Special Challenges of Documenting SLP Services in the LTC Setting Janette Coleman, SLP Norma Jo Majerus, SLP Susan Meska, SLP Bill Goulding, SLP
Agenda Medical Necessity and Skilled Services Evaluations Progress Updates Documentation Auditing Special Challenges: Dementia Dysphagia Group Therapy Quick Regulatory Update
ADVOCATE One who pleads the cause of another
Patient??
There s s a big problem here
Communication Gap Payer Provider
The Communication Breakdown What Payers Need to Know: Why does the patient NEED intervention? Why does it have to be YOU providing it? What We Typically Document: PROCEDURES PERFORMANCE
The Communication Link! What Payers Need to Know: Why does the patient NEED intervention? Why does it have to be YOU providing it? Our Basic Clinical Reasoning Process: The patient had a change in function We feel we can do something about it
Who is the Payer??? Insurance companies which review documentation to determine if therapy services delivered met coverage guidelines. Primary Payers in LTC: Fiscal Intermediaries (FI) Medicare Administrative Contractors (MACs)
What you need to know about FIs/ MACs Reviewers need to easily determine if the medically necessary and skilled services criteria are met. Reviewers are usually not therapists. Claims need to be easily read and understood by a lay reader. It takes less time to pay a claim than to deny one.
What you need to know about FIs/ MACs They want to pay the claims we send in to them. They have efficiency measures they are responsible to meet. They ask us to paint us a picture that we can understand! Oh, and also to use legible writing PLEASE!
Top 3 Reasons for Denials/ Disputes/ Disallowances Failing to Justify: Medical Necessity Skilled Services Functional Progress WHY NOW? WHY YOU? SO WHAT?
Medical Necessity Skilled Services 2/3 to 3/4 1/3 to 1/4
Medical Necessity What has changed? What brought about the change? Will it resolve itself? How does this change affect the patient s everyday life? WHY NOW???
What Is Medical Necessity? It links the medical diagnosis to the change in the functioning abilities of the resident. It justifies the need for intervention. It define other co-morbidities which may impact treatment plan What and WHY?
Medical Necessity Skilled Services 2/3 to 3/4 1/3 to 1/4 Let s talk about that other head
Progress is NOT the King of Reimbursement "Where a valid expectation of improvement exists at the time the therapy program is instituted, the services would be covered even though the expectation may not be realized. However, in such situations the services would be covered only up to the time at which it would have been reasonable to conclude that the patient is not going to improve" In the end it s all about SKILLS!!!
Skilled Services What will you ANALYZE? What will you ADJUST? WHY YOU???
Skilled Analysis What is it?? Skilled analysis is the review of objective data gathered from the patient performance that is utilized to make determinations related to: patient safety patient functional ability patient ability to tolerate advancement in the treatment program patient response to hierarchical cueing strategies determining the most salient cues!
Ongoing Need for Skilled Services The need for skilled service is a strong determination of the duration. Medicare states: The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified therapist or under his supervision. (Medicare SNF Manual, HCFA Pub 12, Section 230.3, 3/80) Is the R.N.A. or C.N.A. able to carry out the FMP to a point that will sustain the pt s level?
Therefore: We need to make a significant shift in our mind set Our evaluations, re-certification forms, and progress update notes are primarily insurance claim forms, not therapy documentation forms!
Documenting Your Evaluation
Once Upon a Time... 1. What happened to the patient? 2. How does it impact their life? 3. What are their functional problems? 4. What is causing those problems? 5. What is your clinical vision for them and how will you know when you re there?
What and WHY? Evaluations Simply stating decline in function does not support the need for skilled therapy services. Report the change in objective, functional terms Identify specific swallowing, functional communication, or other changes Give specific timeframes
Functional Deficits / Performance Areas Observable problems (by almost anyone) Underlying Impairments / Performance Components CAUSES the Functional Deficit This is what is actually TREATED Only a Therapist sees/understands them!
Functional Deficits Auditory Comprehension Auditory Discrimination Cognitive- Linguistics Reading Comprehension Expressive Language Speech Production Swallowing Voice Written Expression
Examples: Cognitive Communication a. attention: sustained, selective, divided, alternating b. orientation: person, spatial, temporal, situation c. memory: restrospective, incidental, prospective d. sequencing: simple to complex e. problem solving: math, money, time, verbal/visual f. reasoning: deductive, inductive q. judgment/safety awareness h. executive function: initiation, organization, integration i. error awareness j. self-correction of errors
Examples (cont.): 4. Pragmatics a. initiation b. turn-taking c. topic maintenance d. interpretation of tone of voice, facial expression, gestures e. appropriateness 5. Reading Comprehension a. visual tracking b. matching forms, letters c. word-object-picture matching d. word/phrase comprehension e. sentence/paragraph comprehension f. multiple paragraph comprehension g. functional reading (schedule, phone book, directions, etc.)
