Documentation for effective patient care communication, medical review and risk
management .
2014 Rehab
Documentation Training
Documentation timeline guidance:
Form Part A/ Managed Care Part B/ Medicaid
Plan of care/
Evaluation
Day of evaluation
suggested: eval same day or
within 24 hrs of order
Day of evaluation
suggested: eval within 72 hrs of order
Updated plan of care
Recertification
Every 30 days (or more
often as needed)
Every 90 days (or more often
as needed)
Daily treatment notes
(logs)
Daily to show
minutes/days/mode to
support RUG
Daily to show
minutes/days/mode/
timed/untimed codes
Clinician Progress
report
Minimum every 10
treatments
Minimum every 10 treatments
DC Summary Best practice: within one
business day of DC
Completed by clinician or
under direction of clinician 3
days prior to DC. Best practice:
within one business day of DC
G-Code Reporting None Part B only
Initial POC, Progress Reports
Updated POC, Discharge
Therapy
Signatures
A signature log should be maintained in the facility
designating signature and legibly printed or typed
name/credentials to identify each author of documentation.
This log is sent with ADRs (Additional Development/
Documentation Requests.)
For non-electronic signatures, a manual signature & basic
credentials with date should be provided. The reviewer
must be able to determine who rendered the service and
who supervised the service of assistants.
MD supervision
Failing to show adequate proof of
physician supervision can result in
denials of therapy claims.
Timely signature/date on POC/updated
POC, MD progress notes, orders, and
certifications help to show appropriate
oversight and involvement. MD notes
that mention therapy progress are
especially beneficial.
Physician Signatures and Dates Digital & faxed signatures are
acceptable. Signature stamps
are not. (source: MM698)
Date received stamps are better
than no date at all
The physician (or NPP) MUST
approve the plan of care
(POC) within 30 days of the
initial treatment.
Best practice:
MD sign and date the
POC/Updated POC form as
proof of monitoring and
approval of the POC.
If MD signature is delayed,
track your attempts to obtain
the signature
MD Orders
When? Who can write?
Prior to eval giving
permission to eval & treat
After eval, clarifying POC w/
frequency & duration (daily
skilled need part A)
Upon change in plan of care
At d/c from therapy if resident
remaining in facility, listing
the date that therapy will
cease
Requirements may vary by state, but Medicare allows orders from physicians, nurse practitioners, clinical nurse specialists (not employed with facility); DO, or physician’s assistants.
Duration of Care Should I always list 30 days
as the therapy duration on my
plan of care and clarification order?
• No. List the actual expected duration of your treatment. For some
diagnoses, this may be 8 weeks or longer, depending on the severity
of the deficits and potential for improvement. Medical reviewers
must verify that “reasonable progress” occurs in a “generally
predictable period of time”—stating the expected duration
accurately helps to meet this expectation
• Remember, updated POC’s/recertifications should report the
remaining weeks left from the initial POC projection.
Example: POC –projected 10 weeks of therapy
First Recertification should project 6 weeks of therapy
Second Recertification should project 2 more weeks of therapy
MD supervision requirements for Medicare Part A
Certification/Recertification is required to verify daily skilled rehabilitation
• MD, PA, NP, and CNS who are not employed by the facility may sign the
certifications
• The initial certification must be obtained at the time of admission, or as soon
thereafter as is reasonable (within 3 days is generally acceptable). The routine
admission order and the signed therapy POC does not serve the certification
criteria for skilled care.
• The first recertification must be made no later than the 14th day and subsequent
recertifications must be made in intervals not exceeding 30 days from the last
dated physician signature.
Recertification statements must contain:
• Written record of the reasons for continued need for extended care services
• Estimated period of time required for the resident to remain in the facility –this
should match your projected therapy duration
• Discharge plans
MD Progress Reports to support
skilled rehabilitation Include updates on the rehab
course in progress notes:
What deficits are hindering return to
prior level of function (PLOF) that
require continued services?
Summarize rehab goals, progress & patient response to therapy.
Provide updates on the DC plan in relation to rehab course progression
Speak to the intensity of therapy services (RUG) —why is it warranted? Short
term stay goal, high functioning previously, progress hindered by less rehab
service, following standard clinical protocol for condition
Example Progress Note Patient continues PT and OT with right knee
ROM improvements from 78 degrees to 90
degrees with pain managed through
medication. Patient is ambulating with a
walker to meals, but demonstrates reduced
weight bearing through the right LE. Patient
able to dress/bathe upper body but requires
some assistance for lower body due to
difficulty bending over. Patient will need to
be independent in ambulation, stairs and self
care skills to return home due to spouse
being gone all day at work. Current
intensity of rehab appropriate & necessary to
advance independence and meet DC goals
Supervision of Assistants
Other requirements
Show clinical analysis (not just observations of pt. performance)
Provide update on goals
Reflect on any treatment approach modifications.
Assistants should document any supervisory contact that occurs via phone.
Follow state co-sign and clinical oversight guidelines.
10th visit progress reports
Co-signature requirement
KY PTA Co-sign DC summary if PTA contributes
KY OTA Co-sign DC summary if OTA contributes
IN PTA Daily phone contact if not on site, no cosigns required
IN OTA Co-sign progress notes & all medical record documentation
Indiana Supervision Basics
COTA: Co-sign by OT within 7 days for all
documentation that will be part of the medical record.
