Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #29 Therapy and the MDS Coordinator: Collaboration = Improved Outcomes Tuesday, August 6 4:45 to 6:15 p.m. Atlantic 3 Upon completion of this presentation, the learner will be able to: summarize the major components that make up the Medicare program; demonstrate knowledge of each step from admissions to benefit period and skilling; and illustrate how to unite the teams, tools and systems that pull clinical and therapy together. Seminar Description: First it is nursing, then it is rehabilitation, then it is nursing again. From where should your revenue be coming? Where should your focus lie? Stop the madness and focus on the resident with a united team who are experts in their discipline but also solid generalists with all the major components of the Medicare system. In this session, with humor and an interactive style, you will be provided with a 10,000-foot perspective of how your program should work, how to build Part B Therapy and how to unite the team. Presenter Bio(s): Mary-Beth Newell, RN, Vice President of Clinical Reimbursement with Post Acute Consulting, is a registered nurse with a specialty in clinical reimbursement. She has over thirteen years of consultant and leadership experience that have resulted in continuous success in clinical reimbursement for up to 150 SNFs in 17 states with diverse patient populations. She has a proven track record of driving multimillion-dollar growth with Case Mix, Part A rates and Part B revenue, while improving Quality Measures and the 5-Star Rating. Melissa Reilly is a licensed physical therapist with over 18 years of experience. As the Senior Therapy Consultant for Post Acute Consulting, she has a varied and rich background and knowledge base. She has successfully helped individual centers and organizations develop unique niche programs that provide value and contribute to census growth. Melissa has worked with state and local government agencies to improve therapeutic interventions at numerous facilities. She excels in developing revenue producing programs while minimizing costs and maximizing the revenue potential of existing programs along with maintaining compliance. Melissa received her Master of Science in Physical Therapy from the University of Rhode Island and has served as an adjunct professor at the Community College of Rhode Island.
THERAPY AND THE MDS COORDINATOR:COLLABORATION = IMPROVED OUTCOMES Mary-Beth Newell, RN Vice President of Clinical Reimbursement and Melissa J. Reilly, MS, PT Senior Therapy Consultant Objectives Define the major components that make up the Medicare program Gain knowledge of each step from admissions to benefit period and skilling Understand how to unite the teams, tools and systems that lead to a collaborative approach between nursing and therapy Medicare Structure Congress (Enacts Medicare Law) Center for Medicare and Medicaid Services (Interprets Medicare Law) Fiscal Intermediary/Medicare Administration Contractor (Interprets CMS Policy) (Claims Processing) Durable Medical Equipment Regional Carrier (DMERC) (Claims Processing) Carrier (MD Offices, etc.) (Claims Processing) Skilled Nursing Facility (SNF) 1
Part A Eligibility Enrolled in Part A Require a skilled service Qualifying hospital stay Admitted to a Medicare certified bed Benefit days available Reasonable & necessary Skilled care is certified/re-certified Practical Matter Criteria Can the daily skilled care only be provided in the SNF as a practical matter? Considerations: Outpatient services are not available in the area where the individual lives Outpatient services are available, but transportation could cause excessive hardship or less effective treatment than in the SNF Consider the availability of a capable and willing caregiver Use of alternate services would adversely affect the resident s medical condition Physician Certification Initial Certification: The initial certification is completed on or prior to admission for Medicare coverage Completed: New admission Re-admitted Acute hospital transfer 30 day window after discharge 2
Physician Recertification Recertification: Each covers a 30 day period Identified type of daily skilled care required Recommendation: When coverage ceases, document the reason on the cert/re-cert form Physician Certification and Recertification Signed and dated by the attending physician or an NP, PA, CNS or physician who has knowledge of the case Faxed copies are acceptable Can also mail a copy for signature Medical Director can sign if he/she has knowledge of the case Maintain a copy in the medical record and one in the financial folder when coverage of services has ceased. (Info available in Medicare Benefit Policy Chapter 8-Sect. 40) Spell of Illness/Benefit Period Begins on the day of admission to the Medicare certified bed Count continues as long as skilled care is provided Count stops when : Not requiring daily skilled care Exhausted benefits 3