Examples (cont.): Swallowing a. oral muscular strength, ROM, and coordination b. sensation: lips/oral cavity c. sensation: oral pharynx d. bolus manipulation (1). bolus formation (2). A-P propulsion of bolus (3). tolerates varied textures (4). tolerates hot/cold temperatures e. swallow response: reflexive, volitional f. appropriate posture g. airway protection
What is Clinical Reasoning The thought process that directs and guides treatment. The knowledge that underlies the process of providing treatment. The narrative process by which Therapists make sense of their perceptions of the patient and how therapy will impact the patient s future functioning.
How Does This Impact Goal Writing? Functional Goals: (OBRA) Why am I seeing this resident? How meaningful is this task to the resident outside of this therapy room? Who else sees / benefits from the impact of therapy on this resident s life?
How to Write Behavioral Objectives Components of the objectives need to include: Functional Outcomes. Participant. The observable behavior to be measured. The condition the behavior will occur in. The measurement of success. The timeline it will be completed by. See examples of each component identified below: To communicate wants and needs, John or patient Will name ADL objects Upon request, given 1 at a time, In 4/5 trials By 2/15/06.
Example Objective To increase the safety of oral intake, Joe will double swallow liquids when cued by staff in 4/5 trials by 5/1/06.
Designing Goals Types of Goals vs. Duration of Treatment -Goals focus on active pt. involvement --Longer durations of Tx -Goals focus on passive pt. involvement and/or on caregiver/ environment --Shorter durations of Tx Restoration Compensation Adaptation
Documenting Your Progress
And then... 1. What impact did you make? 2. Why do you think this occurred? 3. What remains to be done and why do you think it is possible?
Treatment Encounter Note The Treatment Encounter Note must include: Date of the treatment Name of the treatment, intervention, or activity provided Time spent in services represented by timed codes Total treatment time (including untimed codes) Signature & credential of the qualified professional providing the service
Treatment Encounter Note Recommended optional documentation that supports medical necessity: The skilled component of specific exercises/activities Patient self-report Adverse reaction to intervention Communication/consultation with other providers Significant, unusual or unexpected changes in clinical status Equipment ordered
Progress Report Provides justification for the medical necessity of treatment. Must be written at least once every 10 treatment days or once during the interval, whichever is less. An interval of treatment consists of 1 month or 30 calendar treatment days.
Progress Report Content of a progress report: Assessment of improvement, extent of progress (or lack thereof) toward each goal Plans for continuing treatment, reference to additional evaluations results, and/or treatment plan revisions
Soap Note Format: Documentation of Progress S = Subjective O = Objective A =Assessment P =Prognosis and Plan
S : Subjective Content S. The patient was alert, oriented, and attempted all tasks during treatment. Tolerance for therapeutic process was good. Therapist s observation and professional opinion. Can also have quotes from nursing, family, or resident regarding therapy.
O : Objective Content The resident was seen 5/5 treatment sessions to increase safe, adequate nutritional intake. Skilled interventions included: Choice of tasks; choice of oral motor exercises to increase bolus formation and manipulation; modeling; tactile and verbal cueing; positive reinforcement; modification of rate, amount, and placement of food. Criterion for all objectives was 80%. Results are as follows:
O : Objective Content (cont.) To increase safety of oral intake pt. will: 1. Alternate liquids/solids when cued by nursing. 2. Imitate tongue exercises given verbal/tactile cues. 3. Place utensil down between bites given tactile cue Previous Current 35% 55% 45% 60% 50% 66%
A : Analysis and Assessment The resident has increased the safety of oral intake as evidenced by decreased nasal drainage and coughing during meals. Pocketing in the R lateral sulcus has decreased w/ increased tongue strength, coordination and control in conjunction with lingual search. Cueing to reduce rate and amount of food placement has helped resident control the amount of food he has to deal with. Resident s vocal quality remains wet after swallow of thin liquids suggesting pooling in the hypopharynx. Requires continual verbal, visual, and tactile cueing. SLP has trained caregivers during therapy on cues to use when feeding. SLP has written and posted feeding guidelines for all nursing shifts to follow at meals. To date no advancement of diet is warranted.