PTA: Unless PT onsite, must consult with PT at least
once each working day. If consult is not face to face,
each PT may only supervise 3 FTE PTAs; the PT
consult may be by phone.
Kentucky Supervision Basics
PTA: PT supervisory visit every 20 visits or 30 days. (Medicare
requirement still every 10 visits.) Must have a written plan of
supervision and supervise no more than 4 FTE PTAs at any time.
Supervision is defined as accessible by phone during working
hours. Must co-sign d/c summaries if PTA contributed (not required
to co-sign notes or treatment logs.) Should be rare occurrence for
PTA to write part B DC summary—PT has to have seen within 3
days prior
COTA: No less than 4 hrs of general supervision per month & no
less than 2 hrs of face to face supervision. Prorated for part time
COTAs. OT cannot supervise more than 3 FTE COTAs. OT must
maintain a supervision log. Co-sign POC and DC summary
documentation (if COTA contributed) within 14 days
Ohio Supervision Basics COTA: OT may supervise up to 4 full time OTAs and shall
determine the intervention plan that the OTA implements. This must take into consideration the clinical complexity of the patient, competency of the OTA, the OTA's level of training in the treatment technique, and whether continual reassessment of the patient/client's status is needed during treatment/intervention. Cosign all documentation
PTA: PT does not need to be on-site, but available at all times and able to physically respond in an emergency or planned absences; Supervising PT is accountable for the direction of the actions of the PTA. PT must interpret physician referrals; Provide initial patient evaluation, initial and ongoing treatment plans, periodic re-evaluation of the patient and adjustment of the plan of care. PT must complete discharge evaluations. Cosign all documentation
Diagnosis Codes ICD.9 diagnosis codes should describe
the condition(s) and symptoms that
support medical necessity of therapy.
Effective coding is the first level of
defense to succeed under automated
medical review.
Take the time to choose individualized
codes to paint the picture of why you
are getting involved. Make sure
priority codes are communicated so
that the biller includes them on the
claim to Medicare (UB-04).
Rehab: Primary Diagnosis
Hospital insurance
Reflect reason for
extension of hospital
care in ECF
Therapy V-code 1st
listed on claim (UB-
04) if rehab is primary
skilling service & DC
plan is rehab to home
Outpatient therapy
insurance
Primary is main
reason therapy is
needed (may or may
not match facility
primary)
Medicare A Medicare B
V Codes
Encounter V codes
describe circumstances
that influence health
status, but are not acute
illnesses.
V-codes should only be
used for Medicare Part
A residents d/c’ing out
of the facility
Therapy V57 Codes may only be used as primary; include supplementary code(s) to further describe condition
V57 codes include: V 57.89 Multiple therapies
involved V57.1-PT V57.21-OT V57.3-Speech language
therapy V57.81 orthotic training
Rehab Coding Examples
Part A: Admit for Rehab
to home
Part B: Fall in Facility
Primary:
V 57.89 Multiple therapies
Secondary:
V54.13 Aftercare of hip
fracture
Treatment:
719.7 Difficulty walking
719.45 Hip pain With other relevant diagnoses listed in
priority order
Primary:
Parkinson’s 332.0
Secondary/Treatment: 781.2
Abnormal Gait
781.0 Bradykinesia
With other relevant diagnosis listed in
priority order
Coding Tips
AVOID
• Acute codes for
cerebrovascular accidents,
myocardial infarctions, and
fractures
• Vague codes such as
“weakness” or codes
unrelated to why therapy is
involved
USE
• Always use the late-effect codes
• Specific complexities that directly and significantly impacts the rate of recovery
Supporting Treatment diagnosis:
• Shortness of breath 786.05 • Abnormal posture 781.92 • Overweight 278.02 • Dizziness 780.4 • Edema 782.3 • Low vision 369.20 • Feeding difficulties 783.3 • Urge incontinence 788.31 • Impulsiveness 799.23 • Tremors 781.0 • Pain in limb 729.5
Diagnosis: basis for therapy plan
ICD.9 code
Onset date
Test values
Subjective complaints
Expected outcomes
Clinical observations
Objective measures
Clinical Compliance
Establishing Medical Necessity
Providing Medical History impacting current function
Showing Prior Level of Function
Establishing Current Baseline
Justifying Skilled Services
Medical Necessity Establishing Medical Necessity at Evaluation
includes defining why skilled therapy is needed now by showing…
• Recent change in condition/function that warrants an
evaluation . (what new events have caused new changes that
require a skilled clinician to become involved)
Identifying the prior level of function as compared to the
current level of function with objective measurements
• Defining the positive expectation for improvement using
skilled interventions.
Current Referral
Summary statement of the recent functional change.
Examples:
Recent complaints of left wrist & hand pain hindering functional hand use
Recent falls and mobility declines
Impaired ability to chew meats on regular diet and pocketing food
Avoid stand alone statements such as “ recent hospital
stay,” “MD orders,” or “patient request” that aren’t
supported with a functional change summary.
Examples of Non-Covered Services • Services that are diversional, for general flexibility/conditioning, do not
require the professional, sophisticated skills of a therapist to perform.
