therapy documentation - reasonable and necessary final handout · microsoft powerpoint - therapy...

Therapy Documentation: What is Reasonable and Necessary?

Presented By:

Cindy Krafft MS PT, COS-C Director of Rehabilitation Consulting Services

President - Home Health Section APTA

October 21, 2010

243 King Street, Suite 246

Northampton, MA 01060

413-584-5300

fax: 413-584-0220

www.fazzi.com

Speaker Introduction

Cindy Krafft MS PT is the Director of Rehabilitation Consulting Services for Fazzi Associates,

Inc. She has 15 years of home health experience ranging from PRN Clinician to the Director of

Rehabilitation for a six agency home care system. She serves as the President of the Home

Health Section of the American Physical Therapy Association, Chair of the NAHC Therapy

Advisory Committee, and is on the NAHC Regulatory Affairs Committee. She has published a

variety of articles in Caring Magazine, The Remington Report, Success in Home Care, Home

Healthcare Nurse, and the Home Health Section of APTA newsletter. As well as being an expert

on therapy practice in home care she also assists agencies with achieving OASIS competency.

She served as the Clinical Co-Director of the Delta National OASIS-C Best Practices Project and

currently acts as the Clinical Director of the Delta Excellence in Therapy Project. She is a well

received speaker at both the state and national levels on the topics of OASIS, therapy

documentation, program development, therapy utilization, and recruitment.

Instructions and Handouts for: Therapy Documentation

It is very important that you have these materials printed and ready to use prior to the

start of the training.

In order to participate in this training you will need to do the following:

1. Dial 1 (877) 615-4339 at least 10 minutes prior to the start of the webinar.

2. When asked, enter Conference ID 7362497#.

3. Give your agency’s name.

4. At this time you will be entered into the call and in “listen mode.”

5. If at any time you need assistance you may press *0 for the operator.

6. There will be a Q & A period toward the end of the session. Questions will be

answered in the order in which they are received. To ask a question, press *1.

You will have the opportunity to ask your question and then be returned to “listen

mode.” Do not press *1 prior to this time.

7. To view the presentation online you must click on the link sent to you from

GoToWebinar.

Therapists Only: Directions to receive contact hours for the training.

The process for therapy CEUs varies state to state. In order to assist therapists with getting

a session approved, we have provided material that can be submitted to the state licensing

board. Please check with your individual state for more specific information as to the

process.

More information on APTA Guide to Practice can be found at the following websites:

www.cms.gov

www.medicare.com

http://oig.hhs.org

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http://www.cms.gov/

http://www.medicare.com/

http://oig.hhs.org/

Therapy Documentation:

What is Reasonable and Necessary?

October 21, 2010

©2010

Cindy Krafft MS PT, COS-C

Director of Rehabilitation Consulting Services

Fazzi Associates, Inc.

President - Home Health Section APTA

Objectives

• Understand the recent developments that have impacted the scrutiny of therapy documentation.

• Identify the key factors that drive

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Identify the key factors that drive meaningful documentation.

• Discuss the relationship between “progress” and the support of medical necessity.

OASIS M2200

• “In the plan of care for the Medicare payment episode for which this assessment will define a case-mix group, what is the indicated need for therapy visits (total of reasonable and necessary

©2010

visits (total of reasonable and necessary physical, occupational, and speech-pathology visits combined)?”

• The HHA would provide the total number of projected therapy visits, unless NA.

Fazzi Associates, Inc. 1

Therapy and Reimbursement

• CMS attempted models could not predict therapy use.

• Concerns that providers would “skimp on high cost services such as therapy” under

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g cost se ces suc as t e apy u dea PPS model.

• Intent to ensure services were not “under provided.”

Changing Visit Patterns

• 10 visit threshold:

– 50% of high therapy ended between 10 and 13 visits

Tiered model:

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• Tiered model:

– 26% increase in episodes with 14 or more

Additional Issues

• OASIS Functional Scores unchanged yet therapy visits increasing.

• More than 60% of SOC OASIS B scored ambulation as 0 or 1 – why all the “need”

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a bu at o as 0 o y a t e eedfor PT?

• Wall Street Journal Article in April 2010.

• MedPac Reports.


What is Medical Necessity?

• Necessity is defined as:

– An imperative requirement or need for something

Indispensability

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– Indispensability

Coverage Issue

“Therapy would not be covered to effect improvement or restoration of function when a patient suffered a transient and

easily reversible loss or reduction of function ”

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function.

Referrals to Therapy

• Orders must be present and carried out within the agency established time frames:

– No “48 hour rule”

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• The comprehensive assessment should support the referral:

– Consider the impact of the OASIS responses


Documentation Expectations

• Objective assessments done by “qualified therapists.”

• Goals that are measureable and functional.

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• “Accepted standards of clinical practice.”

Assessments

• Create the foundation of the entire therapy plan of care.

• Prior level of function (PLOF) is NOT optional.

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optional.

• Answer the question – “Why is therapy indispensible to this patient?”

