MD supervision Rehab Documentation Training. Physician Signatures and Dates. MD Orders. Therapy Signatures

Transcription

1 MD supervision 2015 Rehab Documentation Training Documentation for effective patient care communication, medical review and risk management. 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 goals and progress are especially beneficial. Documentation timeline guidance: Form Part A/ Managed Care Part B/ Medicaid Plan of care/ Evaluation Updated plan of care Recertification Daily treatment notes (logs) Clinician Progress report DC Summary Day of evaluation suggested: eval same day or within 24 hrs of order Every 30 days (or more often as needed) Daily to show minutes/days/mode to support RUG Minimum every 10 treatments Best practice: within one business day of DC Day of evaluation suggested: eval within 72 hrs of order Every 90 days (or more often as needed) Daily to show minutes/days/mode/ timed/untimed codes Minimum every 10 treatments 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 Physician Signatures and Dates 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 Digital & faxed signatures are acceptable. Signature stamps are not. (source: MM698) Date received stamps are better than no date at all 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 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.

2 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 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 MD supervision requirements for Medicare Part A SNF Certification/Recertification is required to verify SNF stay While this is a facility responsibility, it is helpful for therapists to understand the requirement since >90% of skilled stays are skilled by rehab: MD, PA, NP, and CNS who are not employed by the facility may sign the SNF 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 14 day cert may be signed at the same time as the initial certification. The first recertification must be made no later than the 14 th day and subsequent recertifications must be made in intervals not exceeding 30 days from the last dated physician signature. Recertification statements must contain: Reasons for continued need for services that are an extension of the hospitalization Estimated time for the skilled stay this should match your projected therapy duration Discharge plans and follow up service needs (e.g. home health) 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 10 th visit progress reports Show clinical analysis (not just observations of pt. performance) Provide update on goals Reflect on any treatment approach modifications. Other requirements Assistants should document any supervisory contact that occurs via phone. Follow state co-sign and clinical oversight guidelines. KY PTA KY OTA IN PTA IN OTA Co-signature requirement Co-sign DC summary if PTA signed Co-sign DC summary if OTA signed Daily phone contact if not on site, no cosigns required Co-sign progress notes & all medical record documentation

3 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. 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). 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 Rehab: Primary Diagnosis Medicare A Hospital insurance Reflect reason for extension of hospital care in ECF Therapy V-code 1 st listed on claim (UB- 04) if rehab is primary skilling service & DC plan is rehab to home Medicare B Outpatient therapy insurance Primary is main reason therapy is needed (may or may not match facility primary) 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 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 Multiple therapies involved V57.1-PT V57.21-OT V57.3-Speech language therapy V57.81 orthotic training

4 Rehab Coding Examples Part A: Admit for Rehab to home Primary: V Multiple therapies Secondary: V54.13 Aftercare of hip fracture Treatment: Difficulty walking Hip pain With other relevant diagnoses listed in priority order Part B: Fall in Facility Primary: Parkinson s Secondary/Treatment: Abnormal Gait Bradykinesia With other relevant diagnosis listed in priority order Clinical Compliance Establishing Medical Necessity Providing Medical History impacting current function Showing Prior Level of Function Establishing Current Baseline Justifying Skilled Services Coding Tips Medical Necessity 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 Establishing Medical Necessity at Evaluation includes defining why skilled therapy is needed now by showing Recent change in condition that warrants an evaluation. (what new events have caused new changes that require a skilled clinician) 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. Additional coding training will be provided as we transition to ICD.10 in 2014 Defining the needs for skilled services to establish or update a maintenance program Diagnosis: basis for therapy plan Objective measures Clinical observations Onset date ICD.9 code Test values Subjective complaints 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 Expected outcomes Avoid stand alone statements such as recent hospital stay, MD orders, or patient request that aren t supported with a functional change summary.

