Therapy Documentation: What is Reasonable and Necessary?

Transcription

1 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 June 15, King Street, Suite 246 Northampton, MA fax:

2 Introduction of the Speaker Cindy Krafft MS PT, COS-C is the Director of Rehabilitation Consulting Services for Fazzi Associates. She has been in home health for 14 years in a variety of capacities from PRN clinician to the Director of Rehabilitation for a six agency home care system. She is currently working with agencies to develop their rehabilitation programs, helping them to achieve their highest potential both clinically and financially. She has been a well received speaker at both the state and national levels on the topics of documentation, program development, therapy utilization and recruitment. She is the newly elected President of the Home Health Section of the American Physical Therapy Association and the Chair of the NAHC Therapy Advisory Committee.

3 Instructions and Handouts for: Therapy Documentation Eastern Standard Time 1:00 PM to 2:30 PM Central Standard Time 12:00 PM to 1:30 PM Mountain Standard Time 11:00 AM to 12:30 PM Pacific Standard Time 10:00 AM to 11:30 AM 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) at least 10 minutes prior to the start of the webinar. 2. When asked, enter Conference ID #. 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. Nurses Only: Directions to receive contact hours for the training. 1. Each participant must complete an evaluation in order to receive contact hours. Click on the following link in order to access the online evaluation form: *Please allow four weeks for processing. 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:

4 Therapy Documentation: What is Reasonable and Necessary? June 15, 2010 Cindy Krafft MS PT, COS-C Director of Rehabilitation Consulting Services Fazzi Associates, Inc. President - Home Health Section APTA Objectives Establish clinical and documentation practices that ensure compliance with appropriate utilization. Assess the overall status of your therapy documentation. Implement a structure to support reasonable and necessary when launching new therapy programs. Identify the difference between training and progress. 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 physical, occupational, and speechpathology visits combined)? The HHA would provide the total number of projected therapy visits, unless NA. Fazzi Associates, Inc. 1

5 Utilization Shifts Prior to 2008, more than 50% of Hi therapy cases ended with visits. With the move to the tier model, this group has declined and growth has been seen in: Concerns about fraud and abuse in home care continue to be raised. Recent Developments OASIS Analysis. Payment for MedPac Report. April 2010 Wall Street Journal Article. May 2010 Senate Finance Committee. June ??? OIG What Is It? Office of Inspector General: Mandated by Public Law Protect the integrity of HHS Protect beneficiaries Network of audits, investigations and inspections Office of Audit Services: Reduce waste, abuse and mismanagement and promote economy and efficiency Fazzi Associates, Inc. 2

6 CMS ENHANCES PROGRAM INTEGRITY EFFORTS TO FIGHT FRAUD, WASTE AND ABUSE IN MEDICARE October 2008 As part of these enhanced efforts, CMS is consolidating its efforts with new program integrity contractors that will look at billing trends and patterns across Medicare. They will focus on companies and individuals whose billings for Medicare services are higher h than the majority of providers and suppliers in the community. CMS is also shifting its traditional approach to fighting fraud by working directly with beneficiaries by ensuring they received the durable medical equipment or home health services for which Medicare was billed and that the items or services were medically necessary. RAC Starting Point RAC program established in Medicare Modernization Act in 2003 with demo in three states. Tax Relief Act of 2006 (Section 302) makes RAC program permanent & nationwide no later than RAC Regions Region A: Diversified Collection Services (DCS) Region B: CGI Technologies and Solutions, Inc. Region C: Connolly Consulting, Inc. RegionD: HealthDataInsights, Inc. Fazzi Associates, Inc. 3

7 RAC Mission To detect and correct past improper payments and to prevent tfuture payment issues: Underpayments Overpayments Perspective The RACs will focus on multiple areas of health care and are not required to look into home health specifically. Complacency is a risk. Knowledge and preparation are critical elements of dealing with RACs. Levels of Review Automated Review. Complex Review HHRG Validation. Complex Review Medical Necessity. Fazzi Associates, Inc. 4