• Where a patient suffers a transient and easily reversible loss or reduction in
function which could reasonably be expected to improve spontaneously as the
patient gradually resumes normal activities
• Services in the presence of limited cognition that is so severe that an increase
in function is very unlikely; however, services may be covered:
– to establish & teach a caregiver safety, compensatory strategies, & implementation of a
maintenance program.
– therapy may be reasonable if there are meaningful goals even when they cant comprehend
instructions or remember –e.g. balance or safe transfers. (And goals established based on
the formalized testing score)
– when there is potential to recover lost cognitive abilities-e.g. new CVA
• Prepackaged, non individualized programs such as pre-op joint classes that
have pre-set objectives for all attendees and do not require a therapist’s
unique skill
• Services in the presence of non-cooperation by patient or caregiver
Defining “significant” change
Significant Insignificant
Clear, objective functional change compared to PLOF
Requiring significantly more staff assist or time fed by staff now, fed self last month,
transfers AX2 --was AX1
Risk level is higher Falls, skin, weight loss, contracture
Especially significant--changes that will show up on the MDS from last to current assessment
Return from brief hospital
stay with deconditioning
that will likely improve
without therapy
Dependent 80% with
transfers declines to
dependent 90%
Non-ambulatory resident
requests gait training
Medical History & Complexities Impacting Prognosis:
History & Complexities Living situation/support
Current and past diagnoses &
surgeries impacting current
function
Clinical complexity
clarification (co-morbidities
that will impact prognosis &
rate of progress)
Medications of concern
Info on past rehab experience
Residence/ living
arrangements
Social support
D/C plan/community
involvement
Routine/activities
Prior level of Function (PLOF) Best documented function within last 3-6 months .
MDS & nursing doc should corroborate our PLOF statement. Reviewers want proof of PLOF outside of therapy notes
Therapy documentation should show a
measurable contrast between prior level of
function (PLOF) and current function to justify
rehab involvement.
Typically, long term goals should not be set higher
than the PLOF.
Clarify activity level & involvement
Were they going to the dining room independently?
Managing housework?
Involved in the community?
You may only set
goals for tasks w/an
established recent
change from PLOF
to current level of
function.
PLOF Example:
Mrs. Jones was living alone in an assisted living (AL) apartment.
She completed showers every other morning independently using a
shower bench, she was also able to dress, groom, and toilet herself
independently. She was able to ambulate in her apartment and to
the main dining room (200 ft.) with no AD, but used a rollator
walker to ambulate longer distances especially when visiting her
sister who lives in the same AL on the second floor (approx.
distance of 2,000 feet). She has assistance from AL for
laundry/cleaning, she eats 3 meals/day in the dining room, does not
drive, but does manage her own medications. She enjoys attending
her card club every Tuesday night and her daughter picks her up
every Sunday to go to church.
Helpful facility resources
PLOF/admission form → for new admissions,
transfer from ALF etc.
Significant change form → long term resident
w/recent change
Documentation Example Current Referral: Mrs. Jones suffered 2 falls in the bathroom at night last week in her apartment and was taken to the hospital where she was treated for CHF and altered mental status change. Her daughter reports a gradual decline in cognition and memory for about 3 months and is interfering with her ability to carry out activities of daily living. She presents with a significant decline by now requiring physical assistance for functional transfers compared to being independent and needs constant supervision and verbal cues for sequencing and safety during self care tasks.
Hx/Complexities: CHF, recent falls, cognitive changes, and OA
Impressions: She presents with decreased strength requiring assist to transition from a sitting to standing position, impaired balance seen by LOB backwards during toilet transfers and also demonstrates stooped posture. She does not use appropriate safety techniques during transfers (did not turn on bathroom light, did not lock w/c, did not use grab bar,..). While getting dressed, she was threading both legs into the same pant leg, forgot to put on her underwear, and was unable to locate her shoes requiring cognitive assistance.
Skilled Justification: Mrs. Jones requires skilled OT services to formally assess her current cognitive status, implement compensatory strategies based on her current cognitive level to increase her independence with self care tasks, improve the use of safety techniques, provide progressive strengthening to reduce physical assist with functional transfers, and improve her balance and posture to prevent future falls.
Potential for Achieving Goals
Patient Goals
• Try to use their own words
Example:
“I want to be able to walk to my
sisters again and get dressed without
it taking so long.”
Potential for Achieving Goals
• Try to paint a picture
Example:
Patient wants to rehab back to AL as
soon as possible and is projected to
meet goals in 4 weeks with intensive
6 days/week therapy services to
return to her PLOF. She has strong
family support and consistent
physician supervision.
Initial Assessment/Current Level of Function:
Establishing Baseline:
Summarize the objective current functional findings that apply to your
goals such as level of assistance required with mobility tasks, ADLs, level
of pain, activity tolerance, etc.
Provide the objective data at evaluation that you will need to refer to later,
in order to show functional progress
After reporting the patients current functional status for a particular area,
also state the underlying impairments explaining why they are at that
level. Example:
LB Dressing: Min/Extensive assist 20%
Underlying impairments: LOB when standing,
decreased flexibility to reach feet easily, sits too
close to edge of seat increasing fall risk, and is
unable to gather clothing items due to current
activity tolerance level.
