2017 FOCUSED ON DOCUMENTATION NECESSITIES & PRE-CLAIM REVIEW

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1 2017 FOCUSED ON DOCUMENTATION NECESSITIES & PRE-CLAIM REVIEW PRESENTED BY: MELINDA A. GABOURY, COS-C CHIEF EXECUTIVE OFFICER HEALTHCARE PROVIDER SOLUTIONS, INC. HEALTHCAREPROVIDERSOLUTIONS.COM ADDITIONAL DEVELOPMENT REQUESTS REQUEST FOR MEDICAL RECORDS INFORMATION REQUEST FOR ADR OBTAINED THROUGH EITHER DDE SYSTEM HAVE LIMITED TIME PERIOD TO RESPOND 30 DAYS THIS IS A PREPAYMENT REVIEW WHICH OCCURS AT THE POINT OF BILLING THE FINAL CLAIM 1

2 PROBE & EDUCATE ROUND 2 CLAIMS SUBJECT TO REVIEW AS PART OF THE PROBE AND EDUCATE PROCESS FOR ROUND 2 OF THE PROBE AND EDUCATE PROGRAM, CMS ANTICIPATES MACS WILL BEGIN SENDING ADDITIONAL DOCUMENTATION REQUESTS (ADRS) ON OR AFTER DECEMBER 15, 2016 AND THAT THIS ROUND OF CLAIM REVIEWS AND PROVIDER EDUCATION WILL CONCLUDE IN APPROXIMATELY ONE YEAR. THIS DOCUMENT CONTAINS A SUMMARY OF THE TECHNICAL DIRECTION THAT CMS WILL ISSUE TO THE MACS. CMS IS DIRECTING HOME HEATH MACS TO SELECT A SAMPLE OF 5 CLAIMS FOR PRE-PAYMENT REVIEW FOR FROM EACH HHA WITHIN THEIR JURISDICTION, EXCLUDING THOSE PROVIDERS WHO HAD 5 CLAIMS REVIEWED IN ROUND 1, WITH ZERO OR ONE CLAIM IN ERROR. AS THEY ARE COMPLETING THE SECOND ROUND OF PROBE AND EDUCATE REVIEWS, MACS WILL CONTINUE TO FOCUS ON THE HOME HEALTH AGENCY S (HHA) COMPLIANCE WITH THE POLICY OUTLINED IN CMS-1611-F, AS WELL AS TO MAKE SURE ALL OTHER COVERAGE AND PAYMENT REQUIREMENTS ARE MET. COMPLETE REVIEW PACKET NEED TO OBTAIN ALL INFORMATION ON PATIENT REQUESTED SEE CHECKLIST PERFORM BOTH CLINICAL AND BILLING AUDIT COMPARE THAT INFORMATION WITH ANY PREVIOUS AUDITS WHICH MAY HAVE BEEN COMPLETED REVIEW ADR NOTICE TO DETERMINE IF YOU HAVE REVIEWED ALL REQUESTED INFORMATION AND IF ALL COPIES WERE MADE 2

