Transcript Physician`s Guide to Documenting Medical

Physician’s Guide to Documenting
Medical Necessity
Lisa Bazemore, MBA, MS, CCC-SLP
December 5, 2006
Re-examining Our Documentation
• We have increased scrutiny
 Transmittal 221, 347, 478, 938 – guide to the FI on 75%
rule compliance
 LCD (Local Coverage Determination) – FI guide on
medical necessity
 RAC (Recovery Audit Contractor) – Appointed by CMS to
ensure IRF payments are substantiated
• Leadership
 Understand weaknesses and strengths
 Establish systems for review
 Push for documentation improvement through patient
advocacy.
Industry Trends
• From the beginning of the 75% rule modification
in July 2004, over 113,000 fewer patients in the
United States were admitted to inpatient
rehabilitation facilities.
• Assuming these patient were appropriate for
inpatient rehabilitation admission previously, it
means that 113,000 patients who would have
benefited from inpatient rehabilitation did not
receive it.
• Why?
Industry Trend
• 75/25 Rule – average compliance is 65% and
many units are unnecessarily well above this
compliance level
• Mixed messages scared too many
physicians/medical directors/program
directors into denying patient’s admission
• Improved physician documentation may have
resulted in fewer denied admissions
• Fear of the denial process
• RAC audit process
Medical Necessity
Let’s Try to Define Medical Necessity
There is not one specific aspect of care or one specific service that
defines medical necessity
Rather it is a combination of aspects of care that together
comprise medical necessity
Together these aspects determine which services are covered or
could possibly be denied
Medical Necessity
• Basic Principles
 Service must be reasonable and necessary (in terms of
efficacy and, duration, frequency, and amount) for the
treatment of the patient’s condition
 It must be reasonable and necessary to furnish the
care on an inpatient hospital basis, rather than less
intensive facility such as a Skilled Nursing Facility, or
on an outpatient basis
Medical Necessity
• Services are relevant to a patient’s diagnosis, symptoms,
condition or injury
• Services provided are within the standards of practice for
a specific condition or diagnosis
• Services require the skills of the specific professionals
within your setting
• Services that are provided in your setting possibly would
not be furnished in the same quality or quantity or time
frame in another setting
Medical Necessity
• Services are consistent with patient’s symptoms,
diagnosis, condition or injury
• Services are recognized as the prevailing standards and
are consistent with generally accepted professional
medical standards of the provider’s peer group
• Services treat a condition which could result in physical
or mental disability
• There is not another setting which is more conservative
or substantially less costly
Medical Necessity
• Most patients cannot be equally served in skilled
nursing facilities!
 IRF provides access to 24 hour rehabilitation
physician and nursing, 3 hours of therapy,
etc.
 Increased nursing time correlates with a
decrease in UTI’s and other complications
 Research is being done to determine if
outcomes with hip and knee replacement
patients is equivocal
Key Areas
• Pre-admission screening
 Document needs to stand alone and justify admission
• Physician documentation
 Establishes the justification for admission through H&P
• Nursing documentation
 The rehab nursing plan of care ties the medical
condition established by the physician and the
rehabilitation goals set by therapy
• Therapy documentation
 Demonstrates significant progress toward established
functional goals
• Translate everything into, “What am I doing for this
patient?”
Pre-Admission Screening
• Document should paint the picture for the
reason for admission and convince the reviewer
of the appropriateness of the admission
• Medical Necessity Issues
 Standard practice
 Would patient benefit significantly from “intensive
inpatient” hospital program or “extensive” assessment?
 Is inpatient rehabilitation “reasonable and necessary”?
• 75/25 Issues
 Assists with determination
 Supports RIC, comorbidities
Pre-Admission Screening
Issue
Action
Is inpatient
rehab
“reasonable &
necessary”?
•Treatment is specific & effective for patient’s
condition
•Services are at level of complexity &
sophistication or condition of patient is such
that the services can be safely & effectively
performed only by a qualified therapist
•Must be the expectation that the condition will
improve significantly in reasonable period of
time
•Amount, frequency, and duration of services
must be reasonable for an acute rehab program
to deliver
Physician Documentation
Issues
Action
Establishing
Medical
Necessity
•Why does the patient need to: occupy an acute rehab
Could this care
have been
provided in a
SNF?
bed? receive intensive therapy? at your specific
program?
Reason for admission (medical necessity)
Primary rehab diagnosis
Site the etiologic diagnosis and the rehab impairment classification (RIC)
Review of systems
Active co-morbid conditions – conditions that will be addressed by the
physician
List all medical problems with particular note to those that will affect the
rehab outcome
Identify functional limitations
Determine rehabilitation potential: for functional gain & for return to
independence
Identify pre-morbid function
Other therapy receive and outcome
Identify pre-morbid living situation
Establish general outcome goals: yours and the patient’s
Orders for therapy and nursing – including rehab nursing
Estimate the length of stay as it applies to goals
Note the expected discharge destination
Initiate discharge planning
Physician Documentation
Issues
Action
Close
•See patient every 2 – 3 days
medical
 Do each of these visits serve to demonstrate
supervision
active intervention by the physicians on the
medical and rehabilitation needs of the patient?