Initial Examination / Evaluation:

• Examination:

– History

– Systems Review

– Tests and Measures

E l ti

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• Evaluation:

– Problem list/statement of assessment

• Diagnosis:

– Prognosis

– Plan of Care/Goals

APTA Defensible Documentation for Patient/Client Management


Tests and Measures

• Standardized:

– Must follow the directions

• Validated:

©2010

– Assess research behind the tool

• Value in repeating over course of care:

– Support ongoing need and impact of care

Key Assessment Areas

• Physical Therapy:

– Gait – more than distance, device and level of assistance

• Occupational Therapy:

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– ADLs and IADLS should not be assessed as a group of tasks

• Speech Therapy:

– Clarity of functional impact of testing

• Bottom Line – quantity AND quality of patient performance.

Components of Well Written Goals

• Identification of person who is receiving therapy and will carry out the program.

• Description of the movement or activity that the patient will perform.

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the patient will perform.

• A connection of the movement/activity to a specific function.

Physical Therapy Reimbursement News, Volume 13, Number 3


Components of Well Written GoalsContinued…

• Specific conditions in which the activity will be performed.

• Factors for measuring performance.

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• Time Frame for achieving goal.

Physical Therapy Reimbursement News, Volume 13, Number 3

Measureable AND Meaningful

• Patient will amb 300 feet independently over driveway surface with walker to allow access to mailbox and vehicle.

• Patient will shower with intermittent SBA

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at e t s o e t te tte t Sand use of a transfer bench.

• Patient will demonstrate independent ability to utilize thickener to maintain nectar consistency for safe intake of liquids.

Therapy Interventions

• What is “Training?”

– Gait

– Transfer

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– ADL

– Oral Motor


Need for the Visit?

• Amb 50 feet X 3.

• Patient advanced ambulation to 35’ with walker.

• Patient amb 45 feet with walker, CGA and 50% b l t i t l th

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50% verbal cues to increase step length on the right.

• Patient completed shower activity.

• Standing ex X 10 reps each.

• Ther ex per flow sheet X 10 reps with VC needed 80% of the time for correct technique.

Follow Up Visits

• Patient or caregiver report.

• Interventions provided including (as appropriate):

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– Frequency

– Intensity

– Time

• Patient response to treatment.APTA Defensible Documentation for Patient/Client Management

Follow Up Visits Continued…

• Communication/collaboration with other providers/family/patient as applicable/indicated.

• Factors that modify frequency or intensity of intervention and progression within the plan

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intervention and progression within the plan of care.

• Plan for next visit including interventions with objectives, progression parameters and precautions if indicated within the plan of care.

APTA Defensible Documentation for Patient/Client Management


“Independent”

• Use of this term can be a “red flag” that therapy is not needed or has reached set goals and further visits are not warranted:

– Think like OASIS

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– Consistency between disciplines

Documentation Tools

• Tools need to facilitate good documentation.

• Paper versus electronic???

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• The responsibility will always remain with the therapy professional.

Documentation and Clinical Practice

• From the first visit to the last, determine “why” the patient is being seen.

• If that question does not have a clear answer, the plan of care should be

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a s e , t e p a o ca e s ou d bereassessed.


Documentation References

• Functional Outcomes Documentation for Rehabilitation:

– By Lori Quinn and James Gordon

P bli h d b S d

©2010

– Published by Saunders

• APTA - Defensible Documentation for Patient/Client Management.

Helpful Resources

• American Physical Therapy Association:– www.apta.org:

• Home Health Section

• State Level Associations

• American Occupational Therapy Association:

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p py

– www.aota.org

• American Speech and Hearing Association:

– ww.asha.org

• National Association of Home Care.

• State Home Care Associations.

[email protected]

fazzi.comfazzi.com

©2010

800 ●379 ●0361


The process for therapy CEUs varies state to state. In order to assist therapists with getting a session approved, we have provided material that can be submitted to the state licensing board. Please check with your individual state for more specific information as to the process.

EDUCATIONAL ACTIVITY CONTENT OUTLINE

Title of activity: Therapy Documentation: What is Reasonable and Necessary? Date: October 21, 2010 Purpose/Goal: To provide best practice strategies for accurate documentation of the therapy plan of care and interventions.

OBJECTIVES CONTENT (Topics) TIME FRAME PRESENTER TEACHING METHODS

Review why there is such a focus on therapy services in home care.

Examine the relationship between therapy visits and reimbursement.

Discuss concerns about therapy utilization in home health.

15 mins Cindy Krafft MS PT, COS-C Lecture, power point

Discuss the components of appropriate therapy utilization as they relate to “reasonable and necessary” for both assessments and ongoing visits.

Define reasonable. Define necessary.

Explore medical necessity. 15 mins Cindy Krafft MS PT, COS-C Lecture, power point

Examine examples of documentation samples and audit tools.

Discuss the qualities of documentation that support medical necessity by assessing

actual documentation samples. 10 mins


Lecture, power point

Establish clinical and documentation practices that ensure compliance with appropriate therapy utilization.

Discuss the elements that need to be in place to support medically necessary

therapy services. 10 mins


Question and Answer

Implement the structure to support “reasonable and necessary” when launching new therapy programs.

Explore how to create documentation tools that work when developing new therapy

programs. 10 mins


Question and Answer

therapy documentation - reasonable and necessary final handout · microsoft powerpoint - therapy...

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