Transcript Pre-Admission_Screen_02_09

Proving Medical Necessity Through
the Pre-Admission Screen
Lisa Bazemore, MBA, MS, CCC-SLP
Current Situation
• The battle of medical necessity
 MAC update
 LCD news
 RAC activity
• Final rule considerations
 Conditional versus presumptive compliance
 Market basket freeze
 2009 fiscal year payment changes
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
• Services treat a condition which could result in physical or
mental disability
Setting the Stage
• Criteria of Medical Necessity
1.
2.
3.
4.
5.
6.
7.
Medical Supervision
Rehabilitation Nursing
Relatively Intense Level of Services
Multidisciplinary Approach
Coordinated Care Plan
Significant Practical Improvement
Realistic Goals
Components of Medical Necessity
• Relatively Intense Level of Rehabilitation
Services
 Skilled therapy, 5 days per week
 Must be necessary for meeting the basic needs of the
patient’s health
 Must be consistent in type, frequency, and duration
 Consistent with the patient’s diagnosis
Components of Medical Necessity
• Interdisciplinary Approach
 Members work collaboratively to develop goals and the
treatment plan
 Team members engage and learn from each other
 Collaborative ownership of the patient treatment plan
Components of Medical Necessity
• Coordinated Plan of Care
 Records need to show a treatment plan that
is:
• Derived from team assessment and patient
expectations
• Identifies STG’s and LTG’s
• Defines how disciplines share responsibility
• Supports need for intensive rehab services
Components of Medical Necessity
• Significant Practical Improvement
 We do not expect 100% independence for all rehab
patients
 We do expect reasonable, practical improvement
 Improvement must be the result of skilled services
provided
 Important that it is documented clearly
Components of Medical Necessity
• Realistic Goals
 Aim of treatment needs to be achieving the maximum
level of function possible
 Must be linked to the patient’s prior level of function
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
Pre-Admission Screening
• Why do we conduct a pre-admission screening?
 To gather information on whether the patient is a good
rehabilitation candidate
 To determine whether the unit is equipped to manage the
medical and functional needs of the patient
 To gather preliminary information on the anticipated reason
for admission
 To determine whether the patient will benefit significantly
from an inpatient rehabilitation stay
 MOST IMPORTANTLY-to set the stage for the medical
necessity of the admission
Pre-Admission Screening
• One Local Coverage Determination Policy quotes the Medicare Benefit
Policy Manual saying:
 While preadmission screening is a standard practice in most
rehabilitation hospitals and may provide useful information
for claims review purposes, the absence of preadmission
screening in a particular case is not adequate reason for
denying a claim. However, in a case where an inpatient
assessment showed that a patient clearly was not a good
candidate for an inpatient hospital program, then the
presence or absence of preadmission screening information is
important in determining whether the inpatient assessment
itself was reasonable and necessary. If preadmission
screening information indicated that the patient had the
potential for benefiting from an inpatient hospital program, a
period of inpatient assessment could be covered, up to the
point where it was determined that inpatient hospital
rehabilitation was not appropriate, since preadmission
screening cannot be expected to eliminate all unsuitable
candidates. CMS Publication 100-02, Medicare Benefit Policy
Manual, Chapter 1, Section 110.2
Pre-Admission Screening
• How do you ensure that the pre-admission screening is
reporting the right stuff?
 The obvious items include:
• Diagnoses
• Comorbidities with origin of the condition
• Age
• Current interventions
• Functional Assessment
• Vitals with height, weight, and BMI
Pre-Admission Screening
• How do you ensure that the pre-admission screening is
reporting the right stuff?
• Safety
• History
• Medications with reason for the prescription
• Pre-morbid status/function
• Recommendation of need for 2 or more therapies
• Rehab potential with preliminary discharge
destination
• Areas where improvement is expected
Pre-Admission Screening
• The less obvious things to report?