 Are there changes in orders for the
rehabilitation intervention by other members of
the team?
Document progress with rehabilitation
programs
Document changes in plan of care
Document barriers to attaining goals
Document collaborative efforts of team and
other consulting physicians
Components of the H&P
• Accurate and comprehensive
diagnosis
• Include all active comorbidities
• Review of body systems –
include risks and what
conditions require
continuous management and
may interfere with
participation
• Discuss any prior
rehabilitation efforts
• Identify functional abilities
and deficits
• Give reasons why patient
needs intense rehab not just
state patient will receive PT,
OT and nursing care
• Discuss rehab potential and
why potential is good or
excellent
• Estimate the LOS and
potential discharge location
Components of the H&P
• The Plan is the most important piece of the H&P because it sets
the interdisciplinary care plan
• It defines the medical, nursing, and therapy needs of the patient.
• Suggested goals:






Will consult physical therapy for
Will order occupational therapy for
Will order speech/swallowing therapy for
Rehabilitation nursing is required for the following specific duties Will consult Dr. () with internal medicine.
Will consult Dr. () with rehab psychology to work on maximizing interactions
with therapy, to decrease stress, to work on pain management issues and
adjustment issues as necessary.
 Medical issues being managed closely and require the 24 hour availability of a
physician specializing in physical medicine and rehabilitation are as follows  Goals - The patient is currently () with ADL's, ambulation, and transfers. We
would like the patient to be modified independent with ADL's, ambulation, and
transfers by discharge.
Components of the Daily Note
SUBJECTIVE:
OBJECTIVE:
Vitals: BP , T , P , R , Pulse ox
LUNGS: clear to auscultation bilaterally __, rhonchi __, rales __, wheezes __, crackles __
CV: regular rate and rhythm __ murmurs __, rubs __, gallops __
Abd: soft __, non-tender __, normal active bowel sounds __, obese __
Ext: cyanosis __, clubbing __, edema __, calf tenderness __ (Right __ Left __)
Neuro:
Labs:
PLAN:
1. Justification for continued stay 2. Medical issues being followed closely 3. Issues that 24 hours rehabilitation nursing is following 4. Rehab progress since last note –
5. Continue current care and rehab
Components of the Daily Note
• Medication changes – document why changed
• Lab results – document decisions made based on lab results
• Ordering additional tests/labs – document reason why ordered,
discuss risks, advantages, hasten rehab participation and
discharge
• Document interaction with other professionals
• Document patient’s functional gains as discussed with patient
Components of the Discharge Summary
Medical Issues that required an acute level of care:
Patient is a 63 year old male with a history of… While on the unit we managed these complicated issues…
Brief History of Rehab Stay:
Functional Independent Measures Scores
Ambulation - The patient was () on admission with gait at () feet with/without assistive
device. The patient was () at discharge with gait at () feet with/without assistive device.
Admission
Eating
Grooming
Bathing
UE Dressing
LE Dressing
Toileting
Discharge
Components of the Discharge Summary
continued
Discharge Diagnosis:
Discharge Co-morbidities:
Discharge Follow-up:
Discharge Diet: regular __, ADA __, AHA __, low salt __
Discharge Condition: stable __, fair __, guarded __
DISCHARGE MEDICATIONS:
DISCHARGE LABS:
DISCHARGE RADIOLOGY REPORTS:
PLAN:
1. Discharge medications written
2. Discharge follow-up with
3. Discharge therapy with outpatient/home health care/no therapy needed
Justifying Medical Necessity
These words when used may not support medical
necessity:
Normal
Maintained
Monitoring
Combative
Regression in function
Insignificant
Poor rehab potential
Custodial
Inability to follow directions Minimal
Refused to participate
Plateau
Chronic/long term condition Inappropriate
Demented/Confused
Old onset
Uncooperative
Stable
“Nothing to do. Continue current
care and rehab”
Justification of Medical Necessity
When used appropriately, these words help justify medical
necessity.
Managing
Critical
Risk of infection
Prior level of function
Gains
Appropriate
Progress
Improvement
Motivated
Continued
Responsive
Increase in function
Required the skills of a therapist
Reasonable and necessary
Safe and effective delivery
Medical complications
Reasonable probability
Potential for complications
High risk factor
Safety issues
Significant
The patient has the potential
for a sudden change in status
Why do we do this?
• This is about access to care!
• We have not identified or not admitted too
many patients that with appropriate treatment
to help them recover and regain their prior level
of function would have benefited from an IRF
stay.
• Think back to the old days. Who benefited from
rehab and what types of patients were you
trained to treat in an IRF? Admit those patients,
document appropriately, and be prepared to
fight every denial and everybody wins.
What else can we do?
• Medical Directors should meet with leadership
team to work on case finding
• Review admission times and the admission
process. Make it as easy as possible to admit to
the IRF. See if this paradox exists on your
unit…external admissions are approved more
readily than internal admissions.
• Improve communication with case
management, the patient, and referring
physician when patients are denied transfer or
the transfer is delayed
Questions?
Contact me at:
[email protected]
202-588-1766