Transcript Long Term Care Updates and Documentation Strategies

Long Term Care Updates
and Documentation
Strategies
Tina Young, MSOT, OTR/L
Older Adult MSG
May 2010
Objectives
• Introduction to the upcoming changes:
RAC, MDS 3.0 and RUGS IV
How they will affect OT practice?
• Documentation strategies with emphasis on the
therapist rather than the client:
Medical necessity, skilled services, measurable
progress/goals, coding and more
Goals
• Therapists will be able to state 2 upcoming
changes in October 2010
• Therapists will be able to document better
utilizing at least 5 strategies to prevent/minimize
Medicare denials and improve our clinical
practices
• Therapists will understand the impact of our
documentation on coverage and denials,
protection of our skilled profession
• Therapists will realize documentation is about
the therapists’ skills, not just the client’s
progress
Long Term Care
Changes
• RAC
Recovery Audit Contractors
Contracted through CMS
Post payment review, identify improper
overpayments after Oct 1, 2007
All providers are eligible to be audited, bills to
Medicare Part A and B
Collected over $1Billion in 3 years
Long Term Care
Changes
• RAC continued
Demand letters are sent to Medical Records, if you
don’t respond, expect 100% denial of claim
They will apply the knowledge of Medicare rules
and regulations to validate denials after
reviewing the documentation
They will take $ back!!!!
Long Term Care
Changes
• RAC continued
Documentation can only use approved JCAHO
abbreviations
2014 all documentation must be electronic
nationwide
Claims could be for illegibility or incorrectly spelled
words
Long Term Care
Changes
• RAC continued
Recommendations to consider:
Each goal should have own attainment date
Avoid “as per plan of care” and “patient tolerating
tx well”
Emphasize OTR/OTA collaboration, OTA should
not document changes in plan of care or
emphasis on…. without “collaboration with OTR”
Long Term Care
Changes
• RAC continued
Transfer services from PRN therapists
on evals
Errors procedure must include: single
line through item, word “error”,
initials and date on each entry
Long Term Care
Changes
• RAC continued
“OT evaluations can be denied if the following are not
routinely noted on evals: Physiological status, cognitive
baseline with a specific tool(s), communication status,
specific testing of biom. measures. But due to the abbrev.
ruling, such standard reporting as MMT cannot be
reported in the abbrev., must be "manual muscle testing is
4/5 "(and then each assessment be interpreted),
"indicating good muscle strength in order to support use of
bilat UE in push off from toilet, bed"
J. Winland’s AOTA CEU
Long Term Care
Changes
• MDS 3.0
CMS will adjust computations of ADLs,
Eliminate section T of MDS (projections),
OMRAs will be 1-3 days after therapy
discharge (vs. 8-10 days)
Beginning after October 2010
Long Term Care
Changes
• RUGS IV
Beginning October 2010
66 RUGS (vs. 53)- new categories
Modify the hospital “look-back”
Update case-mix weights, nursing and
therapy
Change in coding therapy minutes on the
MDS i.e. concurrent/group/individual
Long Term Care
Changes
• RUGS IV continued
Nursing will have more brief interview
section for cognition (MMSE)
SLP will document signs/symptoms of
swallowing deficits
Long Term Care
Changes
• Extension of Cap most likely beyond 12/31/10
deadline
• Section 6121 mandates dementia care and
abuse training for all SNF employees by 3/2011
• Incentives for prevention and wellness
• Monitor readmissions to hospitals 1/2013
• CLASS Program developed rollout 2012
Long Term Care
Changes
• What do these 3 changes mean?
Increase in Audits
And Denials
Medicare Denials/Audit
Process
• Appeal process:
Shortened time frame to appeal generally
Within 120 days of receiving the initial
determination denial to pay the claim found on
MSN (Medicare Summary Notice), send a
request for redetermination with all the
documentation requested in the MSN and
additional documentation that supports skilled
therapy services such as: eval, treatment
record, progress notes, discharge summary,
orders nursing notes and physician signed POC
Medicare Denials/Audit
Process
Then you can appeal again with a reconsideration
request, which is reviewed by a qualified
independent contractor other than your
Medicare payer, send documents and letter
The third level of appeal is conducted by an
administrative law judge, minimum of $110 in
controversy
The fourth level of appeal is the Medicare
appeals Council, only if there was an error in the
law or the case is a question of policy or
procedure, minimum of $1090 controversy
Medicare Denials/Audit
Process
• Recommendations:
Respond timely to denials
Respond to ALL Medicare denials
Prepare documentation/clinician to reduce
denials as best defense (hone our
documentation skills)
All clinicians should be educated and
understand the proper coding and
essential documentation policies
Medicare Denials/Audit
Process
• Do NOT assume that the medical
reviewer understands the level of
sophistication of our skilled services.
