billable as treatment time if the

patient is present; this includes time travelling to and from

the home only if you are teaching and training during the

trip.

Functional Maintenance Programs

Covered Non-covered

Strategies required to

minimize deterioration or

suffering over time and/or are

necessary for safety

Training patient, family or

caregivers

Occasional reevaluations to

assess and adjust the program

General, non-specific services

that don’t require skilled

training ( non-specific

PROM, handrolls, etc.)

Discharge Summaries Per CMS: consider the discharge note the last opportunity to justify the medical

necessity of the entire treatment episode in case the record is reviewed.

Further part B requirements outlined in Transmittal 88 include:

DOCUMENTATION TO SUPPORT BILLING

Daily entries, missed sessions & modifiers

Daily Treatment Documentation

Medicare requires daily documentation of treatment “encounter” minutes to support the billed charges & MDS.

Do not round minutes. Record time exactly. Remember the 8 minute rule. Part A treatment time includes set up time Each facility should have measures in place to check for

accuracy of reported minutes Some services require a separate daily entry

Modalities (location, reason, pt. response, settings)

Positioning/splinting

Wound care

Cognitive testing code 96125 requires separate report

ROM testing code requires separate report

Treatments that are longer than 60 minutes in duration

Missed treatments

When treatment is withheld or refused, this should be shown as a daily note entry documenting the reason (illness, LOA, etc.)

Avoid focusing on poor motivation in notes unless planning to DC. If there is a reasonable expectation of progress to support continuing, focus on your interventions & reasoning for that expectation.

Plan ahead to reduce refusals—e.g. time treatment after pain meds, set a less physically demanding STG

Group

Treatment

Purpose of group

Number of participants

How the group relates to

each individual’s goals

Any adjustments made

to grade the group for an

individual

Description of your

skilled strategies

Co-Treatment Effective October 2013, Co-treatment

therapy minutes are required to be

reported in section “O” of the MDS. It is

also recommended to document any co-

treatment sessions in the therapy notes.

You should include the other discipline

that you co-treated with, the rationale for

co-treatment, and specific details of the

session pertaining to your plan of care

and current therapeutic goals.

Functional G-Code Reporting

G code reporting of functional status on the UB-04 is

required for therapy part B claims effective July 2013.

Documentation on the medical record must also report G-

code status using a consistent measurement tool to track

progress.

Supporting the Use of Modifiers

When using a 59 modifier,

notes should clarify how

the intervention was

separate and distinct

By applying the KX modifier,

the therapist is certifying that

their documentation supports

the automatic exception

standards. If the principles of

coding diagnoses, documenting

medical necessity, clinical

complexity and justifying

skilled service taught today are

followed consistently,

documentation to support

exception criteria should be

met

Justification over part B caps Justify in documentation the need to continue services

beyond the part B cap ($1900) and the ($3700)

threshold. Remember anything billed over the $3700

threshold will result in an automatic ADR for review by

your MAC.

Jimmo v. Sebelius case

Overview of case Implications

Medicare beneficiaries

filed suit stating access to

therapy had been denied

due to application of the

“improvement standard”

CMS settlement

announces immediate

change to the law, MAC

training requirements and

changes to the Medicare

manuals

Skilled maintenance

services cannot be

denied automatically

Potential impact for

patients with chronic

conditions

Medical necessity,

reasonableness, and

skilled service

requirements still apply

Medicare Meeting

Report

Summarize what nursing should know about functional status, recent progress, goals for the interdisciplinary team, and any other relevant patient specific issues. Nursing may choose to relate this in the nursing notes, especially if rehab is the primary skilling service for a part A stay.

Review the week’s medical record for accuracy & clarity

Discuss the current RUG & ongoing skilled needs; if remaining skilled, a statement of ongoing medical necessity and continued need for skilled services is recommended in the nursing notes.

Filing Documentation Keep clean, orderly medical records.