Establishing Baseline through objective clinical components
• Why can’t the patient ambulate safely?
• Due to his narrow BOS of 2” compared to the norm of 3” and his slow cadence of 60 steps/minute compared to norm of 81‐125 steps/minute.
I Independent No assist required
MI Modified Independent Independent using adaptive equipment
S Supervision Safety/cognition require therapist to facilitate task
CGA Contact Guard Assist
=MDS limited assist
Guided maneuvering or other hands on, non-weight
bearing assistance
Min Minimal
=MDS extensive assist
1-25% physical assist and/or weight bearing support
Mod Moderate
=MDS extensive assist
26-50% physical assist and/or weight bearing
support
Max Maximal
=MDS extensive assist
51-75% physical assist and/or weight bearing
support
D Dependent 76-100% physical assist and/or weight bearing
support
Assist levels
Including %s in functional assist measures helps to show
measurable progress on future documents when progress occurs
between assist levels
Establishing Effective Baselines To Show Progress Later
Pt. seated in standard w/c with sling seat upholstery (no pressure relieving device in place) creating increased LE adduction & internal rotation of bilateral femurs 25˚. No
footrests in place and feet are unsupported 3” from floor with hip flexion angle 110˚
(vs. optimal 90 ˚.) Pt. with lateral trunk flexion to left approximately 30 degrees with
lateral trunk/axilla rubbing armrest increasing risk of skin breakdown. Braden Score is
12 (high risk of skin breakdown.) Left hemiplegic UE is fully flexed at elbow and wrist,
with hand fisted over adducted/opposed thumb. Gentle ROM of elbow, wrist, and hand
is painful as evidenced by pt. pulling away and groaning when ROM attempted. (will
provide objective ROM measures as able week 1.) Pain graded at 8/10 (severe) on
PAINAD with ROM attempts. Hygiene requires assist of 2 staff with increased
difficulty noted due to present posture & pain w/ subsequent resistance to activities
requiring movement of the left UE.
Patient is leaning in wheelchair
and fisting left hand. She has
become more combative with
care recently. Multiple
contractures noted.
Positioning Baseline continued
Using the positioning patient example, there are multiple factors listed that allow future progress to be objectively documented as the patient responds to skilled intervention
LE position
Base of support
Pressure reduction
ROM measurements
Improvement in hygiene and ease of nursing care
Reduced risk of skin breakdown
Pain reduction
Trunk stability/posture
UE position
Objective Evidence & Tests
HTS recommends completing a formalized test for each patient
If unable to complete the day of eval, set STGs accordingly & establish competencies for therapy assistants
Choose tests based on critical deficits identified at eval
Use of tests with interpretation shows your skill
CMS Benefit Policy Manual (Pub 100-02, 220.2) “The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for therapy.” “Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.”
Discipline specific formalized tests:
Occupational Therapy
• Allen Cognitive Lacing Screen (ACLS)
• Barthel Index
Physical Therapy
• Tinetti Balance and Gait
• Berg Balance Scale
• Timed Up and Go (TUG)
Speech Therapy
• Mann Assessment of Swallowing Ability (MASA)
• Swallowing Ability and Function Evaluation (SAFE)
• Functional Linguistic Communication Inventory (FLCI)
Test interpretation
Cognition tested using ACL protocol for RTI and
ACLS. Results indicate ACL score of 4.2.
Interpretations:
Pt requires 38% cognitive assistance & supervision to remove dangerous objects
outside of the visual field and to solve problems arising from minor changes in the
environment. She may reasonably be expected to spend a daily allowance, walk to
familiar locations in the neighborhood, or follow a simple, familiar bus route. 38%
minimum cognitive assistance is required to recognize and correct hazards in routine
activities. Research indicates pt. will benefit from striking visual cues and that there
is a reasonable expectation for achievement for MI with self care tasks. New learning
is expected for compensatory strategies & adapted routines using skilled techniques
appropriate for this cognitive level. These strategies will be incorporated into OT
treatment.
Progress Report Example
Skill: Analyzed functional cognition using ACLS protocol based on need for cues to follow hip precautions & to use walker. Findings indicating functioning at level 4.2. Incorporating striking visual cues in immediate environment in response to this result.
Continued Skill: Added goal –Pt. will respond to striking visual cues in room to comply with walker use with bed to BSC transfers 100% of the time 3 of 3 days. OT to analyze functional vision for reading posted reminders this week and will incorporate environmental compensations including consistent placement of AD, arrangement of bed position in relation to bathroom door and striking visual contrast adaptations to walker, call light mechanism and mobility aides.
Identifying impairments with baseline measures
Impairment Measure
Pain Pain scale, location, type, what improves/worsens?
Cognition Direction following, memory measures,
safety/judgment, ACL score (& other tests).
Strength/ROM Provide objective measurements based on MMT and
goniometric detail as needed. Name m.group and
specific impact on function
Sensation Light touch, monofilament, dermatome patterns,
proprioception
Neuromotor Tone (Ashworth), coordination, praxis, reflexes
Activity Tolerance Time in functional activity before rest required
Visual/Perceptual Low vision (acuity, print size for reading, visual field
range, etc.) stereognosis, MVPT
Skin Integrity Braden risk score, wound stage/type/description
Identifying impairments with baseline measures
Impairment Measure
Cardio-pulmonary
Status
O2 saturation levels, recovery rate after activity,
6min walk test (may modify to 2 mins), BORG,
perceived exertion etc.