Spell of Illness/Benefit Period Develop Need for Skilled Services: Days 0-30 After Skilled Care Ends Use remaining benefit days Days 31-59 After Skilled Care Ends Require another 3 night hospital stay Use remaining benefit days Days 60+ After Skilled Care Ends Require another 3 night hospital stay New 100 day benefit period Remains at Skilled Level of Care Not eligible for new benefit period Spell of Illness Decision Tree No prior Medicare utilization in the last 60 days 3 Midnight qualifying hospital stay New Spell of Illness Begins Admission to SNF within 30 days 100 possible days of coverage If discharged prior to full 100 days After 60 consecutive days of no inpatient Med A utilization in SNF or Hosp (no daily skilled needs) New spell of Illness may Begin after new qualifying hospital stay Within 0-30 days post discharge: readmission with no new qualifying stay needed Level of care decreases from covered to non-covered for those who remain in the facility Within 31-59 days post discharge: readmission with new qualifying stay needed to pick up remaining days Case # 1 Mrs. Smith was deconditioned after pneumonia & was receiving PT & OT therapy. Her plan was to receive 3 weeks of rehab & then return home. She insisted on returning home after one week. After 3 days, she realized that she was unable to care for herself & wanted to return to the SNF for the rest of her rehab program. Can she return to the SNF without a 3 night hospital stay? How many benefit days does she have upon her return? Will she need a new certification? 4
Case # 2 Mr. Flowers had a stroke & received PT, OT & SLP therapy until he plateaued after 40 days when he was denied his Part A benefit on day 41. On day 57, he falls & fractures his hip. He is sent to the acute hospital. He returns on day 60 & will receive PT & OT services. How many benefit days does he have upon his return? Case # 3 Mr. Gonzalez was admitted with dysphagia & after 3 weeks of speech therapy he was losing significant weight & not progressing. He received a G tube & was receiving 75% of his calories & 1000 cc of fluid through his G tube. 3 months after speech therapy was discontinued, he is admitted for 4 nights to the hospital with a diagnosis of aspiration pneumonia. He returns to the SNF & will receive PT five times a week. How many benefit days does Mr. Gonzalez have upon his return to the SNF? Level of Care Criteria Services must: 1) Pursuant to a physician s order 2) Reasonable and necessary 3) Performed by or under the supervision of professional or technical personnel 4) Require daily skilled services Rehab 5 days 5
Skilled Criteria Skilled Rehabilitation Services PT,OT and SLP Established by the therapists and the physician At least 5 days a week Skilled Nursing Services 7 days a week Established by the physician in conjunction with the SNF team Direct Skilled Nursing Services IV therapy Skilled wound care Pressure or stasis Tube feeding 501+ cc or more in 24 hours & 26%+ of calories Frequent suctioning (nasopharyngeal or tracheal aspiration only) Ventilator Other Skilled Nursing Services New colostomy care & teaching self care Self catheterization Wound care Medication adjustments Pain control/management Care planning & observation Discharge planning & teaching Aggregate of unskilled services Unstable medical conditions 6
Medical Appropriateness Exception Can begin skilled care when more than 30 days has elapsed Must be predictable within a predetermined time period Recommend: Order or MD note upon admission Case # 1 Mrs. Small had a fracture and needs to be non weight bearing & on bed rest for 6 weeks after which she will receive PT & OT services 5x/week. She was covered under skilled nursing services for observation & care plan development for the initial 5 days. The time span between her skilled nursing service ending & rehab beginning will be 37 days The SNF obtained an order from the physician upon admission deferring skilled OT & PT rehab until she is weight bearing Questions & Answers MNEWELL@POSTACUTECONSULTING.COM 508-414-1180 POSTACUTECONSULTING.COM 7
Recent Medicare Part B Changes Medicare Part B Outpatient Therapy Cap Medicare Improvement Standard Clarification Medicare Part B Physician Fee Screen Functional G-Codes and Severity Indicators Medicare Part B Outpatient Therapy Cap Balance Budget Act of 1997 enacted financial limits (caps) on outpatient OT separately and outpatient PT and SLP combined The caps limited the annual amount of outpatient therapy services a beneficiary could receive regardless of condition or need Applied to all outpatient settings except outpatient hospital Although implemented, the caps were suspended under various Congressional moratoria through 2005 Medicare Part B Outpatient Therapy Cap (2) Deficit Reduction Act of 2005 enacted exceptions to the cap Several Acts since then have extended and clarified the caps exception process (see next slide). For 2013, the therapy caps are $1,900 for OT and $1,900 for PT and SLP combined. An increase of $20 from 2012 caps. Providers submit claims with a KX modifier to indicate an exception to the cap was provided and appropriate 8
Medicare Part B Outpatient Therapy Cap (3) On February 22, 2012, the President signed the Middle Class Tax Relief and Job Creation Act of 2012 into law. Law directs CMS to continue to allow exceptions to therapy caps for medically necessary services provided through December 31, 2013. Requires Manual Medical Review when expenditures reach $3,700 for Speech and/or Physical Therapy, $3,700 for Occupational Therapy services provided on or after October 1 through December 31, 2012. Medicare Part B Outpatient Therapy Cap (4) As of January 2013, the Manual Medical Review Process was suspended. Now all claims that reach the $3700 cap are subject to an automatic ADR and either pre or post payment review depending on your state. Jimmo vs Sebelius Settlement Effective January 24, 2013, a federal judge has approved the settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius. Medicare can no longer deny coverage under an Improvement Standard. Effective January 18, 2013 Medicare beneficiaries who require skilled services to maintain or prevent decline, regardless of underlying condition, illness or diagnosis, cannot be denied coverage. This settlement does not increase the benefit coverage of 100 days but it is not limited to services in an SNF. This settlement covers skilled services in home health, and outpatient therapy as well. 9
