Transcript How Do We Document Medical Necessity?

Section 3: Embracing
Medical Necessity
Setting the Stage
• Why do we document care?
 To insure payment for the services rendered
 To insure continuity of care
• Principles of documentation:
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Document to your audience
Focus on deficits
Attainable goals
Progress towards goals
Consider barriers to discharge
Consider return to both home and community
Setting the Stage
• What is Medical Necessity?
 A course of treatment that is seen as most
helpful for the specific health symptoms that
the patient is experiencing. This course of
treatment is determined by the patient and
their healthcare team.
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
Setting the Stage
• 7 Criteria of Medical Necessity
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Medical Supervision
24 Hour Rehab Nursing
Relatively Intense Level of Services
Multidisciplinary Approach
Coordinated Care Plan
Significant Practical Improvement
Realistic Goals
Components of Medical Necessity
• Close Medical Supervision
 24 hour availability of a physician
 Entries in the chart every 2 -3 days minimum
 Greater involvement that in other settings
Components of Medical Necessity
• 24 Hour Rehabilitation Nursing
 Need availability of an RN with rehab experience
around the clock
 Have clear, functional rehabilitation goals
 Nursing is involved in the overall plan of care, not just
medical issues and bowel and bladder management
 Nursing documentation supports FIM scores
 Nursing documentation clearly identifies how they
facilitate the carryover of learning from therapy
sessions
 Nursing documentation supports the medical
management of the patient
Components of Medical Necessity
• Relatively Intense Level of Rehabilitation
Services
The 3 Hour Rule
Minimum of 3 hours of therapy, 5 days per week
Therapy is at a skilled level
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
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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
• Weekly team conference
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
How Do We Document Medical Necessity?
• Team has an ongoing opportunity to document
medical necessity. This is achieved by
documenting:
 That services needed are of a complex nature that they
require a licensed clinician
 Services need to be in an inpatient setting
 Services are consistent with diagnosis, need, and
medical condition
 Services are consistent with the treatment plan
 Services are reasonable and necessary
 Patient is making progress towards reasonable goals
Where Do We Document Medical Necessity?
• Pre-admission Screening
• Physician Documentation
• Team Admission Assessments
• Nursing Admission Assessments
• Patient Care Plan
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Long term goals
Short term goals
Identification of involved disciplines
Weekly progress notes
Discharge summaries
• Team Conference Summaries
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
Preadmission Screening
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Diagnoses
Comorbidities
Age
Current interventions
Functional Assessment
Vitals
Safety
History
Medications
• Pre-morbid
status/function
• Recommendation of need
for 2 or more disciplines
• Rehab potential
• Areas where improvement
is expected
Physician Documentation
Issues
Action
Establishing
Medical
Necessity
•Why does the patient need to: occupy an acute rehab bed?
Could this care
have been
provided in a
SNF?
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:
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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
Team Admission Assessment
• Prior level of function
• Required assistance
• Living situation
• Anticipated discharge
plans
• Patients rehab
expectation
• Individual FIM’s with
emphasis on findings
• ROM and Strength
limits
• Sensation, tone, etc.
• Community
reintegration
• Pain assessments
• Summaries of
findings
Documenting on the Patient Care Plan
• The Patient Care Plan should include:
 Prioritized patient goals
 Impairments, Activity, Participation
 Planned Discharge Site
 Interdisciplinary Long Term Goals
 What disciplines will be involved in the care of
the patient
 Interventions
IAP Example
Admission
Discharge
Impairments
Osteoarthritis in knees, Osteoarthritis in knees, hips,
hips, back, R shoulder
back, R shoulder
Activities
Impaired mobility, LB
dressing, bathing &
toileting
Can’t shop for groceries,
Afraid to cook, can’t
Participation
perform job duties,
can’t play golf
Improved to mod I in mobility,
bathing & dressing
w/adaptive equip.
Able to shop for basic food
items, can prepare simple
meal, will return to work 2
weeks post d/c, return to golf
6 mo post d/c
Documenting Progress
• At least weekly, a summary of the
patient’s progress should be
documented.
 Document progress toward goals
 Detail barriers to achievement of goals
 Describe changes to the plan of care as
appropriate
 Describe patient’s response to treatment
 State the justification for continued stay on
the rehab unit
Daily Documentation of Medical Necessity
• Daily documentation should show skilled
need in:
 Weekly short term goals
 Total units of therapy
 Treatment/training
 Daily comments
What Constitutes a Skilled Service
• Knowledge and training of a professional is
necessary
• Need should be indicated in initial evaluation
• Evidence that skilled services were performed
should be reflected in notes
What Constitutes a Skilled Service
• Services must be of such a level of complexity
and sophistication or the condition of the
patient must be such that the services required
can only be safely and effectively performed by
qualified nurses and therapists.
• Skilled services can be:
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Diagnostic and assessment
Designing treatment
Establishment of compensatory skills
Providing patient instruction
Reevaluations
Skilled versus Non-Skilled
Nonskilled
Skilled
Observed patient trying
to get out of bed. Pt
unable to come to
sitting without help.
Training provided to facilitate
independence in bed mobility.
Tactile and verbal cuing provided to
produce knee flexion and arm
extension and push.
Pt expression - 2 with
nurses.
Pt. taught to use call light and
respond “bathroom”. Pt able to
perform sequence of pushing call
light and responding to nurse 4/5.
Pt – UB Dressing 4
Pt. taught strategies for compensation
of left visual neglect to facilitate
independence in dressing. Min
assist required for buttoning shirt.
Terms
Terms To Avoid
Terms That Connote Skilled
Services
Ambulate
Gait training
Monitor
Assess
Observe
Evaluate
Tires easily
Required rest periods due to…..
Encourage
Instruct/educate
Discuss
Teach
Drills
Tasks
Little change
Continues to require
Pt performed
Continues to progress
Supervised
Analyze
Design
Justifying Medical Necessity
These words when used may not support medical necessity:
Normal
Monitoring
Regression in function
Poor rehab potential
Inability to follow directions
Refused to participate
Chronic/long term condition
Demented/Confused
Uncooperative
Maintained
Combative
Insignificant
Custodial
Minimal
Plateau
Inappropriate
Old onset
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
Denials
• Why do payers tell us they deny claims?
 Patient does not meet eligibility criteria
 Services are not skilled
 Services are not necessary for patient’s
diagnosis, medical condition, or no assessed
need
Denials
• How can we avoid denials?
 Document interventions clearly and precisely
 Use active, descriptive verbs
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?
Lisa Bazemore, MBA, MS, CCC-SLP
[email protected]
(202) 588-1766