Balance Berg, Tinetti, Functional reach test, # LOB episodes
during task, LOB recovery, protective reactions etc.
Gait Stride, step length, cadence compared to norms,
weight acceptance, heel strike, phase of
impairment, AE use, in addition to distance
Communication Expressive,/receptive language, processing speed,
yes/no response accuracy, non-verbal
communication, voice quality
Dysphagia MASA, state stage of swallow impairment and show
proof of physician involvement in plan of care per
local coverage decision
Justifying Skill
For the full duration of care
Justifying Skilled Services Why does this patient require the
sophisticated service of a therapist?
What has nursing already tried? What are you able to do that nursing/family cant?
What are the specific techniques, frames of reference, strategies you are using to support each unit billed?
Failing to continually justify why therapy is needed each week, can lead to therapy denials.
Justification strategies:
predictability & effective use of time
Show predictability—Plan a reasonable duration at SOC &
reflect the full expected duration on the POC & orders
Every treatment billed must count toward the end goal
Meet STGs each week to show steady progress
If a goal isn’t met in 2 weeks—show plan adjustments
Show evidence based practice—use formal tests, show
comparisons to norms, use specific strategies for that dx
Turn less skilled tasks over to nursing/restorative
incrementally—show that you are focused on higher level skills
during therapy week 3 & beyond
Effective Progress
Reports
CMS requires that progress reports be completed a minimum of every 10 treatments or 30 days (whichever comes first.) You may write a note more often, but not less often.
Remember that 1 good progress note could be better than numerous repetitive notes that do not reflect skill.
Progress Reports should be individualized so it could not be used for another patient. Avoid general statements by including detailed information.
CMS Benefit Policy Manual (Pub 100-02, 220.2) “The beginning of the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment.
Progress reports should contain… 1. A statement of current functional status related to the measurable objective in the goal.
2. If the goal was met, or need to continue, discontinue or modify.
3. Under the “Comments” section for each goal, provide specific detailed skilled interventions that show your skill and critical thinking used to address the goal to help make the progress report more individualized.
Ex: what AE was used, specific EC techniques, specific tactile
cues, what environmental modifications were made, what
specific compensatory strategies did you teach the patient to
use, what specific training technique was done with the
caregiver regarding transfers,….
Progress reports should contain… 4. Summary of skilled services provided in the past 10 treatments that correspond
to your billing. Documentation should support each code billed.
5. Pt. and Caregiver Training completed using specific details
Ex 1: Instructed caregivers in safe set up of w/c in bathroom for sliding board
transfer with placement of environmental markers for consistency across staff,
placing sliding board and proper handling technique to initiate the transfer when
moving toward non-hemiplegic side
6. Patient Response: Explanation of how the patient is responding to the
treatment interventions and describe how the therapy is evolving.
7. Continued Skill functional deficits & medical issues (complexities)
impacting therapy & the skilled services needed to address remaining
problems.
Effective use of Rehab Optima library
drop downs
Only choose relevant
skilled intervention
phrases
Avoid using repetitive
phrases
Examples:
• If AROM was marked WFL’s on POC, do not choose “functional activities to increase ROM”
• If FMC was marked intact for fasteners do not choose, “theraputty techniques to improve FMC”
• If patient has a low cognitive level do not choose, “energy conservation during ADL’s”
Examples:
“Dynamic standing balance training” and “progressive standing balance training”
“Progressive resistance exercises” and “therapeutic resistance exercises” and “therapeutic exercises for LE’s”
“Thermal gustatory stimulation to increase swallow initiation” and “thermal gustatory stim to increase swallow timing”
Goal Writing
POC should include one or more short term goals (STG) for each long term goal (LTG.)
Each STG should have a baseline measurement and a PLOF
LTGs should be set for the full duration of the plan
Set STGs to be reasonably achieved in 1-2 weeks.
Use %s to show incremental gains
Update STGs as you achieve them
Revise goals that are not progressing
Break down tasks into component skills
Goals must be functional and measurable
Reasonable expectation of progress
Goal progress is evident in the
documentation over the past 1-2 weeks
Patient is not yet at PLOF
Treatments are based on accepted
standards of care and evolving based
on patient’s response
What if they’re not progressing?
Not meeting goals?
3 options:
Document modification of approaches, plan adjustments, training
Hindrances to reflecting skill:
No initial status for goals
Insufficient detail for goals
Clarifying detail for skilled
interventions lacking
Lists of treatment activities and
observations without info on
skilled facilitation
Skilled interventions not shown
to support every code billed
Unapproved abbreviations
No modification of approaches
based on clinical complexity
No test scores or detailed
measures to show objective
gains outside of goals
No test score interpretation
No implementation of new
approaches based on test
results
Goals not met, but no plan
adjustments
Untimely notes
Taking credit for progress 1. Go beyond observations of performance and state how you
facilitated progress.
2. Focus on measurable functional outcomes—not description of
activities used that could be perceived under review as non-
skilled (clothespin tree, balloon volleyball, ROM ladder)
3. Avoid activities that may seem rote or repetitive –medical
reviewers tend to find these services “maintenance therapy”
that could be performed by restorative.