• Use materials to support the services that
you are providing are within your
profession, standards, guidelines,
specialized knowledge and skills papers
and evidences-based practice resources
Medicare Denials/Audit
Process
To Ensure Payment
• Paint a Picture of the Patient with content
not fluff
• Be specific, clear and concise
• Don’t write defer/refer to…..
• Don’t leave blanks
• Ask a therapist “can I read the note and
know what to do next?”
Medicare Denials/Audit
Process
To Ensure Payment
• Don’t write NT- you didn’t test for a
reason, why
• Use percentages, number of episodes
• Document severity and impact of loss on
whole person
• Support reason for intensity (minutes of
service)
Medicare Denials/Audit
Process
• Statements to avoid:
Tolerated treatment well (assumption
unless stated otherwise)
Continue per plan of care
As above
Good/well
Cognition interferes with therapy
Medicare Denials/Audit
Process
• Cognitive Aspects:
Document skills of a therapist with education
given, visual cues, establish compensatory
strategies for safe return to…, able to
recall…..spaced retrieval cues, use
adaptations/compensatory strategies, strategies
to reduce behaviors, address deficits that lead to
functional loss, caregiver feedback, address the
patient’s need for the goal
Medicare Denials/Audit
Process
• Addressing group therapy
documentation
Reason why for group, write clinical
benefits, group addressed…… to
improve…….
Medicare Denials/Audit
Process
• My recent experience with ADRs:
Dementia diagnoses are most common
Lack of cognitive scores
UI treatment
Lack of sufficient prior level status on evals
Continuing goals met, lack of progress for a reviewer (in the
FIMS section of notes)
Group code, GO283 code, abbreviations, lack of supportive
documentation from physician and nursing, where did
referral come from
Relevant Transmittals that
affect Documentation and
denials
Transmittal #63-documentation needs to be
measurable and asks for functional
assessment scores
Recommend standardized test scores on
evaluations and progress notes
Show baseline and improvement correlated
with function (what does the score
mean?)
Relevant Transmittals that
affect Documentation and
denials
• Transmittal #262
3 requirements for Medicare Coverage
eligibility, MUST be met:
Ordered service by a physician
A skilled service is provided on a daily
basis
Service is reasonable and necessary
Relevant Transmittals that
affect Documentation and
denials
• Transmittal #262 continued
Dementia clients can make progress
Allowed us to treat clients to their
highest level
Relevant Transmittals that
affect Documentation and
denials
• Transmittal #262 continued
Stress remaining abilities that can be
capitalized versus barriers d/t cognition
Cognitive recall is not necessary to
participate in this plan of care nor
necessary for skilled intervention
Documentation: Focus is
YOU
• Standardized tests
• Medical necessity
• Skilled services
• Referral from who,
supportive
documentation
• Physician order
and certification
• Expectation of
Improvement
•
•
•
•
•
•
and correlation to
function
Goals-reasonable,
predictable period of
time
Medical complexities
Prior level
Supervision/cosignatures
Measurable
Coding: ICD-9 and
CPT
Documentation: Focus is
YOU
Need to answer in your documentation:
Why should YOU be involved?
What did YOU do?
Did YOU analyze and adjust POC?
Did YOU say that?
Why are you needed (skills) vs. CNA”?
Documentation: Focus is
YOU
• Initial Evaluation:
Document functional performance prior
level and current level, standardized tests
and relation to function (interpretation or
analysis), all applicable medical
diagnoses, ICD-9 codes, precautions,
contraindications, specific problem areas
being evaluated- body part,
Documentation: Focus is
YOU
• Initial Evaluation:
Qualifications of a therapist needed to
provide intervention, pertinent medical or
therapy history to determine degree of
functional loss, reason for referral-why
evaluating
Documentation: Focus is
YOU
• Reasons for referral:
Identify DME needed, identify number of
medications, how mental/cognitive disorders
impact the rate of recovery, cause of condition,
symptoms, other health services concurrently
being provided (dietitian, social services,
nursing, hospital or physician consultations
Documentation: Focus is
YOU
• If you don’t document the reason for
the referral, it can be denied as not
medically necessary, we should
discuss referral sources’ comments
in our documentation to support our
claim
Documentation: Focus is
YOU
• Evaluations are extremely important
since 2/3 of denials are based on medical
and skilled necessity
• Document how to link medical diagnoses
to functional changes, why have
therapy?, medical dx alone doesn’t say
what we are doing for the patient
• Age, severity, time of onset
• Expectation of improvement
Documentation: Focus is
YOU
• Add social, psychological and medical
stability, motivation, acuity of condition,
prognosis, complexity of condition,
explain why progress may be slower
secondary to medical conditions and co
morbidities, patient self report
Documentation: Focus is
YOU
• Medicare recommends we use tests and
measures published in research: KELS,
Dynamometer, Functional Reach Test,
MMT, RPE (rating of perceived exertion),
goniometric ROM, TUG, BERG, ACL,
CPT
Documentation: Focus is
YOU
• Explain results of tests: i.e. MMT
below 3/5, patient is unable to utilize
UE for feeding successfully without
assistance or would be unable to
assist with bathroom transfers
Documentation: Focus is
YOU
• If no standardized tests used,
Medicare recommends functional
progress towards goals which is the
standard independence scale that
we use most often.
