Therapy STARS Project: Medical Necessity Presented By: Cindy Krafft MS PT President Home Health Section APTA Director of Rehabilitation Consulting Services and Nancy Buseth PT, RN Senior Rehabilitation Consultant November 8, 2011 243 King Street, Suite 246 Northampton, MA 01060 Phone: 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.
Speaker Introduction Nancy Buseth RN, PT is the Senior Rehabilitation Consultant for Fazzi Associates, Inc. She has 10 years of home health experience ranging from staff therapist to Director of Rehabilitation and Director of Referral Management and Community Relations. She is a member of the Education Committee for the Minnesota Home Care Association and is actively involved in the Association. She has published articles for Caring Magazine and Home Health Line. She has been a speaker at both the National and State level for home care. She was a core member for a Care Navigation team within a hospital system to decrease re-hospitalizations and decrease hospital length of stay. She worked as an RN in the field of Geriatrics, prior to getting her Physical Therapy degree.
Therapy STARS Project Webinar 1: Medical Necessity Cindy Krafft PT, MS Director of Rehabilitation Consulting Services Record Review Round 1 Over 1,500 records representing more than 500 therapists. In final stages of writing reports. Calls to be completed by end of November. Record Content SOC/ROC OASIS. 485/Plan of Care. Therapy Assessments. Therapy Reassessments. Therapy Orders. Therapy Visit Notes.
Defending Medical Necessity Between 80% and 90% of the records could not support the number of therapy visits as medically necessary. What is Medical Necessity? Necessity is defined as: An imperative requirement or need for something Indispensability SOC/ROC OASIS Fundamental component to support why therapy referral was made. Issues: ADL/IADL items Ambulation/Fall Risk Cognition/Swallowing
ADL/IADL Items WHERE IS THE OT?? Grooming Upper Body Dressing Lower Body Dressing Bathing Toileting Hygiene Meal Preparation Medication Management M1860 Ambulation Ask yourself. Is a 0 or 1 homebound? What does 2 really mean? What about Fall Risk? Time Points Supporting SLP Cognitive Behavioral. Communication. Feeding and Eating. Meal Preparation. Medication Management. Fall Risk.
485/Plan of Care Eval and Treat. 1 day 1. 1 3 week 9. Dealing with delays. Interventions. Goals. Therapy Assessments Create the foundation of the entire therapy plan of care. Prior level of function (PLOF) is NOT optional. Answer the question Why is therapy indispensible to this patient? Issues by Discipline Physical Therapy: Gait More than distance, device, and level of assistance Occupational Therapy: 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.
Skilled Assessment Measurements: ROM Strength Balance Vision Pain Sensation Communication Cognition Environment Equipment Functional Impact: Ambulation Transfers Bathing Dressing Toileting Incontinence Medication Management Swallowing Home Management What Does a Therapist See? Gait Deficits : Patient 1 Visual and cognitive issues Patient 2 Leg length discrepancy and pain ADL Deficits : Patient 3 Anxiety and lack of transfer bench Patient 4 Balance and arm in a sling Swallowing Deficits : Patient 5 Posture and muscular weakness Patient 6 Attention and memory Tests and Measures Standardized: Must follow the directions Validated: Assess research behind the tool Value in repeating over course of care: Support ongoing need and impact of care
Objective Data? AROM/PROM? Manual Muscle Testing? Components of a Transfer? Gait Cycle? Time Based Activities? Pain Assessments? Pressure Ulcer Risk? OASIS? How Far Can We Go? Goal Setting Considerations: Prior level of function Homebound status Patient goals Need to expand view beyond being functional in the home environment for those patients that want to re enter the community. 150 Feet Rule Any rules of thumb that would declare a claim not covered solely on the basis of elements, such as lack of restoration potential, ability to walk a certain number of feet, or degree of stability, is unacceptable without individual review of all pertinent facts to determine if coverage may be justified. Medical denial decisions must be based on a detailed and thorough analysis of the beneficiary s total condition and individual need for care.
Measureable Goals CONSIDER: ROM MMT Distances Level of assistance Environment Testing Scores Specific Equipment Caregiver role Specific Instructions Any Complicating Factors AVOID: Fair/good/poor WFL LRAD Household Community Safe Increase Improve Min/mod Modified Independent Meaningful Goals Connection to what is meaningful TO THE PATIENT Consider: To allow patient to So patient can To comply with Therapy Reassessments Audit results showing some issues with completion in the correct time frames. Larger issues with content NOT meeting the standardto to support continuing therapy.
Every 30 Days Minimally : Starts with the first visit from therapy Continues until discharge May cross certification periods DON T wait until the last minute Counting Visits 13 (before 14) Single Therapy: On literal 13 th Rural exception Completion resets 30 days Specific to each cert period 19 (before 20) Single Therapy: On literal 19 th Rural exception Completion resets 30 days Specific to each cert period Multiple Therapy: Close to No Ranges Completion resets 30 days Specific to each cert period Multiple Therapy: Close to No Ranges Completion resets 30 days Specific to each cert period Reassessment Documentation Clinically supported statement of expectation that the patient can continue to progress or resume progress after plateau or regression. Speak to the effectiveness of therapy in relation to the goals. Plans to continue or discontinue: Refer to clinical findings (objective assessments) and treatment plan revisions
Therapy Orders Ranges Extending Care Modalities Therapy Assistants DC = Goals Met Therapy Visit Notes Following the Plan of Care. Independent. Direction of the assistant. Repetitive Interventions. Skilled Interventions Intervention = interference. Disruption of the current process. Driven by the assessmentfindings.
Medical Necessity is Indispensible Disruption Next Steps Agency Calls to Review Reports: Nancy Buseth Cindy Krafft Webinar in January: Utilization Management Therapy Roundtable: Participation is key! Contact Information Website Fazzi.com E Mail ckrafft@fazzi.com Twitter Account FazziRehab