CMS Benefit Policy Manual (chapter 8, 30.4.1.2)
“Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive
walking are appropriately provided by supportive personnel, e.g., aides or nursing
personnel, and do not require the skills of a physical therapist. Thus, such services are not
skilled physical therapy.”
Justification of Skilled Service Ex. 1
Instead of just documenting observations/assist levels, focus on the skilled intervention:
As a result of OT facilitation of task sequencing, training in one handed dressing techniques and the use of adaptive equipment, pt. completing UB ADL tasks with min assist improved from mod assist. Bathroom modifications including grab bar now enable pt. to step into tub with mod assist.
Justification of Skilled Service Ex. 2 Non-skilled:
Pt. tolerating 25 reps of LE exercise all planes with red T-band
Skilled:
Promoting improved postural-core stability for dynamic functional activity through progressive balance, proprioceptive, and bilateral integration challenges via reciprocal movement patterns based on PNF guidelines within limits of prescribed cardiac precautions.
Ongoing Justification Updated POC/Recertification
Assessment summary since last progress report
• Summarize the skilled interventions and pt./caregiver education provided in the last 10 treatment sessions. What has the patient accomplished over the previous documentation period that is directly related to your skilled intervention?
Assessment summary since Eval/SOC
Summarize the patient's progress since evaluation and discuss what deficits still remain and what skilled interventions are needed to overcome those deficits in the week(s) ahead? How are you adjusting your approaches based on the patient’s response?
Updated plan of care
Opportunity to show comprehensive analysis of progress, remaining deficits, how you are using test scores to guide intervention, how you are making adjustments based on patient response/clinical complexities, safe transition strategies
Audit Tips : ther-ex 97110 Generalized strength & endurance training is not considered skilled in the absence of clinical complexity. Focusing on functional application of skills is especially important after the 10th visit. Majority of treatment should focus on function vs. reps of exercise—reflect this in coding choices & notes.
“Documentation should describe new exercises added, or changes made to
the exercise program to help justify that the services are skilled.
Documentation must show that exercises are being transitioned as
clinically indicated to an independent or caregiver-assisted exercise
program (HEP)). An HEP is an integral part of the POC and should be
modified as the patient progresses during the course of treatment. It is
appropriate to transition portions of the treatment to an HEP as the patient
or caregiver master the techniques involved in the performance of the
exercise... Documentation must clearly support the need for continued
therapeutic exercise greater than 12-18 visits. “
Audit Tips : neuro 97112 Notes must reflect appropriate use of code with emphasis on balance, coordination, tone, proprioception or other neuro-muscular component skills
Supportive Documentation Recommendations for 97112
“Objective loss of ADLs, mobility, balance, coordination
deficits, hypo- and hypertonicity, posture and effect on function
Specific exercises/activities performed (including progression of
the activity), purpose of the exercises as related to function,
instruction given, and/or assistance needed, to support that the
skills of a therapist were required”—NGS LCD 7/11/11
Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.
Audit Tips : gait 97116
Supportive Documentation Recommendations for 97116
“Objective measurements of balance and gait distance, assistive
device used, amount of assistance required, gait deviations and
limitations being addressed, use of orthotic or prosthesis, need for
and description of verbal cueing , presence of complicating factors
(pain, balance deficits, gait deficits, stairs, architectural or safety
concerns) Specific gait training techniques used, instructions given,
and/or assistance needed, and the patient’s response to the
intervention, to demonstrate that the skills of a therapist were
required”—NGS LCD 7/11/11
Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.
Audit Tips: cognitive therapy
Coverage for 97532 (cog skills) is
limited to the following conditions:
• 310.1 PERSONALITY CHANGE
DUE TO CONDITIONS
CLASSIFIED ELSEWHERE
• 310.8 OTHER SPECIFIED
NONPSYCHOTIC MENTAL
DISORDERS FOLLOWING
ORGANIC BRAIN DAMAGE
• 310.9 UNSPECIFIED
NONPSYCHOTIC MENTAL
DISORDER FOLLOWING
ORGANIC BRAIN DAMAGE
• 96125 cognitive testing (memory, reasoning, sensory processing, visual perceptual status, orientation, temporal and spatial organization, social pragmatics, decision-making & executive function)
• requires an extensive formal report to show test results and analysis of those results and is billed per hour of the therapist’s time
Providing handrolls, “carrots”, bed wedges, or prefab splints that do not require adaption/adjustment or other skill are not covered services
Monitoring a splint or other positioning program for more than a few days to analyze tolerance is not considered skilled.
Coverage
guidelines:
splints
Coverage guidelines:
wheelchairs
Positioning:
Issuing cushions, finding footrests etc. is not skilled unless complicating factors documented to justify
Provide detailed measurements & descriptions of problem areas to reflect medical necessity and show your skill
Then address the underlying issues impacting positioning first, BEFORE ordering equipment or modifying the w/c
W/C Management 97542
May only be billed for 3 days unless there are significant complexities and documentation supports the additional treatment
Coverage guidelines:
dysphagia
When billing 92610 swallow eval or 92526 swallow treatment the ICD.9 code for dysphagia must be present. These include:
438.82 Dysphagia cerebrovascular disease, 464.01 Acute laryngitis with obstruction, 464.51 supraglottitis unspecified with obstruction, 478.30 -478.34 codes related to paralysis of vocal cords, 478.6 edema of larynx, 507.0 pneumonitis due to inhalation of food or vomit, 787.20 dysphagia unspecified, 787.21 dysphagia oral phase, dysphagia oropharyngeal phase, 787.23 dysphagia pharyngeal phase, 787.24 dysphagia pharyngoesophageal phase, 787.29 other dysphagia
92526 is an untimed code and may be billed 1x per day.