Documentation: Focus is
YOU
• Last option if not using standardized tests
per Medicare:
“Ask the client- at the present time, would
you say that your health is excellent, very
good, fair or poor?” Document the
response at eval and discharge.
Documentation: Focus is
YOU
• ICD-9
Choose a code that is close as possible to a 5 digit
number = highest level of specificity
Main function of codes is to set up screens or
filters for medical review, a diagnosis may be
used as an item in a medical review
They are updated October 1st each year
Rehab diagnosis is the impairment based
diagnosis relevant to the problem to be treated.
Documentation: Focus is
YOU
• ICD-9
• Try to use exception codes and complicating Co
morbidities (CC) codes, they will qualify a client
for caps and exceptions
• Be sure to include all of the applicable codes
• Some instances the medical diagnosis has an
inherent correlation to rehab services i.e. MS
• Some diagnosis is associated with the medical
diagnosis i.e. CVA
Documentation: Focus is
YOU
• ICD-9
• V codes are allowed such as
V43.64 THR
V43.65 TKR
V49.75 BKA
V 49.66 AEA
Documentation: Focus is
YOU
• POC (Plan of Care)
Document necessity of therapy with: client self
reporting, goals, treatment
intensity/frequency/duration, certified POC with
physician signature in 30 treatment days,
identifies procedures and modalities used,
outcomes/goals must be
measurable/realistic/time limited, potential to
return to premorbid status, include discharge
criteria and follow up care
Documentation: Focus is
YOU
• POC (Plan of Care) continued
Document intervention requires complex
skill level by a clinician
Outcome measures and intervention need
to change if there is limited change in
function
Changing of LTG and dates need to have
justification documented
Documentation: Focus is
YOU
• Goals Criteria for being measurable:
1 Performance- client focused,
objective, observable behavior
(Who/What)
2 Criteria- degree to measure
outcome (quality of action)
3 Conditions- when, where, with
whom and under what
circumstances
4 Time Frame- date, when
Documentation: Focus is
YOU
• POC (Plan of Care) continued
Outcome measures need to have a
baseline of function to measure change
Standardized test scores alone are not
functional performance related to
occupation
Outcomes need to be measurable and
client centered (not written like: therapist
will do….)
Documentation: Focus is
YOU
• Terminology to Avoid
Slow progress, little progress noted, patient
agitated or confused, unable to learn,
disoriented to time and place, poor
attention span, no problems noted, little
hope for progress
Documentation: Focus is
YOU
• Suggested terminology
Redirected patient behavior, individualized training
program to maximize performance, customized
treatment approach to match condition of
patient, techniques to teach new skill added to
program, condition continues to require skilled
services, deficits continue to compromise safety,
positive results with safety issues addressed
Documentation: Focus is
YOU
• Treatment Encounter Notes
Identify the daily skilled treatment activities and
daily modalities provided, identify the
professional daily providing the service, use
CPT codes that match the treatment providedtimed and untimed codes, the note is the
justification for the billing doe on the claim,
Medicare assumes the client tolerated the
treatment unless there is documentation stating
otherwise, client’s response to intervention is a
good idea
Documentation: Focus is
YOU
• Treatment Encounter Notes continued
Document consistent units and timed
treatment minutes on the claim
Document change in frequency and
intensity of treatment from the POC
Document change in skilled treatment
activities or modalities (added/deleted)
between progress notes
Documentation: Focus is
YOU
• CPT Coding
Selection of code is based on -skills required
intent of service
desired outcome
Skills required= technical skills
physical effort
mental effort and judgment
risks involved if it could go wrong
Documentation: Focus is
YOU
• CPT Coding
Consider which service is more
intricate, intense and/or highly
skilled
Documentation: Focus is
YOU
• CPT Coding
Descriptions given for each code but it is up
to the interpretation of the clinician
Recommend consistency in methods and
practices in addition to how to define or
explain intent
Documentation: Focus is
YOU
• Progress Notes/Reports
Summarized the intervention and provides
justification for medical necessity, current
functional performance from previous
performance, progress towards outcomes for
each goal objectively/measurable/describe
changes in treatment care, identify
additions/deletions/changes to the expected