3 PRE-CLAIM REVIEW (PCR) PCR IS DIFFERENT THAN PRIOR AUTHORIZATION DUE TO TIMING OF REVIEW AND WHEN SERVICES BEGIN: PRIOR AUTHORIZATION REQUESTS ARE SUBMITTED PRIOR TO SERVICES BEGINNING AND PROVIDERS WAIT UNTIL THEY HAVE A DECISION BEFORE PROVIDING SERVICES PCR REQUESTS ARE SUBMITTED AFTER INITIAL ASSESSMENTS AND INTAKE IS COMPLETE, SERVICES HAVE STARTED, RAP FILED AND BEFORE A FINAL CLAIM IS SUBMITTED FOR THE FINAL EPISODE PAYMENT PCR IS A REQUEST FOR A PROVISIONAL AFFIRMATION OF COVERAGE! ZPICS/RAS AND SUCH CONTRACTORS CAN STILL REQUEST THE RECORDS FOR FULL MEDICAL REVIEW. IF AN AGENCY IS ON 100% ZPIC REVIEW THEY WOULD NOT BE SUBJECT TO PCR. IF THE AGENCY IS ON A LESS THAT 100% ZPIC REVIEW THEN THEY ARE SUBJECT TO PCR FOR THE ONES THAT ARE NOT REVIEWED BY THE ZPIC. PRE-CLAIM REVIEW (PCR) IF REFERRAL ORDERS INCLUDE MULTIPLE DISCIPLINES, TO BE PROVIDED TO THE PATIENT, THEN MULTIPLE DISCIPLINE INFORMATION MUST BE SENT IN TO BE AFFIRMED. EXAMPLE: ORDER INCLUDES PT AND SN THEN BOTH MUST BE SENT IN FOR PCR TO BE AFFIRMED G CODES/HCPCS CODES THAT WILL BE BILLED ON THE CLAIM MUST ALL BESENT IN FOR PCR. IF ONLY SN IS ORDERED AND PT IS ADDED THREE WEEKS INTO CARE THEN AT THE POINT OF BILL THE PT WILL STILL BE PAID AS USUAL BECAUSE IT WAS ADDED AFTER THE FACT. REQUEST FOR ANTICIPATED PAYMENT (RAP) NEEDS TO BE SUBMITTED AND ACCEPTED PRIOR TO SUBMITTING FOR PCR. THIS OPENS THE BENEFICIARY RECORD FOR THE HOME HEALTH EPISODE INTHE COMMON WORKING FILE AND ALLOWS FOR THE PCR INFORMATION TO BE INTEGRATED INTO THE EPISODE. 3

4 PRE-CLAIM REVIEW (PCR) LOW UTILIZATION PAYMENT ADJUSTMENT (LUPA) EPISODES ARE NOT SUBJECT TO PCR LUPA IS AN ADJUSTMENT THAT APPLIES TO PAYMENT WHEN A HOME HEALTH EPISODE HAS LESS THAN 5 VISITS THAT HAVE BEEN PROVIDED TO THE PATIENT AND THEREFORE THE EPISODE WILL BE PAID PER VISIT NOT EPISODICALLY. IF THE PATIENT IS THOUGHT TO BE A LUPA AT THE BEGINNING AND THEN FOR WHATEVER REASON RECEIVES 5 OR MORE VISITS IN THE EPISODE, THE PATIENT WOULD REQUIRE PCR BEFORE BILLING THE FINAL CLAIM. ANY TIME THERE IS A NEW 60 DAY EPISODE TO BEGIN THERE MUST BE NEW PCR NEW SOC DISCHARGE AND READMIT RECERTIFICATION TRANSFERRING THE RECEIVING HOME HEALTH MUST HAVE A PCR PRE-CLAIM REVIEW (PCR) THE REQUEST MUST CONTAIN CERTAIN ELEMENTS TO BE CONSIDERED COMPLETE: BENEFICIARY INFORMATION CERTIFYING PHYSICIAN INFORMATION HOME HEALTH AGENCY INFORMATION SUBMITTER INFORMATION CONTACT AT YOUR AGENCY FOR QUESTIONS OTHER INFORMATION BENEFIT PERIOD, SUBMISSION DATE, FROM & THRU DATES, INDICATE WHETHER INITIAL OR RESUBMISSION, STATE WHERE SERVICE IS RENDERED REQUIRED DOCUMENTATION 4