97150 may be billed for group dysphagia treatment (revised summer 2011)
FMP development is covered for 2-4 visits to train caregivers; avoid excessive durations with unsupported skill (e.g. “monitoring” of diet consistency tolerance)
Nursing Documentation To Support Rehab
Nursing should document to show a change in status warranting a new therapy evaluation
Nursing should document weekly to support therapy services with a summary of progress, problems, & nursing carry-over interventions
Regular communication of the most pertinent info re: recent week’s therapies to nursing is important. Weekly rehab meeting and/or written communication forms are good tools
MDS coding should support not contradict the interdisciplinary team charting
Documentation shows skilled
need
Minutes are justified to support the
RUG
Justifying skilled stay & RUG level To support a Medicare A skilled stay, documentation must
show:
1. Clear skilled need
2. Minutes provided are reasonable & necessary for condition
(UTI and CVA are not the same intensity)
3. Treatment is evolving based on patient’s responses
Speaking to the Intensity
The RUG level achieved (RU, RV, RH) should support medical necessity through your documentation. Examples: • Specific MD protocol • Barriers to DC home • Community Involvement • Clinical Complexities • Acute Changes • Planned Short Stay • High level D/C expectation • Advancement of strategies • Split treatments /BID
Tips from past audits
Watch length of service
Services that were initially skilled,
may be denied as “maintenance
therapy” if duration is too long.
Meet & adjust goals each week
Avoid repetitive treatment notes
Very low level patients aren’t
supported for long durations
Use caution with :
PROM, distance of ambulation,
strengthening, monitoring equipment
Safe Transition
Effective Discharge Planning
Home Assessments
• Should be completed 7-10 days prior to DC
• Use a standard Home Visit Report
• Educate patient using the Safety Checklist
• Home assessments are billable as treatment time if the
patient is present; this includes time travelling to and from
the home only if you are teaching and training during the
trip.
Functional Maintenance Programs
Covered Non-covered
Strategies required to
minimize deterioration or
suffering over time and/or are
necessary for safety
Training patient, family or
caregivers
Occasional reevaluations to
assess and adjust the program
General, non-specific services
that don’t require skilled
training ( non-specific
PROM, handrolls, etc.)
Discharge Summaries Per CMS: consider the discharge note the last opportunity to justify the medical
necessity of the entire treatment episode in case the record is reviewed.
Further part B requirements outlined in Transmittal 88 include:
DOCUMENTATION TO SUPPORT BILLING
Daily entries, missed sessions & modifiers
Daily Treatment Documentation
Medicare requires daily documentation of treatment “encounter” minutes to support the billed charges & MDS.
Do not round minutes. Record time exactly. Remember the 8 minute rule. Part A treatment time includes set up time Each facility should have measures in place to check for
accuracy of reported minutes Some services require a separate daily entry
Modalities (location, reason, pt. response, settings)
Positioning/splinting
Wound care
Cognitive testing code 96125 requires separate report
ROM testing code requires separate report
Treatments that are longer than 60 minutes in duration
Missed treatments
When treatment is withheld or refused, this should be shown as a daily note entry documenting the reason (illness, LOA, etc.)
Avoid focusing on poor motivation in notes unless planning to DC. If there is a reasonable expectation of progress to support continuing, focus on your interventions & reasoning for that expectation.
Plan ahead to reduce refusals—e.g. time treatment after pain meds, set a less physically demanding STG
Group
Treatment
Purpose of group
Number of participants
How the group relates to
each individual’s goals
Any adjustments made
to grade the group for an
individual
Description of your
skilled strategies
Co-Treatment Effective October 2013, Co-treatment
therapy minutes are required to be
reported in section “O” of the MDS. It is
also recommended to document any co-
treatment sessions in the therapy notes.
You should include the other discipline
that you co-treated with, the rationale for
co-treatment, and specific details of the
session pertaining to your plan of care
and current therapeutic goals.
Functional G-Code Reporting
G code reporting of functional status on the UB-04 is
required for therapy part B claims effective July 2013.
Documentation on the medical record must also report G-
code status using a consistent measurement tool to track
progress.
Supporting the Use of Modifiers
When using a 59 modifier,
notes should clarify how
the intervention was
separate and distinct
By applying the KX modifier,
the therapist is certifying that
their documentation supports
the automatic exception
standards. If the principles of
coding diagnoses, documenting
medical necessity, clinical
complexity and justifying
skilled service taught today are
followed consistently,
documentation to support
exception criteria should be
met
Justification over part B caps Justify in documentation the need to continue services
beyond the part B cap ($1900) and the ($3700)
threshold. Remember anything billed over the $3700
threshold will result in an automatic ADR for review by
your MAC.