Pull copies when MD signed original filed

Discipline dividers and date ordered filing—most recent on top

File documentation promptly

Medical Review Entities

Preparedness and Responsiveness

Medical Review Entities State Survey

State Survey Team

oVisits facility onsite at least annually (and upon

complaint or for follow up to be sure previously

identified problems are corrected) to be sure both

Medicare and state regulations for nursing

facilities are being met

oPrepare by making sure documentation is up to

date and filed in the medical record for access at

any time day or night

Medical Review Entities Medicaid Review

Hewlett Packard (HP) is contracted by Medicaid to audit MDS data for accuracy

They visit at least every 15 months

Prepare by consistently following HTS procedures for reporting MDS minutes including stapling a copy of the encounter note to the section P and T form given to the MDS coordinator

Medical Review Entities

WPS is the Medicare Administrative Contractor (MAC)

entity through CMS (Center for Medicare Services) that

manages Medicare claims for Indiana.

CGS is the MAC for KY and OH

Highmark Medicare Services is the PA MAC

Reviews are generated as part of specific initiatives (i.e.

OT widespread probe review,) and/or based on data

triggers such as billing errors, high RUG levels with a

high ADL score (i.e. RUC), high volume LOS outside of

sample norms (i.e. pepper reports)

Types of medical review Review Entity Pre-

pay Post Pay

RACs Recovery Audit Contractors √

CERT Comprehensive Error Rate Testing

√

MACs Medicare Administrative Contractors (includes part B cap reviews)

√

QIO Quality Improvement Organization √

ZPICs Zone Program Integrity Contractor √

State Auditors (may re-RUG) √

92

MANUAL MEDICAL REVIEW OVER $3700 THRESHOLD

Prepayment Review Demonstration Effective April 1, 2013

States Impacted Instructions Review Time Frame

FL, CA, MI, TX,

NY, LA, IL, PA,

OH, NC, MO

MAC sends ADR to provider

requesting ADR documentation be

sent to the RAC (unless an

alternative process is

communicated by the MAC)

RAC completes pre-payment

review within 10 business

days of receiving additional

documentation & notifies MAC

of payment decision

Postpayment Review Demonstration Effective April 1, 2013

Remaining

States

MAC identifies claims meeting

threshold, requests ADR, & pays

claim. ADR from MAC asks provider

to send records to RAC. RAC

conducts post payment review &

notifies MAC of payment decision

Post payment review

timeframes are not specified in

the 3/21/13 CMS update to

the Therapy Cap Services

webpage at the time of the

submission of this handout.

Continue to check the website

for further instruction.

Preparing for Audits

• HTS clinical consultants complete monthly chart reviews on Rehab Optima for each facility. They will e-mail any suggestions to help support the services as billed. All corrections must be completed within one week. Staff identified as having consistent documentation errors that are not improving with routine audits may be required to participate in remedial documentation training.

• Clarifying entries related to the clinical plan of care or the rehab course that follows (progress notes, updated plan of care, daily notes, DC summary) should be entered into the record so that it is evident when the clarification was documented and by whom. In most cases, entering the clarification as a signed, dated daily note is appropriate. The daily note may reference the document for which you are providing clarifying information.

LET’S TAKE A LOOK!!

Medical Review

Generally the first step of a review is a notice that comes through the online system to the facility business office requesting additional information on a claim (ADR -additional documentation request )

Make sure the business office knows to contact rehab when an

ADR is received.

Follow the directions on the letter exactly sending only what is requested.

Check documentation thoroughly prior to sending. Include a cover letter with any clarifying information needed.

Keep copies of everything sent along with records of dates mailed, etc.

ADR response tips

Track due dates and respond promptly

Read through the record to determine how clearly a significant change in function, medical necessity and skilled service justification is documented

Address missing signatures, missing documents, and errors directly

Write a brief position statement overviewing the case and referencing proofs for Medicare coverage requirements

Include supportive

documentation for look back

periods for part A (may be

outside of coverage dates

requested)

In order to show a

reasonable expectation of

progress, may need to send

documents prior to dates of

service in question

Denial Process-cont

Prevent denials by following the documentation guidelines learned in this tutorial

Plan for denial appeals by educating the business office to contact rehab promptly when receiving correspondence from CMS (WPS/CGS) regarding denied therapy claims.

THANK YOU!

eking@proactivemedicalreview.com

amartin@proactivemedicalreview.com

(812) 431-4804