P : Prognosis and Plan Continue to treat 5x/week following current plan of care. Additional compensatory strategies to follow include chin tuck during the swallow, double swallow on liquid intake, and thickening liquids to honey. Will attempt all next week. The skills of a SLP remain necessary to analyze, modify, and advance the program as the resident achieves mastery. Prognosis for continued gains is good due to resident tolerance for treatment, stimulability to cues, and progress to date.
Reporting Progress for Longer Periods
And They Lived Happily Ever After... 1. What is your ongoing clinical vision for them and how will you know when you re there? 2. What remains to be done and why do you think it is possible? 3. Why could only YOU have brought the changes about? 4. What impact did you make?
Discharge Note A discharge note is required at the end of the plan of care. It shall be an interval note covering the period from the last interval note to the date of discharge. Not required for unexpected discontinuation It may include additional information that summarizes the entire episode of treatment or justifies treatment that may have extended beyond those usually expected for the patient s condition.
Essential Components of Documentation D/C Note Functional Maintenance Programs: What is the level of resident functioning at the time of discharge? Has an FMP been developed and trained to nursing/family? Do the caregivers demonstrate competency with carryover of the program? Has a re-screen been scheduled?
Auditing Documentation 1. Compliance 2. Quality
Two-Pronged Approach Monitor for Compliance Large % of claims, if not all claims Focus on yes/no regulatory (CMS) issues Monitor for Quality Smaller, selected sample of claims Focus on Medical Necessity & Skilled Services
Compliance Audit: Elements to Consider for Inclusion Physician's Orders (timely, correspond to Plan) Physician Certification (90 days - Part B, 30 days - Part A) Evaluations: No blanks Patient demographics are accurate Onset date is correct Primary diagnosis/ Treatment diagnos(e)s and ICD-9 codes correct & related to one another Informed consent indicated Objective, measurable difference in function (PLOF vs CLOF) evident Service dates accurate STGs and LTGs identified along with Plan (frequency/ intensity/ duration)
Compliance Audit: Elements to Consider for Inclusion Daily Encounter Notes: Date of the patient visit; Identification of each specific intervention/modality provided with times and described in language that can be compared with the billing on the claim to verify correct coding. Total visit time: This includes all time spent providing direct service to the patient. Signature and professional identification of the qualified professional who furnished the services.
Compliance Audit: Elements to Consider for Inclusion Progress Updates: At least every 10 Tx days (Part B) Goals updated Documentation filed in Medical Record in timely manner Care Plan completed Dysphagia Medical Work Up form completed (if appropriate)
Quality Audit
Quality Audit
Dementia How to document Medical Necessity and Skilled Services related to Dementia treatments
Dementia: Medical Necessity Why is treatment necessary at this time? What changes have occurred in the course of the patient s disease process? Is there a likelihood for further decline without skilled intervention? What is the risk to patient if therapy is not provided at this time?
ICD-9 Codes - Dementia Symbolic Dysfunction (apraxia, agnosia, acalculia, agraphia) 784.60 Other symbolic dysfunction (unspecified) 784.69 Alzheimer s Disease 331.0 Alcoholic Dementia 291.2 Head Injury 959.01 Huntington's Chorea 333.4 Parkinson s Disease 332.0
Potential Evaluation Tools for Dementia Ross Information Processing- Geriatric (RIPA-G) Functional Linguistic Communication Inventory (FLCI) Arizona Battery for Communication Disorders (ABCD) Claudia Allen Resources (904)-673-4925
Dementia: Medical Necessity Example Resident is losing weight and unable to complete more than 50% of the meal due to short attention span and distractibility and is not currently functioning at highest optimal level. Skilled ST services are required in order to determine the resident s optimal functional level and to establish an FMP. Without skilled intervention, resident is at risk for continued weight loss along with rapid functional deterioration and potential social isolation. Nursing has indicated that resident is showing increased frustration secondary to the decreased ability to effectively communicate wants and needs. Skilled ST services are indicated to assess cognitive/communication skills and to provide caregiver training on how to facilitate optimal function.
Dementia: Elements of initial assessment supporting skilled services Identification of underlying impairments specific to dementia Identification of the adjustments, adaptations, changes, variations that are made to the task, resident, environment, assistance level or the way caregivers interact with the resident. Objective measures of underlying impairments with baseline data Goals written which are specific, measurable and with a time frame
Example: Pt. able to respond to 1-step commands w/ 70%; Y/N accuracy at 65%. Uses verbal and referential communication of body lang, gestures and vocal prosody to convey meaning-staff not picking up on these cues. Sustained attention at 60 sec. Can maintain sustained attention for 2 min for personally relevant tasks. Able to I.D. environ. signs with 67%. Becomes overwhelmed with multi- food items and ceases meal. Staff interpreting as meal completion.
Possible Goals for Dementia (a few examples) Will (explain/follow) safety strategies for ADL with (1-100%) acc. W/ (cueing strategies) Will learn effective use of a memory book to compensate for residual memory with (1-100%) acc. Will distinguish between familiar self-care objects by size, shape, color w/ 75% acc. W/in 3 weeks, communicate basic needs to staff effectively 80% of time using verbal/referential communication w/ staff awareness of referential indicators of communicative intent.
Dementia: Ongoing documentation of medical necessity and skilled service Description of risks to patient if treatment not provided at this time Gap between current status and LTG Prognosis for continued improvements Analysis and Adjustments made as course of treatment Description of education provided to patient and caregivers
Example: An FMP was established for communication and oral intake w/ consistent performance noted. Staff in-serviced on communication strategies (volume variation, gestures, facial expressions, vocal inflection). As a result decreased episodes of agitated responses and striking out at others has been noted. Pt. now communicating w/ staff 90% of time w/o agitation or withdrawal. Meal modification was provided in accordance with resident ability and task vigilance. Resident now able to express personal choice for clothing selection, activity participation and meal options.
Dysphagia How to document Medical Necessity and Skilled Services related to Dyphagia treatments
Dysphagia: Medical Necessity All relevant diagnoses that contribute to functional changes in swallowing; including new diagnosis from recent hospitalization (as appropriate) as possible cause Recent instrumental assessment or medical work-up which identifies the phase(s) of swallow impacted Risks to patient if therapy is not provided at this time Prognostic statement specific to swallowing
Why do we need an instrumental assessment? Appropriate selection of ICD-9 code for billing to validate phase of swallow To guide treatment through validation of physiology of swallow and structural changes which impact effectiveness of swallow To determine effectiveness of compensatory strategies to allow least restrictive diet consistency
ICD-9 Codes Dysphagia 787.21; oral phase only from bedside assessment 787.22; oropharyngeal phase per instrumental assessment 787.23; pharyngeal phase per instrumental assessment 787.24; pharyngoesophageal phase per instrumental assessment 787.29; suspect phase beyond oral phase with neurologic or cervical origin but not validated through instrumental assessment 787.20; suspect phase beyond oral phase but not validated through instrumental assessment (for conditions other than neurologic or cervical origin)
Dysphagia: Medical Necessity Example Patient is 85 year old female with recent hospitalization for exacerbation of COPD and respiratory distress. PMH includes aspiration pneumonia, HTN and mild dementia. Patient was referred by nursing staff due to noted coughing with liquids and poor appetite/refusal to eat. Per MBS completed during this hospitalization, there is evidence of penetration but absence of frank aspiration. Patient has very low endurance and shortness of breath during intake. Patient is at risk for weight low, dehydration and possible aspiration. Prognosis is good given patient s stated motivation to continue regular diet and effectiveness of swallow compensations noted during MBS.
Dysphagia: Elements of initial assessment supporting skilled services Identification of underlying impairments specific to swallowing Objective measures of underlying impairments with baseline data Goals written which are specific, measurable and with a time frame
Example: Moderate oropharyngeal dysphagia with impaired coordination of respiration/swallow evidenced by change in respiration rate after swallow (from 18 bpm to 26 bpm) requiring 3 minutes to recover; drop in oxygen saturation by 5% immediately after swallow of liquids; impaired strength of jaw and reduced bolus formation evidenced by increased mastication time (up to 2 minutes) with regular consistency, so on Goal: Within 2 weeks, patient will use superglottic swallow to facilitate airway protection in 3/5 trials in order to maintain respiration rate to 18-20 bpm during intake.
Dysphagia: Ongoing documentation of medical necessity and skilled service Description of risks to patient if treatment not provided at this time Gap between current status and LTG Prognosis for continued improvements Analysis and Adjustments made as course of treatment Description of education provided to patient and caregivers
Example: Patient has made good gains in coordination of swallow respiration mechanisms allowing for improved airway protection. Diet texture was modified to mechanical soft as an interim measure to allow maximum caloric intake until endurance and strength can be impacted through graded resistive exercises and effective use of energy conservation techniques with mealtime. Nursing staff have been instructed to transport patient to meals to conserve energy and provide written cue card with supraglottic swallow technique to patient prior to meal. Patient has demonstrated understanding and appropriate demonstration of swallow compensation with written cue only but she does not always remember to bring her cue card to the meal table. Patient remains dependent on staff for set up of cues at mealtime and would be unable to safety continue oral intake of advanced textures without intervention. Patient is compliant with current modified diet but expresses desire to continue therapy to advance to regular texture again and wanting to get stronger. Prognosis is good for continued improvements given stated motivation and staff support. Patient remains at risk for weight loss and aspiration.
Group Therapy How to Document Group Treatments
Group Therapy Consists of 2-4 residents per therapist. All residents are usually doing the same or parts of a related activity under the direction and supervision of a therapist. These are under an order of a physician.
Group Therapy Settings; We need to consider that: Patients are often more motivated to address their deficits when they realize their peers are supportive and empathetic. Groups require documentation of both the content of treatment and its results when provided in this format. It should also describe the pt s. response.
Successful Group Therapy Demonstrates: Group Dynamics-that change constantly as residents learn from each other. Group Cohesion-that sense of belonging and of being supported and accepted by others in the group. This is very motivating to group members. A natural learning environment that is different from the controlled one on one setting inclusive of noise, unexpected stimulation, and unpredictable events while the resident practices the skills they are being trained in.
Group documentation needs to indicate What type of group the resident was involved in. How many times they were seen in a group setting. Why was the resident seen within a group setting. What was the resident s response to the group
Example: During the stated treatments, John was seen in one cognitive linguistic group session to reinforce his ability to problem solve within a more challenging environment. Focus of the group was to identify the best solution to the problems given through determination of possible solutions and then pros and cons discussed by the group participants. Initially John was able to only elaborate upon possible solutions generated by other participants. By the end of the session, John gained confidence and was able to initiate a probable solution to a problem stated and generated a pro and a con to the solution he offered.
Example Gwen was treated in one communication group to increase intelligibility and carryover during conversation with peers. During the discussion of planning a holiday party, Gwen lead the group utilizing her compensatory strategies of using fewer syllables per breath, decreased rate, and exaggerated articulation of all phonemes which resulted in her peers requesting repetition of her utterances only 3 times during that session.
Example Ron was seen in one communication group to increase turn taking during communication. When cued, Ron was able to initiate a topic and then follow up with an appropriate statement. However, group dynamics limited his ability to attend to the task to a moderate degree.
Quick Update on Regulatory Changes 1. MDS 3.0 2. MACs 3. VBP - Payment for Services
MDS 3.0
Blah Blah
Blah
Are Residents Able To Respond? Blah
Blah Blah
The MAC Process How Medicare Administrative Contractors (MACs) will replace Fiscal Intermediaries (FIs) & How it might impact you!!!
15 A/B MAC Jurisdictions MAC Awards as of 9-12-08 2 - NHIC 3 - Noridian 6 13 NGS 14 8 1 - Palmetto 5 - WPS 15 12 -Highmark 2 - NHIC 4 - Trailblazer 11 10 7 Pinn acle 9 - FCSO 1 - Palmetto
Timelines J3 Noridian in effect as of Spring 2007 J4 Trailblazer in effect as of Spring 2008 J5 WPS in effect as of 6/08 J12 Highmark in effect as of 12/08 at latest J1 Palmetto in effect as of 10/08 at latest J13 NGS in effect as of 11/08 at latest J2 NHIC in effect as of 12/31/08 at latest J7 Pinnacle in effect as of 2/09 at latest J9 First Coast in effect by 3/09 at latest J 6, 8, 10, 11, 14, 15 Scheduled to be awarded 9/08, effective Fall 2009
Payment Reform - Mounting Pressure to Use Objective Measures Value-Based Purchasing (VBP) 12/29/06 Transmittal 63: Documentation required to indicate objective, measurable beneficiary physical functioning. Asked for functional assessment scores from commercially-available instruments or tests and measures validated in professional literature.
CMS Develops 2-Pronged Approach Short-Term: Short-Term Alternative for Therapy Services (STATS) Develop a bridge payment system between when Tx Caps Exception Process expires (12/31/09) and long-term tool is ready (2013 at earliest). Long-Term: Developing Outpatient Therapy Payment Alternative (DOTPA) ID, collect and analyze therapy-related information tied to beneficiary need and treatment effectiveness. Piloting uniform assessment tool for Post Acute Care (PAC) called CARE (Continuity Assessment Record & Evaluation).
ADVOCATE One who pleads the cause of another
ADVOCATE Giving Voice to the Voiceless
No job is finished until the paperwork is done!