Skills of a Therapist Evidenced in documentation by emphasizing the subjective reports and objective descriptions of changes necessitating the skills of the therapist/assistant Best practice recommendation is to document therapist skill by indicating/describing all physical/tactile, cognitive/verbal, and visual cues provided during therapy intervention Medical Necessity The services must be of a level of complexity and sophistication that requires specific knowledge, skill, judgment, and services can only be performed by a licensed therapist or assistant The patient is expected to improve materially in a reasonable and generally predictable amount of time The services are necessary to safely and effectively establish a maintenance program Interventions must be consistent with accepted standards of medical practice and be specific for the condition of the patient The intensity, frequency, and duration of treatment are reasonable and appropriate for the individual patient Medicare Part B Physician Fee Screen The Part B fee screen for each procedure is comprised of three Relative Value Unit (RVU) components: Work component Practice expense component Malpractice component Some procedures are time based and others are serviced based (and may only be billed once per day per discipline) 10
Multiple Procedure Payment Reduction Physician Payment and Therapy Relief Act of 2010 codified the modification of the multiple payment procedure reduction (MPPR) by applying a reduction to the practice expense (PE) component for the second and subsequent billed SNF outpatient therapy services 50% reduction for Skilled Nursing Facilities effective April 1 st, 2013 The PE component identifies the expected cost for preparing a patient for a procedure and is intended to reimburse providers for such costs Multiple Procedure Payment Reduction (2) CMS believes that since the PE component is part of every therapy procedure, providers are being overpaid for prep time when more than one procedure is performed in a day for a patient MPPR applies to OT, PT, and SLP services when performed on the same day for the same patient and reflects that the PE component has been reduced for multiple procedures and multiple units G-Codes Reasoning behind the G-Codes As a result of the Middle Class Tax Relief Act of 2012, CMS was mandated to collect information regarding the beneficiaries function and condition, therapy services furnished, and outcomes achieved In the future, CMS hopes to use this data to reform the current payment system 11
When is this effective? Effective January 1, 2013 CMS has allowed for a transition testing period from January 1, 2013 through June 30, 2013 Any claim submitted after June 30 that does not contain the G-code requirements will not be paid 12
Severity Indictors What is the most important reasons Therapy and MDS must work together? Reimbursement and Quality Outcomes of our residents Not just Medicare A coordination for minutes but coordination for diagnoses and reason for skilling a resident CMI Quality Measures Why is a resident skilled Often we let Rehab drive the bus because the resident is in a rehab category Rehab and Nursing need to coordinate in order to coordinate education, medication teaching, discharge planning and what happens if a resident suddenly refuses therapy Do we have enough to skill for nursing? 13
Quarterly Screen Process Obtain a list of residents each month from the MDS Department whose quarterly/annual MDS Assessment is required to be completed Complete a Therapy Screen of the residents on the list at least 2 weeks in advance of the Quarterly Assessment Reference Window This will ensure that patients in need of and receiving therapy services will be captured and reflected on the MDS Rehab RUG scores often will carry a Medicaid case mix score that will capture over a Nursing RUG score Quality Measures What is therapy role? Short Stay Measures: Percent of residents who self report moderate to severe pain Percent of residents with pressure ulcers that are new or worsened Percent of residents assessed and given appropriately the seasonal influenza vaccine Percent of residents assessed and given appropriately the pneumococcal vaccine Percent of residents who newly received an antipsychotic medication Quality Measures Therapy Role? Long Stay Measures Percent of low risk residents who lose control of their bowel or bladder Residents who have/had catheter inserted and left in the bladder Percent of residents who were physically restrained Percent of residents whose need for help with daily activities increased Percent of residents who lose too much weight Percent of residents who have depressive symptoms Percent of residents who received an antipsychotic 14
How to you effectively build a Caseload? Therapy Screens Screening is a preliminary process of gathering and integrating information to determine the need for further examination or intervention Based on a problem-focused, systematic collection and analysis of data to identify individuals in need of physical, occupational, or speech therapy intervention or other health care services A screen is a process involving patient observation, chart review, and discussion with nursing staff to determine if PT, OT or ST is indicated Therapy Screens (2) Facilities should establish a process in which screen requests for therapy services are formally presented to the therapy department All facility departments and caregivers (including family members) should be educated on the screen referral process Once received the therapy department should respond to the screen request as timely as possible (encourage to be same day or at the latest within 24 hours) 15