5 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 You may only set goals for tasks w/an established recent change from PLOF to current level of function. Prior level of Function 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? Defining significant change PLOF Example: Significant 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 Insignificant 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 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. Medical History & Complexities Impacting Prognosis: History & Complexities 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 Living situation/support Residence/ living arrangements Social support D/C plan/community involvement Routine/activities Helpful facility resources PLOF/admission form for new admissions, transfer from ALF etc. Significant change form long term resident w/recent change

6 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 undergarments, and was unable to locate her shoes requiring moderate 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. 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 steps/minute. 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 Describe clinical reasoning for progress expectation 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, independent prior level of function and met all goals during prior rehab stay last year. Assist levels I Independent No assist required MI Modified Independent Independent using adaptive equipment S Supervision Safety/cognition require therapist to facilitate task CGA Min Mod Max Contact Guard Assist =MDS limited assist Minimal =MDS extensive assist Moderate =MDS extensive assist Maximal =MDS extensive assist Guided maneuvering or other hands on, non-weight bearing assistance 1-25% physical assist and/or weight bearing support 26-50% physical assist and/or weight bearing support 51-75% physical assist and/or weight bearing support D Dependent % physical assist and/or weight bearing support Including %s in functional assist measures helps to show measurable progress on future documents when progress occurs between assist levels 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 Effective Baselines To Show Progress Later Patient is leaning in wheelchair and fisting left hand. She has become more combative with care recently. Multiple contractures noted. 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.) 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.

7 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 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. 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. See a suggested list of tests on the HTS portal. Use of tests with interpretation shows your skill CMS Benefit Policy Manual (Pub , 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. Identifying impairments with baseline measures Impairment Pain Cognition Strength/ROM Sensation Neuromotor Activity Tolerance Visual/Perceptual Skin Integrity Measure Pain scale, location, type, what improves/worsens? Direction following, memory measures, safety/judgment, ACL score (& other tests). Provide objective measurements based on MMT and goniometric detail as needed. Name m.group and specific impact on function Light touch, monofilament, dermatome patterns, proprioception Tone (Ashworth), coordination, praxis, reflexes Time in functional activity before rest required Low vision (acuity, print size for reading, visual field range, etc.) stereognosis, MVPT Braden risk score, wound stage/type/description Test interpretation Identifying impairments with baseline measures 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. Impairment Cardio-pulmonary Status Balance Gait Communication Dysphagia Measure O2 saturation levels, recovery rate after activity, 6min walk test (may modify to 2 mins), BORG, perceived exertion etc. Berg, Tinetti, Functional reach test, # LOB episodes during task, LOB recovery, protective reactions etc. Stride, step length, cadence compared to norms, weight acceptance, heel strike, phase of impairment, AE use, in addition to distance Expressive,/receptive language, processing speed, yes/no response accuracy, non-verbal communication, voice quality MASA, state stage of swallow impairment and show proof of physician involvement in plan of care per local coverage decision

8 Justifying Skill For the full duration of care 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 , 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. 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. 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 techniques, specific tactile cues, what environmental modifications were made, what specific compensatory strategies did you teach the patient, what specific training was provided caregiver etc. 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 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: 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.

9 Effective use of Rehab Optima library drop downs Reasonable expectation of progress Only choose relevant skilled intervention 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 Avoid using repetitive phrases 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 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? Succinct documentation Avoid excessive lists of library items that take away from the key deficit areas being treated Each plan of care and progress report should reflect individual patient needs and skilled interventions in response to those needs. Repetitive use of the library makes all entries seem the same Do not rely solely on the library. Enter narrative information to clarify your skilled services and individualized care Not meeting goals? 3 options: Tip: Read the final document for clarity. Some entries contain long strings of library phrases that do not combine to make a cohesive sentence. Document modification of approaches, plan adjustments, training 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 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

10 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 nonskilled (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, ) 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. 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? 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. 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 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. Audit Tips : ther-ex 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 10 th 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 visits.

