documenting rehab services for a medicare reviewer for referral must be comprehensive and complete...

Documenting Rehab Services

For a Medicare Reviewer

Jaclyn Warshauer, PT

LeadingAge Missouri 9/27/2012

2

Practice Settings

The basic concept of documenting medical

necessity and skilled services transcends

all therapy disciplines and all practice

settings

This presentation will focus on what a

medical reviewer will look for in

documentation regardless of setting

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Objectives

Understand the medical review process

Learn the key pieces of documentation

that “sell” the reviewer

Understand the pros and cons of

electronic documentation

The Importance of Good

Medical Records

5

Why Document Well??

Documenting is part of providing care – it’s

not optional

Necessary tool for tracking success and

making treatment modifications when

indicated

Expectation from regulators, payors and

patients in order to get paid

Used to defend our care

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Why Document Well??

According to the GAO, for fiscal year 2010, HHS reported an estimate of almost $48 billion in Medicare improper payments

Causes cited include inadequate documentation, medically unnecessary services, coding errors

GAO recommendations:

Improve (expand) prepayment reviews

Develop a “robust” process to identify vulnerabilities

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Why Document Well??

The health care reform law provides $350

million to fight fraud, waste, and abuse

new provisions that provide for enhanced

electronic data collection, screening, and

mining designed to aid in identifying problem

areas and problem providers

The Scoop on Medical

Reviewers

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Medical Reviewers

Vast majority are nurses

Reviewers have productivity requirements

To PAY a claim is a simple 2-step process

To DENY a claim is a time consuming

multiple step process

Reviewers are audited too

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Productivity

How you can help

Document payable services

Quality, not Quantity Clear, concise, objective, measurable,

functional and legible

Paint the complexity of the patient’s condition

Describe the complex nature of the treatment

provided

Assessment of the patient/activity and the

treatment adjustments made

Medical Review Selection

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Medical Review Cannot Look

at Every Record

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Medical Review (MR) Selection

Providers may be selected for MR when

Atypical billing patterns are identified

Data Mining (looking for Outliers)

A particular kind of problem is identified

Such as errors in billing a specific service

Evaluation of other information, such as OIG

work plan, CERT error rate reports, RAC

vulnerabilities, GAO reports

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Physical Therapy: Length of Service

Jan - Mar 2011 (example)

18.0

16.0

20.0

36.3

12.8

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

State Avg Provider 1 Provider 2 Provider 3 Provider 4

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Don’t be an Outlier

Do not to fall into treatment/documentation

patterns of:

ICD-9 Codes

CPT Codes

RUG levels

Frequency

Duration

UNIQUE

PATIENT

INDIVIDUALIZED

PLAN OF CARE

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If you are an outlier…

Recognize when you might be an outlier

There are valid reasons to be an outlier

Be diligent in your documentation

If identified as an outlier and/or on probe

review:

EXTRA diligent in documentation

All payment decisions are made based on the

documentation, and the documentation alone

Documentation -

Selling the Reviewer

A few quick points…

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Documentation

Insurance coverage determinations are

made based on the documentation, and

the documentation alone

The reviewer knows nothing else about the

patient or the quality of your facility

The documentation is used to determine if

the patient’s condition and level of function

required the special knowledge and skills

of a therapist

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Documentation – Paint a Picture

The therapist knows the

patient and any

complications in

physical, cognitive,

emotional,

psychological, and

social situations that

might affect their need

for skilled therapy

services

Documentation should

draw a picture of the

patient complexity for

medical reviewers

Documentation should

also paint a picture of

the sophisticated

nature of the

treatment provided

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The Reviewer’s Thoughts

“Make it easy for me to pay this.”

Avoid making the reviewer search to

determine if the services are medically

necessary

Risks some important piece of information

being missed

Risks findings of inconsistencies in the

documentation = denials

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Documentation Points

Today’s training will focus on some of the

key elements in the evaluation and

progress reports that assist the reviewer in

making medical necessity and skilled

services coverage decisions

Not an all inclusive listing of all elements that

should be part of these therapy reports

Initial Evaluation

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Documentation

It’s all about the Initial Evaluation!

