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?
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Tina Young, MSOT, OTR/L
Older Adult MSG
RAC, MDS 3.0 and RUGS IV
How they will affect OT practice?
Medical necessity, skilled services, measurable progress/goals, coding and more
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
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!!!!
Documentation can only use approved JCAHO abbreviations
2014 all documentation must be electronic nationwide
Claims could be for illegibility or incorrectly spelled words
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”
Transfer services from PRN therapists on evals
Errors procedure must include: single line through item, word “error”, initials and date on each entry
“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
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
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
Nursing will have more brief interview section for cognition (MMSE)
SLP will document signs/symptoms of swallowing deficits
Increase in Audits
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
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
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
To Ensure Payment
To Ensure Payment
Tolerated treatment well (assumption unless stated otherwise)
Continue per plan of care
Cognition interferes with therapy
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
Reason why for group, write clinical benefits, group addressed…… to improve…….
Dementia diagnoses are most common
Lack of cognitive scores
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
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?)
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
Dementia clients can make progress
Allowed us to treat clients to their highest level
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
Referral from who, supportive documentation
Physician order and certification
Expectation of Improvement
Standardized tests and correlation to function
Goals-reasonable, predictable period of time
Coding: ICD-9 and CPTDocumentation: 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”?
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,
Qualifications of a therapist needed to provide intervention, pertinent medical or therapy history to determine degree of functional loss, reason for referral-why evaluating
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
“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.
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.
V 49.66 AEA
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
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
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
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….)
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
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
Identify the daily skilled treatment activities and daily modalities provided, identify the professional daily providing the service, use CPT codes that match the treatment provided- timed 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
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
Selection of code is based on -skills required
intent of service
Skills required= technical skills
mental effort and judgment
risks involved if it could go wrong
Consider which service is more intricate, intense and/or highly skilled
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
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
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
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
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
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
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 __
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
Example: if __cue is not used, the client’s success rate drops to __. __cues enhance ADL task, allowing percentage
of function/independence .
Document why chose group therapy
Write clinical benefits
“Group addressed…… to improve……”
Describe level of functioning
Speed of response/response latency
Appropriateness of response
Describe successive approximations
HCR CEU 2010
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
Knowing that change occurred, what will you
What would you do more of?
What would you do less of?
What would you do differently?
HCR CEU 2010
Consider every note having:
Consider every note having:
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
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.
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.