8 HHRG Validation Slated for FY Will require the submission of additional documentation. Do the records support the HHRG/ case mix? OIG 2009 Work Plan Accuracy of Coding and Claims for Medicare Home Health Resource Groups: We will review Medicare claims submitted by HHAs to determine the extent to which the home health resource group (HHRG) billing codes that are used in determining payments to HHAs are accurate and supported by documentation in the medical record. The Social Security Act, 1895, governs the payment basis and reimbursement for claims submitted by HHAs including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of coding by HHAs. OASIS Implications Are the responses consistent and supportive throughout the document and the plan of care? Are the diagnoses selected ected supported and used according to coding rules? Therapy utilization and medical necessity? OASIS C transition risks? Fazzi Associates, Inc. 5

9 Medical Necessity Slated for FY Will require the submission ss of additional documentation. What is medical necessity? Necessary Speaks to the need for a skilled clinician to be involved with the care. Changes in the patient status does not automatically support necessity: Is it occurring because of unique and specific interventions or by accident? Could it have occurred without the clinician being involved? Independent Use of this term can be a red flag that therapy is not needed or has reached set goals and further visits it are not warranted: Think like OASIS Consistency between disciplines Fazzi Associates, Inc. 6

10 Showing Skilled Need Comprehensive Assessment Patient Plan of Care Care Coordination Documentation Tools Tools need to facilitate good documentation. Paper versus electronic??? The responsibility will always remain with the therapy professional. Reading Documentation OASIS. Comprehensive Assessment. Plan of Care. Orders. Visit Notes. Do you see medical necessity? Fazzi Associates, Inc. 7

11 What to Look For Overriding issue: Can you determine why the patient requires skilled therapy to be involved in the case? Key Areas: Comprehensive Initial Assessment: Previous Functional Status is critical Goals that are functional AND measureable: Define why it is important to the patient Clear necessity of each therapy visit: Could it have been done by someone else? Components of Review Tool Clinicians involved. Orders. Number of visits completed. Initial assessment. Goals. Medical Necessity. Quantify risk. Fazzi Audit Findings Over 75% of records have visits removed. Average financial risk is about $1,000 per record. Main issues: Incomplete Assessments Interventions not relating to assessment Goals not functional Goals Met not supported Unclear need for all visits provided Fazzi Associates, Inc. 8

12 Assessments? Patient amb household distances with walker and SBA. Patient amb 35 feet with SBA and required 50% verbal cues to maintain equal step length bilaterally. ll Patient completes ADLs with modified independence. Patient completes bathing using a transfer bench with supervision throughout the task due to min unsteadiness noted with fatigue. Goals? Patient will amb 385 feet on appropriate surfaces with least assistive device. Patient will amb 300 feet independently over driveway surface with walker to allow access to mailbox and vehicle. Patient will complete ADLs safely. Patient will complete ADLs with a focus on self management. Patient will shower with no AD independently as was previous functional level. Amb 50 feet X 3. Need for the Visit? Patient advanced ambulation to 35 with walker. Patient amb 45 feet with walker, CGA and 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. Fazzi Associates, Inc. 9

13 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 reassessed. Implications for Program Development Practice patterns that are different that peer agencies can be a trigger for a documentation audit. Different does not mean bad bad. Awareness of risk and a plan to be proactive is key to audit readiness BUT is not audit prevention. Components of Documentation Initial Examination/Evaluation: Examination: History Systems Review Tests and Measures Evaluation: Problem list/statement of assessment Diagnosis: ICD-9 implications Prognosis Plan of Care/Goals APTA Defensible Documentation for Patient/Client Management Fazzi Associates, Inc. 10