Jimmo v. Sebelius case
Overview of case Implications
Medicare beneficiaries
filed suit stating access to
therapy had been denied
due to application of the
“improvement standard”
CMS settlement
announces immediate
change to the law, MAC
training requirements and
changes to the Medicare
manuals
Skilled maintenance
services cannot be
denied automatically
Potential impact for
patients with chronic
conditions
Medical necessity,
reasonableness, and
skilled service
requirements still apply
Medicare Meeting
Report
Summarize what nursing should know about functional status, recent progress, goals for the interdisciplinary team, and any other relevant patient specific issues. Nursing may choose to relate this in the nursing notes, especially if rehab is the primary skilling service for a part A stay.
Review the week’s medical record for accuracy & clarity
Discuss the current RUG & ongoing skilled needs; if remaining skilled, a statement of ongoing medical necessity and continued need for skilled services is recommended in the nursing notes.
Filing Documentation Keep clean, orderly medical records.
Pull copies when MD signed original filed
Discipline dividers and date ordered filing—most recent on top
File documentation promptly
Medical Review Entities
Preparedness and Responsiveness
Medical Review Entities State Survey
State Survey Team
oVisits facility onsite at least annually (and upon
complaint or for follow up to be sure previously
identified problems are corrected) to be sure both
Medicare and state regulations for nursing
facilities are being met
oPrepare by making sure documentation is up to
date and filed in the medical record for access at
any time day or night
Medical Review Entities Medicaid Review
Hewlett Packard (HP) is contracted by Medicaid to audit MDS data for accuracy
They visit at least every 15 months
Prepare by consistently following HTS procedures for reporting MDS minutes including stapling a copy of the encounter note to the section P and T form given to the MDS coordinator
Medical Review Entities
WPS is the Medicare Administrative Contractor (MAC)
entity through CMS (Center for Medicare Services) that
manages Medicare claims for Indiana.
CGS is the MAC for KY and OH
Highmark Medicare Services is the PA MAC
Reviews are generated as part of specific initiatives (i.e.
OT widespread probe review,) and/or based on data
triggers such as billing errors, high RUG levels with a
high ADL score (i.e. RUC), high volume LOS outside of
sample norms (i.e. pepper reports)
Types of medical review Review Entity Pre-
pay Post Pay
RACs Recovery Audit Contractors √
CERT Comprehensive Error Rate Testing
√
MACs Medicare Administrative Contractors (includes part B cap reviews)
√
QIO Quality Improvement Organization √
ZPICs Zone Program Integrity Contractor √
State Auditors (may re-RUG) √
92
MANUAL MEDICAL REVIEW OVER $3700 THRESHOLD
Prepayment Review Demonstration Effective April 1, 2013
States Impacted Instructions Review Time Frame
FL, CA, MI, TX,
NY, LA, IL, PA,
OH, NC, MO
MAC sends ADR to provider
requesting ADR documentation be
sent to the RAC (unless an
alternative process is
communicated by the MAC)
RAC completes pre-payment
review within 10 business
days of receiving additional
documentation & notifies MAC
of payment decision
Postpayment Review Demonstration Effective April 1, 2013
Remaining
States
MAC identifies claims meeting
threshold, requests ADR, & pays
claim. ADR from MAC asks provider
to send records to RAC. RAC
conducts post payment review &
notifies MAC of payment decision
Post payment review
timeframes are not specified in
the 3/21/13 CMS update to
the Therapy Cap Services
webpage at the time of the
submission of this handout.
Continue to check the website
for further instruction.
Preparing for Audits
• HTS clinical consultants complete monthly chart reviews on Rehab Optima for each facility. They will e-mail any suggestions to help support the services as billed. All corrections must be completed within one week. Staff identified as having consistent documentation errors that are not improving with routine audits may be required to participate in remedial documentation training.
• Clarifying entries related to the clinical plan of care or the rehab course that follows (progress notes, updated plan of care, daily notes, DC summary) should be entered into the record so that it is evident when the clarification was documented and by whom. In most cases, entering the clarification as a signed, dated daily note is appropriate. The daily note may reference the document for which you are providing clarifying information.
LET’S TAKE A LOOK!!
Medical Review
Generally the first step of a review is a notice that comes through the online system to the facility business office requesting additional information on a claim (ADR -additional documentation request )
Make sure the business office knows to contact rehab when an
ADR is received.
Follow the directions on the letter exactly sending only what is requested.
Check documentation thoroughly prior to sending. Include a cover letter with any clarifying information needed.
Keep copies of everything sent along with records of dates mailed, etc.
ADR response tips
Track due dates and respond promptly
Read through the record to determine how clearly a significant change in function, medical necessity and skilled service justification is documented
Address missing signatures, missing documents, and errors directly
Write a brief position statement overviewing the case and referencing proofs for Medicare coverage requirements
Include supportive
documentation for look back
periods for part A (may be
outside of coverage dates
requested)
In order to show a
reasonable expectation of
progress, may need to send
documents prior to dates of
service in question
Denial Process-cont
Prevent denials by following the documentation guidelines learned in this tutorial
Plan for denial appeals by educating the business office to contact rehab promptly when receiving correspondence from CMS (WPS/CGS) regarding denied therapy claims.
THANK YOU!
(812) 431-4804