outcome and client’s response to changes,
revisions to POC
Documentation: Focus is
YOU
• Progress Notes/Reports continued
Document specialized skills used by the clinician to
validate medical necessity
Document current status in relation to functional
goals
Document need for intensity of therapy for
functional outcome
Document changes of skilled services if different
than the original POC (additions/deletions) and
explain the clinician’s reasoning
Documentation: Focus is
YOU
• Progress Notes/Reports continued
Identify the body part when documenting
therapeutic exercises or identify activity
when billing for therapeutic activities
Describe type of group activity in the
progress note if billing group therapy for
Medicare Part B
Documentation: Focus is
YOU
• Discharge summaries:
Document changes from the entire care to
justify medical necessity, including if
services were extended beyond the
customary length of time, summarize
progress in client’s ability to engage in
functional occupational activities,
recommendations for future needs, follow
up plans and referral information
Documentation: Focus is
YOU
• Discharge summaries:
Document progress toward goals in the
summary
Document appropriate carry over training to
client or caregiver
Document medical necessity for the
interventions used
Document clear skilled progress from last
note to discharge i.e. 1/31 to 2/5
Documentation: Focus is
YOU
• Cognition Aspects:
Document deficits lead to functional
loss such as disorientation and
memory loss
Caregiver feedback, education given
Interventions: visual cues,
distractions, strategies to reduce
behaviors, able to recall __ spaced
retrieval cues, use compensatory
strategies for safe return to__ or use
calendar for __
Documentation: Focus is
YOU
• Cognition Aspects:
Document how you are addressing
impaired cognition that is affecting __
Skills of a therapist or needs OT for __
Determine if the patient has a need for the
goal
Documentation: Focus is
YOU
• Cognition Aspects:
Example: if __cue is not used, the
client’s success rate drops to __.
__cues enhance ADL task, allowing
percentage
of function/independence .
Documentation: Focus is
YOU
• Group Therapy
Document why chose group therapy
Write clinical benefits
“Group addressed…… to
improve……”
Documentation: Focus is
YOU
• General things to consider when treating and
then documenting:
Use percentages
Describe level of functioning
Speed of response/response latency
Appropriateness of response
Describe successive approximations
HCR CEU 2010
Documentation: Focus is
YOU
• General things to consider when treating and
then documenting:
Number of episodes/occurrences
Physiological variations in the activity
What happened when you did what you did with
the patient?
Why is that change significant from a functional
point of view?
HCR CEU 2010
Documentation: Focus is
YOU
• General things to consider when treating and
then documenting:
Knowing that change occurred, what will you
do now?
What would you do more of?
What would you do less of?
What would you do differently?
HCR CEU 2010
Documentation: Focus is
YOU
Consider every note having:
 Statement of some progress
 Types of modalities provided and why
 Potential for future progress
 Plan for following week
 Use quotes from protocols and regulations
 Use standardized tests
Documentation: Focus is
YOU
Consider every note having:
 Strengths
 Barriers to discharge or
complicating factors
 Goals not met- why
 Teaching provided
Documentation: Focus is
YOU
• Tips:
Document with client present
Consider carryover effect
Break mindset that treatment is more
important “I could be treating other
patients”
Our jobs depend on our documentation
Our clients depend on our documentation
Documentation: Focus is
YOU
• Example
Mr. Smith demonstrates left sided neglect and left
sided visual deficits secondary to recent CVA.
Mr. Smith continues to have decreased oral intake
secondary to left sided neglect and left sided
visual deficits. Weight loss will result since
foods and liquids to the left are not consumed.
Documentation: Focus is
YOU
• Example
Mrs. Smith demonstrates poor posture while
seated out of bed in her wheelchair.
Mrs. Smith demonstrates skin tears and poor
positioning of flaccid arm found behind her,
sitting on it and entangled with the wheelchair
itself. Mrs. Smith will demonstrate ability to
maintain neutral position for __increments with
__adaptations for __sessions.
Resources
• OOTA CEUs, Board meetings and Older Adult
MSG Roundtable discussions
• Monica Robinson’s many CEUs
• OT Practice 12(2) February 2007
• OT Practice August 14, 2006
• HCR’s many CEUs and related trainings
• Ohio Health employee education
• Jan Winland’s AOTA CEU update 2010