• Medical conditions with emphasis on what will
require ongoing treatment in rehab
• Quality and type of support offered by the caregiver
• What the patient’s pre-morbid participation level
and level of interest were
• What special needs the patient will have upon
admission (wheelchair measurements, oxygen,
isolation)
Pre-Admission Screening
• Look for information in all sections of the chart:
 Labs
 X-Rays
 Respiratory needs
 Cardiac needs
 Safety concerns
Pre-Admission Screening
• Make the case for medical necessity:
 Explain how the conditions of participation are met
 What are the anticipated medical needs?
 What will the nurses be involved in while caring for this
patient?
 Does this patient require on-going hospital level care
and intense therapy? For what?
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”?
 Think and document defensively: “Why does this patient
need inpatient rehab vs. a lower level of care?”
• 60% Rule Issues
 Assists with determination
 Supports RIC, comorbidities
Pre-Admission Screening
• Traps:
 Beware of forms that are not completely filled in
 Ensure that the medical director reviews each admission and
signs the pre-admission screening form to show consent to
admit
 Make sure the pre-admission screening form is available to
staff upon admission to be used for gathering additional
patient information
 This is a preliminary document that will have the anticipated
impairment group code and etiologic diagnosis, but physician
has the final say in what the reason for admission is following
his/her assessment
 Do not close a medical record before ensuring that the preadmission screening form is filed in the chart
Pre-Admission Screening
• Principles of case finding:
 Look for patients who meet the conditions of
participation.
• Require physician supervision 24/7
• Require rehab nursing
• Need 3 hours of therapy from a multidisciplinary
team
• Have the potential to improve significantly
Pre-Admission Screening
• Principles of case finding:
 Does diagnosis matter?
• Diagnosis matters, but clinical presentation matters more
• Patients who do not have a rehab diagnosis may meet criteria
more than those with a rehab diagnosis
 How do you educate referral sources?
• Ask for referrals based on conditions of participation
 Who do you miss if referrals are made on diagnosis alone?
• Medically complex cases?
• Are these patients valuable?
Pre-Admission Screening
• CMG Matrix Examples:
 Patient 1 is 80 years old and had an admission motor score
of 31.0.
• With CMG 0804$13,285
10 days
$1,328 per day
• With CMG 2003$17,576
14 days
$1,255 per day
Pre-Admission Screening
• CMG Matrix Examples:
 Patient 2 is 86 years old and had an admission motor score
of 38.0
• With CMG 0802$10,279
8 days
$1,285 per day
• With CMG 2002$13,617
11 days
$1,238 per day
Pre-Admission Screening
• CMG Matrix Examples:
 Patient 3 is 73 years old and had an admission motor score
of 21.0
• With CMG 0806$20,125
15 days
$1,342 per day
• With CMG 2004$23,451
18 days
$1,302 per day
Pre-Admission Screening
• Principles of case finding:
 Look for patients with on going medical needs
• Set up a preliminary plan for care in the IRF
• Establish argument for why post-acute care is necessary
• Justify admission
Pre-Admission Screening
• Principles of case finding:
 Is discharge disposition important?
• Must have a reasonable chance of returning home or
achieving greater independence as a result of the rehab
stay
• When the discharge plan is SNF, an IRF stay may still be
justified
• Documentation should support the need for 24/7 medical
and nursing supervision needs and multidisciplinary care
Pre-Admission Screening
• Principles of case finding:
 How functional is too functional?
• When the patient can walk 150 feet with minimal assistance,
there may be more to the story
• Dig in and get more information
• Patient function is one piece of the puzzle: Find out what else is
going on
 How impaired is too impaired?
• If acute care therapy has not evaluated a patient, it may be ok
to admit them anyway
Predictive qualities:
Ability to sit on the edge of bed
Length of time in a chair
Amount of assistance with bed mobility
Motivation and willingness to participate in care
• If it is clear the patient will not be able to tolerate 3 hours of
intensive therapy within 10 days of admission they are likely too
impaired