5 PRE-CLAIM REVIEW (PCR) PCR DECISIONS COULD POSSIBLY INCLUDE BOTH PROVISIONALLY AFFIRMED AND NON-AFFIRMED G CODES/HCPCS CODES UNDER A UTN IN THIS CASE THE PROVIDER HAS TWO OPTIONS: 1. SUBMIT THE FINAL CLAIM WITH ALL THE G CODES/HCPCS CODES WITH THE UTN AND THE PROVISIONALLY AFFIRMED GCODES/HCPCS WILL APPROVE FOR PAYMENT AND THE NON- AFFIRMED HCPCS WILL DENY WITH APPEALS RIGHTS PCR IS SUBMITTED WITH SN AND PT ON THE REQUEST AND ONLY SN IS AFFIRMED. WITH THIS OPTION YOU WILL FILE THE FINAL CLAIM WITH ALL SERVICES ON THE CLAIM AND ONLY THE SN WILL PAY, CREATING A PARTIAL DENIAL (PT) AND THE AGENCY WOULD HAVE FULL APPEAL RIGHTS FOR THE DENIED PT. OR PRE-CLAIM REVIEW (PCR) 2. RESUBMIT THE PCR FOR THE NON-AFFIRMED HCPCS CODES WHICH WOULD RESULT IN A NEW UTN BASED ON THAT DECISION WHICH WOULD THEN NEED TO BE USED ON THE FINAL CLAIM UNDER THIS OPTION YOU WOULD RESUBMIT THE PCR REQUEST WITH ADDITIONAL INFORMATION TO SUPPORT THE THERAPY THAT WAS NON-AFFIRMED PREVIOUSLY AND HOPEFULLY IT WILL BE AFFIRMED THIS TIME AND THE NEWLY ISSUED UTN WILL INCLUDE AFFIRMED FOR ALL SERVICES MAKE SURE THINGS ARE IN PLACE FOR YOUR BILLERS TO KNOW WHICH UTN IS TO BE USED ON THE CLAIMS. SOMEONE WILL HAVE TO BE DILIGENT ABOUT MAKE SURE THOSE GET UPDATED WHEN RESUBMISSION REQUESTS OCCUR. ALSO, REMEMBER THAT AS STATED EARLIER, IF ONLY ONE DISCIPLINE IS ORDERED WITH THE REFERRAL AND OTHER DISCIPLINES ARE ADDED LATER THEY WILL STILL BE PAID ON THE FINAL CLAIM. 5

6 PRE-CLAIM REVIEW (PCR) IF THE ORIGINAL REQUEST IS RETURNED PARTIALLY NON-AFFIRMED YOU WILL NEED TO RESUBMIT THE ENTIRE CHARTING FOR THE 2 ND REQUEST..NOT JUST THE INFORMATION FOR THE SERVICES THAT WERE NOT AFFIRMED ONCE THE PCR GOES INTO EFFECT, THERE WILL BE A 3 MONTH PERIOD DURING WHICH THE ONLY ISSUE IN FILING A CLAIM WITHOUT A UTN WILL BE THAT THE CHART WILL THEN BE FORCED INTO A PCR SITUATION AND NOT PAID UNTIL ONE IS OBTAINED WITH IT BEING AFFIRMED. AFTER THE 3 MONTHS, IF A CLAIM IS FILED WITHOUT A UTN AND IT GOES THROUGH THE PCR PROCESS AND IS THEN AFFIRMED, PAYMENT WILL BE PAID WITH A 25% PENALTY APPLIED AND NO APPEAL RIGHTS FOR THAT 25%! MEDICAL NECESSITY FOR HH SN DIRECT CARE NOTE: While a wound might not require skilled nursing care, the wound may still require skilled monitoring for signs and symptoms of infection or complication or skilled teaching of wound care to the patient or caregiver. Coverage or denial based on all of the documented clinical findings. The plan of care must contain the specific instructions for the treatment of the wound. The size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented. 6

7 Document to Support the Focus of Care Paint the Picture with the Initial Clinical Summary Can be used for the agency's F2F addendum to support the medical necessity for HH services and homebound status Should be concise and patient-specific Include reason for referral for HH services Give overview of related treatments, new and changed medications, hospitalizations, surgeries, tests, recent emergency care State the primary focus of care (primary diagnosis) for HH services; prioritize secondary diagnoses Document to Support the Focus of Care Paint the Picture with the Initial Clinical Summary Support medical necessity Identify patient/caregiver deficits to be addressed, new diagnoses or exacerbation of condition, new or changed medications or treatments, specific needs for teaching, observation, or direct care Include patient and caregiver availability, ability, and willingness to participate and/or perform Identify safety issues, risks, non-compliance, or any other obstacles to care Include assessment findings supporting homebound Required assistance, normal inability to leave home, considerable and taxing effort 7

8 Document to Support the Focus of Care The 60-day and Recertification Clinical Summary Maintain proof of sending to the physician Synopsis of the care provided Supports necessity for services provided Disciplines remaining active Clinical findings related to reportable vital signs Labs and specimens and overview of results Wound description, measurements, healing status Catheter changes, ostomy care and/or IV needs Includes planned updates to the POC Progress towards reaching prior goals Clinical assessment findings supporting homebound Document to Support the Focus of Care Every Skilled Nursing visit note should include: Clinical assessment Response/changes in behavior to previous services Detailed rationale explaining need for services The complexity of the service to be performed Skilled services provided during the current visit Patient/caregiver s response to skilled services Plan for next visit based on rationale of prior results Any other pertinent characteristics of patient/home Specific objective & measurable progress achieved 8