11 Audit Tips : neuro Notes must reflect appropriate use of code with emphasis on balance, coordination, tone, proprioception or other neuro-muscular component skills Supportive Documentation Recommendations for 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 visits. Coverage guidelines: splints 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. Audit Tips : gait Supportive Documentation Recommendations for 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 visits within a 4-6 week period. 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 May only be billed for 3 days unless there are significant complexities and documentation supports the additional treatment Audit Tips: cognitive therapy Coverage for (cog skills) is limited to the following conditions: PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE cognitive testing (memory, reasoning, sensory processing, visual perceptual status, orientation, temporal and spatial organization, social pragmatics, decisionmaking & 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 Coverage guidelines: dysphagia When billing swallow eval or swallow treatment the ICD.9 code for dysphagia must be present. These include: Dysphagia cerebrovascular disease, Acute laryngitis with obstruction, supraglottitis unspecified with obstruction, codes related to paralysis of vocal cords, edema of larynx, pneumonitis due to inhalation of food or vomit, dysphagia unspecified, dysphagia oral phase, dysphagia oropharyngeal phase, dysphagia pharyngeal phase, dysphagia pharyngoesophageal phase, other dysphagia is an untimed code and may be billed 1x per day 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)

12 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 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 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 Safe Transition Effective Discharge Planning Documentation shows skilled need Minutes are justified to support the RUG Speaking to Rehab Intensity The minutes/days of treatment provided and RUG level billed (RU, RV, RH) should be supported in documentation. Why does the patient require high intensity? Specific MD protocol for conditions being treated To address barriers to DC home Return to community Clinical Complexities being addressed (multiple disciplines, time intensive treatment) Acute Changes Planned Short Stay High level D/C expectation Advancement of strategies Split treatments /BID would benefit condition and facilitation goal progression Home Assessments Should be completed 7-10 days prior to DC when possible 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.

13 Functional Maintenance Programs 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 Non-covered General, non-specific services that don t require skilled training ( non-specific PROM, handrolls, etc.) 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 requires separate report ROM testing code requires separate report Treatments that are longer than 60 minutes in duration 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: 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 Daily entries, missed sessions & modifiers DOCUMENTATION N TO SUPPORT BILLING 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

14 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 cotreatment 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. How do I appropriately select the G-Code Category? The clinician must select the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. When the beneficiary has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary. In these cases, the clinician may choose the functional limitation that is: Most clinically relevant to a successful outcome for the beneficiary; The one that would yield the quickest and/or greatest functional progress The one that is the greatest priority for the beneficiary. In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address. Functional G-Code Reporting G-code Example G code reporting of functional status on the UB-04 is required for therapy part B claims effective July Documentation on the medical record must also report G- code status using a consistent measurement tool to track progress. G-codes and modifiers is required for specific dates of service (DOS): At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service / eval At least once every 10 treatment days -- the functional reporting is required on the claim for services on same DOS that the services related to the progress report are furnished Recommend to include functional reporting at least one time during the claim (month) period even if the patient has not reached the 10th visit At the time of discharge from the therapy episode of care, if data is available When functional limitation ends and another begins, separate days 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

15 Justification over part B caps Justify in documentation the need to continue services beyond the part B cap ($1940) 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 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 Implications Skilled maintenance services cannot be denied automatically Potential impact for patients with chronic conditions Medical necessity, reasonableness, and skilled service requirements still apply 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 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. Medical Review Entities Preparedness and Responsiveness

16 Medical Review Entities State Survey State Survey Team o Visits 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 o Prepare by making sure documentation is up to date and filed in the medical record for access at any time day or night Types of medical review Review Entity Prepay 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) 94 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 Preparing for Audits Proactive Medical Review clinical consultants complete monthly chart reviews on Rehab Optima for each facility. They will 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 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) 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.

17 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. eking@proactivemedicalreview.com sbaker@proactivemedicalreview.com amartin@proactivemedicalreview.com (812) THANK YOU!