14 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. A connection of the movement/activity to a specific function. Physical Therapy Reimbursement News, Volume 13, Number 3 Components of Well Written Goals Continued Specific conditions in which the activity will be performed. Factors for measuring performance. Time Frame for achieving goal. Physical Therapy Reimbursement News, Volume 13, Number 3 Components of Documentation Follow Up Visit: Patient or caregiver report Interventions provided including (as appropriate): Frequency Intensity Time APTA Defensible Documentation for Patient/Client Management Fazzi Associates, Inc. 11

15 Components of Documentation Continued Follow Up Visit (Continued): Patient response to treatment/interventions Communication/collaboration with other providers/family/patient p as applicable/indicated Factors that modify frequency or intensity of 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 Documentation References Functional Outcomes Documentation for Rehabilitation: By Lori Quinn and James Gordon Published by Saunders APTA - Defensible Documentation for Patient/Client Management. Read Your Documentation! Every clinician needs to periodically read his or her documentation to determine if it reads as it was intended. Documentation o represents ese both the skills s of the individual as well as those of the profession as a whole. Particular risk when changing tools. Fazzi Associates, Inc. 12

16 RAC Contact Info Region A: Diversified Collection Services Region B: CGI Region C: Connolly Consulting Region D: HealthDataInsights Part A: Helpful Resources American Physical Therapy Association: Home Health Section State Level Associations American Occupational Therapy Association: American Speech and Hearing Association: ww.asha.org National Association of Home Care. State Home Care Associations. fazzi.com Fazzi Associates, Inc. 13

17 Home Care Therapy Roundtable and Therapy Audits Special Webinar Discount Fazzi s Home Care Therapy Roundtable is unlike any other program in the industry. As a member of the Roundtable, you will gain access to highly engaging interactive online sessions held monthly. Each session will open with a preliminary discussion by a small panel of experts on an important home care issue and then is opened up for discussion. You ll hear different opinions, engage in interesting conversation, and gain best practice strategies from some of home care s most seasoned experts. This is your chance to network with other therapy professionals in the industry while gaining insight that will help you succeed. Primary Annual Subscription Unit Price Total Therapy Roundtable Annual Subscription (Webinar Discount) $600 Additional Sites Requires Purchase of Primary Annual Subscription Unit Price Roundtable Additional Sites Annual Subscription (per site) $500 Number of Subscriptions Total (Unit price X sites) Note: Pricing above is per site for up to 5 sites. Please call for individual pricing if you have more than 5 sites. Agency Name Address Primary Contact Phone Additional Site Participant Name (Optional) Phone Additional Site Participant Name (Optional) Phone Payment Information Bill Me Check Enclosed Payable to: Fazzi Associates 243 King Street, Suite 246 Northampton,MA OR Fax to Visa Mastercard Amex Discover Credit Card Number Expiration Date CID Code Cardholder Name Signature Amount to be Charged Date $300 Discount Coupon Therapy Audit As a webinar participant, you are eligible to receive $300 off your next therapy audit. Promotion Code FazziSave300. But don't wait, this offer expires August 7, *One discount per agency. Discount extended to all live and recording therapy webinar purchases. Audit need not be completed before coupon expiration With the proposed cuts facing our industry, you cannot afford to lose money with documentation that does not support medical necessity. To learn more about Fazzi's therapy auditing services or schedule your next audit, contact Cindy Krafft, MS, PT, COS-C at ckrafft@fazzi.com. Don't forget to mention the promotion code on the coupon to receive your discount!

18 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: June 15, 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. Discuss the components of appropriate therapy utilization as they relate to reasonable and necessary for both assessments and ongoing visits. Examine the relationship between therapy visits and reimbursement. Discuss concerns about therapy utilization in home health. Define reasonable. Define necessary. Explore medical necessity. 25 mins Cindy Krafft MS PT, COS-C Lecture, power point 20 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. 15 mins Cindy Krafft MS PT, COS-C 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 Cindy Krafft MS PT, COS-C 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 Cindy Krafft MS PT, COS-C Question and Answer Questions and answers. 10 mins Cindy Krafft MS PT, COS-C Question and Answer