9 Document to Support the Focus of Care CMS clearly states generalized documentation does not support the need for skilled care. Terminology such as: Patient tolerated treatment well Caregiver instructed in medication management, or Continue with POC are vague or subjective and should not be used. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services. Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Document to Support the Focus of Care Avoid Under or Over-Documentation A descriptive, patient & visit-specific narrative that contains the above mentioned CMS requirements is imperative in each visit note. Cloned or copy-pasted narratives were identified by the OIG as targeted areas of concern in EMR records. Denials are likely when only check-boxes are utilized. Fraud charges could result if the electronic record is overdocumented and misrepresents services that were actually provided. 9

10 F2F/Certification FINAL RULE 2015 Update Final Decision: We are finalizing our proposal to eliminate the face-to-face encounter narrative as part of the certification of patient eligibility for the Medicare home health benefit, effective for episodes beginning on or after January 1, The certifying physician will still be required to certify that a face-toface patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in (a)(1)(v)(A), and to document the date of the encounter as part of the certification of eligibility. F2F/Certification FINAL RULE 2015 Update HHAs should obtain as much documentation from the certifying physician s medical records and/or the acute/post-acute care facility s medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS and its review entities upon request. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided. Therefore, in order to determine when documentation of a patient s face-to-face encounter is required under sections 1814(a)(2)(C) and 1835 (a)(2)(a) of the Act, we proposed to clarify that the face-to-face encounter requirement is applicable for certifications (not recertifications), rather than initial episodes. A certification (versus recertification) is considered to be any time that a new SOC OASIS is completed to initiate care. 10

11 MLN Matters Number: SE1436 Certification Requirements: Who Can Perform a Face-to-Face Encounter According to 42 CFR (a)(1)(v)(A), the face-to-face encounter can be performed by: The certifying physician; The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health); A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician; or A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician. According to 42 CFR (d)(2), the face-to-face encounter cannot be performed by any physician or allowed NPP (listed above) who has a financial relationship with the HHA. MLN Matters Number: SE1436 Certification Requirements: Supporting Documentation Documentation in the certifying physician s medical records and/or the acute/post-acute care facility s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided. According to the regulations at 42 CFR (c), Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the home health agency, review entities, and/or CMS. Certifying physicians who show patterns of noncompliance with this requirement, including those physicians whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as provider-specific probe reviews. 11

12 MLN Matters Number: SE1436 Information from the HHA, such as the patient s comprehensive assessment, can be incorporated into the certifying physician s and/or the acute/post-acute care facility s medical record for the patient. Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered. The certifying physician must review and sign off on anything incorporated into the patient s medical record that is used to support the certification of patient eligibility (that is, agree with the material by signing and dating the entry). The certifying physician s and/or the acute/post-acute care facility s medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient s: Need for the skilled services; and Homebound status. MLN Matters Number: SE1436 The certifying physician s and/or the acute/post-acute care facility s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter: 1. Occurred within the required timeframe; 2. Was related to the primary reason the patient requires home health services; and 3. Was performed by an allowed provider type. This information can be found most often in, but is not limited to, clinical and progress notes and discharge summaries. Please review the following examples included at the end of this article: Discharge Summary; Progress Note; Progress Note and Problem List; or Discharge Summary and Comprehensive Assessment. 12

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16 CERTIFICATION OF F2F DATE THE CERTIFYING PHYSICIAN MUST ALSO DOCUMENT THE DATE OF THE FACE TO FACE ENCOUNTER AS PART OF THE CERTIFICATION. CERTIFYING PHYSICIAN IS NOT REQUIRED TO SIGN A DISCHARGE SUMMARY, ETC. FROM A FACILITY ENCOUNTER, BUT MUST CERTIFY THAT THE F2F ENCOUNTER OCCURRED AND THE DATE. WISE TO ALSO INCLUDE THE PHYSICIAN S NAME THAT PROVIDED F2F VISIT. I CERTIFY THAT THIS PATIENT HAD A FACE TO FACE ENCOUNTER WITH DR. JOHN SMITH ON 09/01/16. SUPPORTING DOCUMENTATION SUCH AS THE DISCHARGE SUMMARY SHOULD INCLUDE THE VISIT INFORMATION FOR WHEN THE PATIENT WAS SEEN BY JOHN SMITH ON 09/01/16. THIS STATEMENT IS BEING ACCEPTED WHEN INCLUDED ON THE 485/POC. 16