What if your facility is new to screening request process? Develop a Referral Recognition Program Functional Maintenance Programs The specialized skill, knowledge and judgment of a therapist may be required, and services are covered, to design or establish a maintenance program, assure patient safety, train the patient, family members, caregiver, and/or unskilled personnel and make infrequent but periodic reevaluations of the program May be concurrent with rehabilitative treatment May evaluate and establish a maintenance program without rehabilitation therapy being indicated Functional Maintenance Programs (2) When the intent of therapy is not necessarily rehabilitative, but to develop a maintenance program to delay or minimize functional deterioration, instructing patients and/or caregivers is expected to require 2-4 visits with supporting documentation being necessary to justify more visits Patient/Caregiver Training Environmental Modification 16
Dining Room Meal Observation Occupational Therapists and Speech Language Pathologists are encouraged to observe resident dining hours for: Challenges with self-feeding due to limited strength, endurance, range of motion, coordination, perception, cognition, etc. Signs and symptoms of swallowing problems (aspiration) such as watery eyes, runny nose, cough, holding food in mouth, leakage of food from mouth, complaints of discomfort with diet, etc. Therapists utilize a course of therapeutic exercise, therapeutic activity, self-care management including adaptive equipment, swallowing treatment, and cognitive retraining as needed to improve function and safety Activities Observation and Co-leading Occupational and Physical Therapists should observe and at times co-lead activity sessions in order to: Ensure that activities are graded to match residents physical and cognitive abilities and note changes from baseline performance If the selected activity has been presented at too low a level for a resident, often you will find the resident becoming restless, exhibit disruptive behaviors, or even trying to exit the activity session If the selected activity has been presented at too high a level for a resident, often you will find the resident becoming restless, confused, or even asleep during the session Become aware of residents who may be having increased room isolation Restorative Programs Designed to follow therapy interventions and maintain resident progress/independence/quality of life Reduce the risk of secondary complications, illness and infection associated with functional decline Meetings should occur routinely between the restorative and therapy department to: Ensure programs are being carried out as instructed and resident progress towards goals is being tracked Barriers to progress or unanticipated gains are reported to therapy for potential therapy intervention or modification of the program Communication and competency remain effective 17
Splint/Brace/Prosthetic Log Physical and Occupational Therapy should have a master log of all residents with active treatment programs for orthotics (splints), braces, and prosthetics Log should be routinely reviewed to ensure: Devices are in active use and are being appropriately applied per an established schedule Skin integrity and color are intact (no abnormal redness or skin deterioration) Range of motion is being performed along with the skin checks pre and post splint application Lost devices, inconsistent application, and failure to monitor skin/joint integrity are easy citations for surveys Alternate Diet/Thickened Liquid Log Occupational and Speech Therapy should have a master log of all residents on an altered diet, thickened liquids, and/or who have been issued adaptive equipment to assist with self-feeding Log should be routinely reviewed to ensure: Diet and liquid status is being followed and tolerated as established and consistent with physician orders Adaptive equipment remains present and is utilized appropriately and residents are supported at appropriate level of care Resident positioning is conducive to support eating and feeding at highest level of independence at least restrictive diet Community Outpatient Therapy Determine if facility is conducive to providing community based outpatient therapy services Although no formal regulations are in place, check with the State Department of Health for procedural expectations such as: Clinic entrance and waiting area sufficiency Conflict with SNF resident rooms and common areas Access to emergency medical services Retention of medical records Access to treatment area and equipment Start by offering continuation services to Part A discharges 18
ADL Documentation Whether electronic or manual all facilities document on resident performance and how much staff support was needed to complete Activities of Daily Living If an electronic system is utilized, reports can be generated which will compare a resident s performance and support levels from one period of time to another in order to note functional declines, stabilization, or improvement A therapy screen should be completed whenever a functional decline or improvement is noted to determine if further therapy intervention is necessary Inservices Introduction to OT, PT, and SLP Personnel/Services Rehab Indicators and Referral Process Smart Mechanics/Safe Patient Handling Swallowing and Diet Modification Adaptive Equipment for Activities of Daily Living Dementia Capable Care and Environmental Modification Success Stories Questions & Answers MREILLY@POSTACUTECONSULTING.COM 401-742-4168 POSTACUTECONSULTING.COM 19