Documentation for Older Adults: What does yours say?

1. Documentation for Older Adults: What does yours say? Tina Young, MSOT, OTR/L Older Adult MSG March 26, 2011 tyoung@oota.org

2. Goals • 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

3. Long Term Care Changes • What do these changes mean? Increase in Audits And Denials

4. Medicare Denials/Audit Process Recommendations: Respond to ALL Medicare denials Prepare documentation/clinicians to reduce denials as best defense (hone our documentation skills)

5. 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

6. 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)

7. 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

8. 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

9. Medicare Denials/Audit Process • Addressing group therapy documentation Reason why for group, write clinical benefits, group addressed…… to improve…….

10. 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?)

11. 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

12. Relevant Transmittals that affect Documentation and denials • Transmittal #262 continued Dementia clients can make progress Allowed us to treat clients to their highest level Stress remaining abilities that can be capitalized versus barriers due to cognition Cognitive recall is not necessary to participate in this plan of care nor necessary for skilled intervention

13. Documentation becomes fact, Louder than what we do. Joyce Smith

14. Medical necessity Skilled services Referral from who, supportive documentation Physician order and certification Expectation of Improvement Standardized tests and correlation to function Goals-reasonable, predictable period of time Medical complexities Prior level Supervision/co- signatures Measurable Coding: ICD-9 and CPT Documentation: Focus is YOU

15. 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? Why are YOUR needed (skills) vs. CNA? HCR CEU

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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.

25. Documentation: Focus is YOU • POC (Plan of Care) 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

26. Documentation: Focus is YOU • POC 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….)

27. 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

28. 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

29. 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

30. 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

31. Documentation: Focus is YOU • CPT Coding Consider which service is more intricate, intense and/or highly skilled

32. Documentation: Focus is YOU • Progress Notes/Reports 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

33. 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

34. 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

35. 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 __

36. Documentation: Focus is YOU Consider every note having: • Statement of some progress • Types of modalities provided and why and to where • Potential for future progress • Plan for following week • Use quotes from protocols and regulations • Use standardized tests

37. 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

38. Resources • OOTA CEUs, Board meetings and Older Adult MSG Roundtable discussions • OOTA State Pre-Conference 2010 Older Adult Focus • 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