17 RECERTIFICATION/ESTIMATE OF CARE RECERTIFICATION INCLUDES THAT THE PHYSICIAN MUST INCLUDE IN HIS/HER RECERTIFICATION STATEMENT OF THE PATIENT, AN ESTIMATED AMOUNT OF TIME THAT SERVICES WILL CONTINUE TO BE REQUIRED! THIS CAN BE AS SIMPLE AS: I CERTIFY, THAT IN MY ESTIMATION, CONTINUED SERVICES WILL BE REQUIRED FOR. THERE MUST BE DOCUMENTED EVIDENCE THAT THE ESTIMATION OF TIME ORIGINATED FROM THE PHYSICIAN. A STATEMENT FOR THE ESTIMATION OF SERVICES IS REQUIRED FOR EVERY RECERTIFICATION 60-DAY PERIOD COMMON MISTAKE.ESTIMATION IS 60 DAYS AND WE WRITE POC FREQUENCY AND GOALS FOR 30 DAYS.. Homebound Definition In the Calendar Year (CY) 2012 Home Health (HH) Prospective Payment System (PPS) proposed rule published on July 12, 2011, CMS proposed their intent to provide clarification to the Benefit Policy Manual language regarding the definition of "confined to the home". In the CY 2012 HH PPS final rule published on November 4, 2011 (FR ), CMS finalized that proposal. In order to clarify the definition, CMS is amending its policy manual as follows: 17

18 Homebound Definition For purposes of the statute, an individual shall be considered confined to the home (homebound) if the following two criteria are met: Criteria-One: The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence OR Have a condition such that leaving his or her home is medically contraindicated. If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below. Criteria-Two: There must exist a normal inability to leave home; AND Leaving home must require a considerable and taxing effort. HOMEBOUND & HOME HEALTH NEED DOES THE PATIENT HAVE A NORMAL INABILITY TO LEAVE HOME? AND DOES LEAVING THE HOME REQUIRE A CONSIDERABLE AND TAXING EFFORT? STRUCTURAL IMPAIRMENT IS THERE A STRUCTURAL IMPAIRMENT? STRUCTURES OF THE NERVOUS SYSTEM EYE, EAR AND RELATED STRUCTURES STRUCTURES INVOLVED IN VOICE AND SPEECH STRUCTURES OF THE CARDIOVASCULAR SYSTEM STRUCTURES OF THE IMMUNOLOGICAL SYSTEM STRUCTURES OF THE RESPIRATORY SYSTEM STRUCTURES RELATED TO THE DIGESTIVE SYSTEM STRUCTURES RELATED TO THE METABOLIC AND ENDOCRINE SYSTEMS STRUCTURES RELATED TO THE GENITOURINARY SYSTEM STRUCTURES RELATED TO MOVEMENT SKIN AND RELATED STRUCTURES 18

19 HOMEBOUND & HOME HEALTH NEED DOES THE PATIENT HAVE A NORMAL INABILITY TO LEAVE HOME? AND DOES LEAVING THE HOME REQUIRE A CONSIDERABLE AND TAXING EFFORT? FUNCTIONAL IMPAIRMENTS IS THERE A FUNCTIONAL IMPAIRMENT? MENTAL FUNCTIONS SENSORY FUNCTIONS AND PAIN VOICE AND SPEECH FUNCTIONS FUNCTIONS OF THE CARDIOVASCULAR SYSTEM FUNCTIONS OF THE HEMATOLOGICAL AND IMMUNOLOGICAL SYSTEMS FUNCTIONS OF THE RESPIRATORY SYSTEM FUNCTIONS OF THE DIGESTIVE SYSTEM FUNCTIONS OF THE METABOLIC AND ENDOCRINE SYSTEMS GENITOURINARY FUNCTIONS NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS FUNCTIONS OF THE SKIN AND RELATED STRUCTURES HOMEBOUND & HOME HEALTH NEED DOES THE PATIENT HAVE A NORMAL INABILITY TO LEAVE HOME? AND DOES LEAVING THE HOME REQUIRE A CONSIDERABLE AND TAXING EFFORT? ACTIVITY LIMITATIONS ARE THERE ACTIVITY LIMITATIONS? COMMUNICATION MOBILITY SELF-CARE DOMESTIC LIFE INTERPERSONAL INTERACTIONS AND RELATIONSHIPS 19

