welcome and thank you for joining us today!

Welcome and Thank You for Joining Us Today!

Some reminders about the functions of today’s phone/webcast presentation: This is a RECORDED PRESENTATION of the “Changes in Physical

Therapy Documentation” webcast with Nita Barchus, P.T. For the phone bridge, there are functions available to ALL callers: On your phone, press *2 to raise your hand to ask a question The phone bridge is in Q&A Mode - All guests are muted (guests MUST press

*7 to talk) The text chat room will be disabled during the LIVE Q & A session. You are

encouraged to submit your text questions using the link on the webcast page in the upper left corner.

During the live Q & A session we are assuming that all callers have completed listening to the recorded webcast. You are welcome to email Nita directly with your comments, suggestions for future sessions and questions at [email protected]

Copies of today’s slides are available to download directly from the link provided on the webcast page.

PLEASE TAKE THE TEST BEFORE THE SURVEY AND WAIT UNTIL THE END OF THE PRESENTATION!

CHANGES IN PHYSICAL THERAPY DOCUMENTATIONNita Barchus, P.T.MEG Associates Consulting Group, Inc.

Changes in Physical Therapy Documentation

OBJECTIVES Explain the essential components of

therapy documentation for reimbursement

State what to include in reassessments Demonstrate how to document for a

nurse reviewer if you are a therapist Perform an appropriate therapy

documentation review if you are a nurse

Changes in Physical Therapy Documentation

OUTLINE

Essential components for reimbursement OASIS Therapy Evaluation Revisit Notes Reassessments DC Summary

How to review therapy documentation if you are a nurse

Q and A

Essential Components for Reimbursement


The Basic Requirement has not changed:

Treatment must be Reasonable, Necessary, and Require the Skills of a Therapist


How does Medicare determine whether therapy treatment is reasonable and

necessary?


OASIS The Start of Care OASIS is the place to begin

documenting that therapy treatment is reasonable and necessary

This is the first information Medicare receives from your agency about the patient

Whether completed by a nurse or a therapist it must show that therapy is reasonable and necessary


OASIS• M1020 Diagnoses

List must include one or more diagnoses to explain why the patient is receiving therapy

• M1800s ADLs and IADLsShould indicate that assistance is required – if the patient is independent in all, then he/she probably does not need therapy


OASIS M1800s (cont’d)

Answers must be consistent with the therapist(s) evaluations - Interdisciplinary communication will be required between the nurse and therapists

There is often a discrepancy between the nurse’s answer to M1860 Ambulation/Locomotion and the physical therapist’s evaluation


OASIS

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.

0 – Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).

1 – With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.

2 – Requires use of a two-handed device (e.g. walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

3 – Able to walk only with the supervision or assistance of another person at all times.

4 – Chairfast, unable to ambulate but is able to wheel self independently.

5 – Chairfast, unable to ambulate and is unable to wheel self.6 – Bedfast, unable to ambulate or be up in a chair.


OASIS

M1900s Prior Level of Function ADL/IADL and Fall Risk If PLOF was dependent with ADLs and

IADLs, the therapist(s) must be careful to set realistic goals, and must include caregiver training

Essential Components for Reimbursement:

Therapy Evaluation


Therapy Evaluation

Must document functional limitations (such as assistance required/ safety concerns with bed mobility, transfers, gait, stairs, dressing tasks, making needs known, swallow)

Remember: This will be reviewed by a nurse; so functional limitations, treatment plan, goals must all be to written so that it is apparent to a nurse that PT/ OT/ ST is reasonable and necessary


Therapy Evaluation

Must list functional goals Examples:

The patient will transfer from the bed to the BSC with SBA in 2 weeks

The patient’s balance will improve to low fall risk, as evidenced by an improvement in the Tinnetti score to >24 points

The patient will perform upper body dressing with min assist


Therapy Evaluation

Plan of care It is often appropriate to frontload visits to

address the home environment in terms of fall risk factors, medical equipment needs, patient and family education and training for safety


Revisit Notes


Revisit Notes

• This is where skilled care is documented• Every note must indicate that skilled care was

provided, or the visit is not billable:-Treatment plan should be adjusted every visit

-Any set-back should be explained

-Treatment should address functional limitations, not only therapeutic exercise

-Training should be documented for gait and transfers


Revisit Notes

• Steady progress toward functional goals must be documented

• Interdisciplinary communication should be documented


Therapy Reassessments



Reassessments are required at the 13th visit, the 19th visit, and at least every 30 days. (If more than one therapy discipline is seeing the patient, each must reassess close to and before the 13th and 19th visits)

The purpose of reassessments is to justify continued billing!



Medicare says each therapy discipline must “functionally reassess the patient and compare the resultant measurement to prior measurements” Re-stating the functional goals and

addressing progress, or lack of progress, toward each satisfies the requirement

Objective measurements may or may not be functional



Examples: The patient will transfer from the bed to the BSC

with SBA in 2 weeks: Good progress – pt now requires min assist.

The patient’s balance will improve to low fall risk, as evidenced by an improvement in the Tinnetti score to >24 points: Good progress – Tinnetti score at initial eval was 16/28 indicating high fall risk; current score is 21/28 indicating moderate fall risk.

The patient will perform upper body dressing with min assist: Goal met



If the measurements do not indicate progress toward the goals, and/or do not indicate that therapy is effective, but the therapy continues, the therapist must document why the physician and therapist have determined that therapy should be continued.


Discharge summary


Discharge Summary

Because it often lays right on top of the PT/ OT/ ST section of the chart (if records are filed in reverse chronological order), it is the first thing an auditor will see when reviewing therapy records – it can be a very useful document in proving that treatment was reasonable and necessary!

If goals are not re-stated and progress addressed in the DC summary, it is probably not being used to best advantage.

Reviewing Therapy Documentation if You

Are a Nurse

Reviewing Therapy Documentation if You Are a Nurse

OASIS guidelines are the same, no matter who is filling it out

Therapy Evaluation must have clear functional goals

Therapist(s) should be in right away if there are safety concerns such as fall risk; impaired mobility contributing to pressure ulcer risk or to incontinence; etc


Therapy Revisit Notes must indicate steady progress is being made toward the functional goals

Skilled care must be evident at every visit Handwriting must be legible If these things are not apparent to you,

chances are good they will not be apparent to the nurse who is auditing the chart for Medicare!


Therapy Reassessments must restate goals from the initial evaluation and document what progress has been made toward those goals – Medicare requires a functional comparison between timepoints be made by the therapist


The Discharge Summary should also restate goals and indicate which were met, and for goals that were not met, an explanation should be given

Now we will have an OPEN Q&A

Q and A

Thank You for Joining Us Today!

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If you have any problems or are not able to listen to the entire RECORDED webcast, the recording will be available at the SAME LINK included in

your invitation email from June 15th through June 30th .

If you have further questions you can email Nita at

[email protected] us with comments or suggestions for our moderator at

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welcome and thank you for joining us today!

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