The initial evaluation sets the stage for all subsequent therapy services

Reviewers will begin to anticipate how much therapy might be needed for the condition described

Poor or scant evaluation documentation risks that ALL subsequent therapy services will be denied

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Initial Evaluation

Descriptive

Must have some sentences/short paragraphs

Makes it a “real” patient for the reviewer

Avoid using check boxes/drop down boxes for

describing the Reason for Referral, Recent

History, and any Assessment Summaries

Narrative description describing the unique patient

history and condition is preferred

Connect the dots for the reviewer

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Initial Evaluation

Complex

Describe the complex nature of the patient’s

condition

Where not obvious describe the impact the

complexities will have on the plan of treatment

Complexity = Amount of therapy

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Initial Evaluation

Logical

Must make the reviewer think, “Oh, I can see

why this patient requires therapy now.”

Logical flow from the reason for referral, to the

examination findings/scores, to the selected

treatment interventions, and the subsequent

goals

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Reason for Referral What Changed and Why

Describe the change in condition

Include the mechanism of injury or cause for the

change in condition

Reason for Referral must be comprehensive and

complete

Paint the picture for “Why Now”

Must be more than one sentence/phrase – should

tell the patient’s story

In many cases the reviewer should only have to read

the Reason for Referral to begin to conclude that

therapy is medically necessary

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Reason for Referral Examples

Avoid: “Physician Referral.”

Avoid: “Recent hospitalization. Now

requires OT to regain function.”

Avoid: “SLP necessary to regain PLOF.”

Avoid: “Patient with decline in mobility

function. Would benefit from skilled PT.”

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Reason for Referral Example

(Fracture) Patient is a 66 yo male who suffered a tibial fracture on 5/1/11 as a result of a fall down the stairs. The patient now presents to therapy with chief complaints of pain, stiffness, and weakness, and impaired ability to perform walking without a significant limp or at a normal speed, especially on uneven surfaces, occasionally requiring use of a single crutch. Patient requires a brace during ambulation. Therapy is necessary to regain PLOF of safe ambulation without a brace or crutch, and without significant deviations.

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(Positioning) Pt is an 85 yo female resident of the SNF

who presents with increasing tone and contractures in

the right UE as a result of a previous CVA. Patient has

been on a restorative program. Nursing notes

increased positioning and ROM difficulties in the past

month which have resulted in difficulty achieving

adequate ROM in R UE for completing hygiene and an

increased concern for skin breakdown. Nursing

reports increasing frequency of PROM without

success. The patient is now being referred to therapy

to address positioning and ROM necessary for

hygiene and skin integrity.

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(Functional Decline) Patient is a 73 year old female who presents with a decline in ability to dress, print and manipulate small items due to increased tremors, contracture of bilateral hands due to RA and poor ROM in left shoulder due to old MVA. The patient started noticing a decline approximately 1 month ago which has since resulted in the patient now requiring significantly more assistance for the completion of writing during bill pay, manipulating coins in hand during purchases and UB dressing. Due to co-morbidities, this patient will require the skilled intervention of a therapist in order to regain the lost function. Patient will also benefit from comprehensive HEP to maintain joint mobility, strength and overall function following D/C.

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(Speech) Patient is a 93 year old female who

presents with a recent decline in abilities to

make wants and needs known due to severe

hearing impairment. Six months ago, the patient

was able to communicate wants and needs

effectively, but the patient since has had

difficulty with such things as making

independent choices during ADLs and

conversing with peers. Speech therapy and

aural rehabilitation is necessary to allow for

improved functional communication.

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(SAH) 70 yo resident admitted to SNF following hospitalization for Subarachnoid hemorrhage for which she was treated surgically by aneurysm clipping. Post operatively she began to develop left sided weakness and facial droop. Cognitively, pt. is noted to have deficits of organization, recall, expressive language and articulation. Due to oral leakage, stasis, coughing, decreased lingual function and range of motion, pt. is currently NPO because it was felt that she could not get enough nourishment PO. A PEG tube is currently in place. SLP necessary to regain safe swallow and communication abilities to return home with husband.

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Medical History

List the medical conditions and

complexities that are current and may

potentially have an impact on the therapy

plan of treatment

Listing every medical condition that patient

has ever had risks the reviewer not looking at

any of the conditions

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Measuring Function

Document a Current Level of Function (LOF) measure for each functional deficit that you will be addressing in therapy Baseline from which to measure progress

Must also document a Prior LOF measure for each functional deficit addressed in therapy Reference for establishing appropriate LTGs

Used to determine the patient’s potential

Also include the overall PLOF such as “lived at home alone, drives, does yardwork…”, “resident of SNF…”, “Lived in ALF with 1 meal a day and once a week cleaning…”

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Measuring Function

If there is little or no difference between

PLOF and CLOF provide written

justification for why therapy is medically

necessary

(Reviewers love objective measures!)

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Why can’t I walk/talk/dress like before?

Underlying Impairments

A reviewer wants to know the answer to this question as well

The answer is in the Underlying Impairments

Need to measure every Underlying Impairment impacting the patient’s function that will be addressed in the plan of care Be thorough in your assessment

This is the Therapist’s bread & butter – this is what we get paid to treat

You can’t treat it if you didn’t measure or objectively describe it


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Standardized Measurement Tools

Use standardized measurement tools when

possible

Tinetti, Berg Balance, DASH, Oswestry, Peabody,

NOMS, etc

Be sure to describe the value of the score for

the reviewer

ACL: 4.2 Moderate cognitive impairment

Borg: 5 Severe breathlessness

Berg: 39/56 Medium fall risk

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What the reviewer is thinking so far…

The diagnoses, the medical history, and the reason

for referral suggest that this patient requires

therapy

Measurable change in function

that likely will not resolve on its own

The amount and type of impairments described are

consistent with the level of functional deficit

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Plan of Care

Goals

Frequency & duration

Interventions

Logical plan of care based on the evaluation findings

The reviewer already has an idea of what your POC will be based upon your evaluation…there should be no surprises

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Goals

Goals are part of the medical necessity

picture

All goals must be objective, measurable

and related to function

All goals should have a baseline measure

within the evaluation

Measured functional deficit – Measured

underlying impairment


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Interventions

Can’t treat it if you didn’t measure it

No skilled pain assessment/description ≠ pain

modalities

No skilled cognitive assessment ≠ no

cognitive training

Can’t treat it if it’s WFL or WNL

Strength is WFL ≠ no strengthening ther ex

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Rehabilitation Prognosis

Provide a prognosis and include a “due to” statement

Prognosis should be written related to the likelihood of achieving the therapy LTGs

“Prognosis for achieving goal is good due to recent PLOF of independent and motivation to regain independence.”

Rarely should prognosis be “poor”

Either the goals are not appropriate or no longer appropriate and should be adjusted, or the patient should be discharged

Progress Notes:

Supporting Coverage for

Ongoing Therapy

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Coverage

Two factors mainly affect reimbursement

decisions – medical necessity and skilled

services

Inadequate documentation of medical

necessity and/or skilled services risks denial

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Medical Necessity

WHY NOW?

Complex change in condition that

necessitates your skilled therapy

intervention

Functional Deficits related to Underlying

Impairments that fall within your Scope of

Practice

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Skilled Services

WHY YOU?

Your skilled assessment, analysis,

adjustments, progressions and special

techniques that are necessary for this

patient to regain function (or to develop a

maintenance program)

The activities that only the therapist has the

knowledge to provide

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Coverage

Complex Patient

Condition

Sophisticated Therapy

Treatment

Skilled Therapy

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Skilled Therapy

Alleviating impairments and functional

limitations as determined by the

evaluation through...

designing,

implementing, and

modifying therapeutic interventions

Medicare pays for therapist’s brains,

not just hands!

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Skilled Therapy

The services must be so inherently

complex that they can only be safely and

effectively performed by a

therapist/assistant

Services that can be performed by or taught

to non-skilled persons or can be completed as

an independent program are NOT skilled

therapy

Non-skilled: the patient, personal trainer, CNA,

spouse, caregiver, aide, tech, etc

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Skilled Therapy

THERAPIST

Assessment

Analysis

Adjustments

Progressions

Modifications

Special techniques

ASSISTANT

Adjustments

Progressions

Special techniques

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Skilled Therapy?

Skilled Services Provided:

US

Ther Ex

NMR

Ther Act

Self Care Training

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Skilled Therapy?

Monday Wednesday Friday

Amb w/ ww 40’

min assist

Amb w/ ww 65’

min assist

Amb w/ ww 70’

CGA

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Skilled Therapy?

6/15 6/17 6/19

Codmans x 25

Pulley 10 x 2

AROM FL 10 x 2

AROM ABD 10 x2

ER/IR 10 x 2

Codmans x 25

Pulley 15 x 2

AROM FL 10 x 2

AROM ABD 10 x2

ER/IR 15 x 2

Codmans x 25

Pulley 20 x 2

AROM FL 10 x 2

AROM ABD 10 x2

ER/IR 15 x 2

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The Quick Hit Denial

Repetitive

Services

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Skilled Services Easy Denial

Reviewers expect to see

documentation of adjustments,

progressions and/or

modifications to your treatment interventions

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Bottom Line:

Description of your skilled analyses,

adjustments and progressions MUST be

documented

Assistants – except the “analysis piece”

Skilled treatment requires more documentation than just “ther ex” or “therapeutic activities”

Progress Notes

WHY IS THERAPY STILL

TREATING?

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Why do we do Progress Notes?

Justification for treatment…

1. Provide an update on the patient’s status

1. Function

2. Underlying impairments

3. Goals

2. Describe the skilled services that have been

provided

3. Indentify the areas that will be addressed in the

upcoming week(s) to substantiate the need for

ongoing skilled intervention

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Time Continuum for Progress Notes

Goals

Current

Status Toward

Each Goal

Previous Report

Skilled Services

Provided Since Previous

Report to Achieve the

Progress Toward Goals

Impairments to be Addressed

in Upcoming Weeks

to Facilitate Further


1 2 3

Goal Status Update

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Goals

Goal Prior Week

Level

Current Week

Level

Be sure to address all aspects of goals Each function addressed

Any underlying impairments

Don’t change the measurement scale mid-stream

Avoid not measuring a goal If unable to measure, give rationale for deferral

Recognize when a STG is met as stated Indicate GOAL MET

Upgrade, Discontinue, or add new goals as appropriate

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Medical Necessity: Progress Toward Goals

According to CMS:

There must be an expectation that the patient’s

condition will improve significantly in a

reasonable (and generally predictable) period

of time, or the services must be necessary for

the establishment of a safe and effective

maintenance program required in connection

with a specific disease state

The plan should strive to provide treatment in

the most efficient and effective manner,

balancing the best achievable outcome

with the appropriate resources

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Analyze, Modify & Justify Document the reasons for the delay in progress

Document measures taken to improve response

to treatment

Document why a positive response is expected

in the future

slow gains decline lack of gains

Documenting

Skilled Services Provided

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Avoid the Litany of Services

AVOID: Listing of CPT descriptors

“Ther Ex, Ther Act, NMR, Diathermy”

AVOID: Listing of general treatment interventions

“ADLs, strengthening, balance, endurance, adaptive equipment training”

AVOID: Combination of the two

“Ther Ex for strengthening, Ther Act for transfers, NMR for balance, Diathermy for pain”

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Skilled Services since Last Report

Provide a summary of ALL adjustments,

progressions, modifications and special

techniques provided since the last report

Need to “prove” to the reviewer that the

services are not repetitive

What did you do different this report period

than the last report period?

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Skilled Services since Last Report

A statement or summary to justify the skilled nature of each CPT code billed since the last report

Not TASKS…but Adjustments, Progressions and Special Techniques

“Strengthening ex’s progressed to…”

“Balance activities advanced from __ to __...”

“Manual cues necessary during left LE stance to facilitate effective weight shift

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Skilled Services Note

Therapist or Assistant

Progression of hip/glut strengthening ex’s

to now include weighted resistance;

progression of standing balance activities

from bilat support to unilat support; pre-

gait/balance activities that facilitate

unilateral LE standing, wt shifting,

clearance and step length. Required

manual cues to control movement of RLE

in swing phase of gait.”

97110, 97112, 97116

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Skilled Services Note Therapist or Assistant

Manual therapy to reduce edema prior to

ther ex. Edema clearing in a shorter

amount of time. Able to increase motion

and stretch duration with prolonged stretch

to thumb flexors and fingers. Fine motor

coordination training advanced to include

smaller objects as pincer grasp improves.

Progressed HEP program to add nerf ball

squeezes for grip strength and ROM.

97140, 97110, 97112

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Skilled Services

Design of strategies to enhance swallow

endurance over the course of a meal.

Introduced the use of an "effortful" swallow

with the cue to "feel the squeeze!". This

technique is designed to enhance bolus

propulsion and conservation of energy needed

for repetitive swallows over the course of a

meal. Implemented respiration coordination

strategies through the use of an incentive

spirometer to increase breath support.

92526

Patient/Caregiver Training

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Patient/Caregiver Training

Reviewers like to see that you are involving the patients/caregivers in their care Demonstrates efficiency

Shows that you’re not using therapy time for unskilled activities

Talk about any training done – even if it’s very simple Discussed sitting posture to reduce back pain

Instructed in Ankle Pump exercise when sitting

Transition any ex’s that have become repetitive – no longer need skilled intervention Again, shows that you’re only using therapy time for those

activities that require skill

Document any updates or revisions to any previous instructions

Remaining Functional

Deficits

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Remaining Functional Deficits/


Be sure to MEASURE the functional

deficits and underlying impairments that

you are currently treating or will be treating

Measures are needed to support the medical

necessity of the specific interventions used

WHAT’S MISSING??

“Patient has the following remaining

impairments impacting function: dec’d

strength to all extremities, dec’d balance

and decreased endurance.”

(Reviewers Love Objective Measures!!)

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Remaining Functional Deficits/


Document occasionally to answer the

question

“Why can’t this patient continue to improve on

their own or with the help of a

caregiver/restorative aide program?”

What remains so complex about this patient?

Why are YOU still treating????

Medicare Manual Medical

Review: A Few Progress

Note Points…

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Medicare Manual Medical Review

CMS is implementing an exceptions

process for beneficiaries that exceed

the $3700 therapy threshold

$3700 for OT ; $3700 for PT-SLP Combined

The Medicare FI/MAC will conduct

manual medical review of therapy

documentation to determine if an

exception will be granted

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Extended Length of Stay

Supporting medical necessity as the patient

progresses through treatment becomes more

challenging

Balance between making progress and still

continuing to be complex

Documentation should demonstrate significant

meaningful and practical progress in a reasonable

period of time

Documentation needs to describe what remains

complex (through objective terms) about the patient

such that their care requires your level of skill

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Extended Length of Stay

Supporting skilled services as the patient

progresses through treatment also becomes

more challenging

Need to clearly show that the services are not

“repetitive”

Need to show that the techniques remain complex

or the patient requires constant analysis and

adjustments

Reviewers are very focused on skilled services

when auditing the longer episodes of care

Remember that Quick Hit Denial for repetitive services?

Electronic Documentation

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Cons

The documentation is still only as good as the therapist making the entries Even with controls for “required” fields and

electronic mapping, need to do internal documentation audits

Difficult for the reviewer to obtain a unique picture of the patient (Significant con!) Feels like there’s just a bunch of dots on the page

and nothing is connected

Some documentation programs carry over entries from the previous days Denial risk

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Pros

LEGIBLE!

You can control the fields that are required

Allows for starter phrases or controlled entries using

language suggestive of medical necessity or skilled

services

Make use of the narrative entry areas! Show the individuality

of the patient’s condition and their plan of care

Reports and alerts for missing or incomplete

documentation

Can be accessed from a distance

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CONTACT INFORMATION:

Jaclyn Warshauer, PT

[email protected]

documenting rehab services for a medicare reviewer for referral must be comprehensive and complete...

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