20 HOMEBOUND & HOME HEALTH NEED WHY DOES THIS PATIENT NEED HOME HEALTH? OUTLINE WHAT THE CLINICIANS WILL BE PROVIDING TO HELP CORRECT/HEAL THE ISSUES USED TO SUPPORT HOMEBOUND/CLINICAL NEED: HOW DO THE SKILLS OF A NURSE OR THERAPIST ADDRESS THE SPECIFIC FUNCTIONAL AND STRUCTURAL IMPAIRMENTS AND THE ACTIVITY LIMITATIONS? THE SKILLS OF A NURSE ARE NEEDED TO MONITOR THE HEALING PROCESS OF THE SURGICAL WOUND AND EDUCATE THE PATIENT OR CAREGIVER ON THE DRESSING CHANGES AND MONITORING SIGNS AND SYMPTOMS OF INFECTION. PHYSICAL AND OCCUPATIONAL THERAPY IS NECESSARY TO EVALUATE THE PATIENT S FUNCTIONAL STATUS, CAPACITY FOR IMPROVED MOBILITY AND SELF CARE OR TO IMPLEMENT A PERSONALIZED PATIENT CENTERED PLAN OF CARE TO ADDRESS ACTIVITY LIMITATIONS. THERAPY DOCUMENTATION 20

21 THERAPY DOCUMENTATION General Principles Governing Reasonable and Necessary PT, OT and ST services The service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. The skilled services must be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury. General exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy. THERAPY DOCUMENTATION Initial Therapy Assessment For each therapy discipline, a qualified therapist (instead of an assistant) must assess and document the patient s function using a method which includes objective measurements which correspond to the therapist s discipline and POC goals. Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must functionally assess the patient. 21

22 THERAPY CLARIFICATIONS EVALUATION AND POC GOALS MUST INCLUDE: OBJECTIVE MEASURES OF FUNCTION (E.G. SWALLOW, BATHING, DRESSING, WALKING, STAIRS, USE OF DEVICES) DESCRIBED CORRELATION BETWEEN TREATMENT FOR ILLNESS/INJURY TO PROFESSIONAL STANDARDS MEASURABLE GOALS RELATED TO ILLNESS/INJURY SHORT AND LONG TERM GOALS NOW ENCOURAGED NOT NECESSARILY BOTH REQUIRED SPECIFIC TARGET DATES THERAPY DOCUMENTATION Therapy Reassessment At least once every 30 days, for each therapy discipline Performed by a qualified therapist (instead of an assistant) Must provide an ordered therapy service, Must functionally reassess the patient Must compare the resultant measurement to prior measurements Must document the effectiveness of therapy, or lack thereof. The 30-day clock begins with the first therapy service (of that discipline) and resets with each reassessment 22

23 THERAPY DOCUMENTATION DEFICITS COMMON ADR DENIAL REASONS: HHA DID NOT SUBMIT THE REQUIRED REASSESSMENT(S) WHEN RESPONDING TO THE ADR REQUEST CREDENTIALS MISSING ILLEGIBLE CREDENTIAL WITH SIGNATURE ILLEGIBLE SIGNATURE OF THE THERAPIST POC MISSING SHORT AND LONG TERM GOALS GOALS MISSING SPECIFIC TARGET DATES OBJECTIVE MEASUREMENT RESULTS ARE NOT DOCUMENTED REASSESSMENTS ARE NOT BEING COMPLETED WITHIN THE REQUIRED TIMEFRAME 23

24 Melinda A. Gaboury, COS-C Chief Executive Officer Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN