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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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long term care updates and documentation strategies

Long Term Care Updates and Documentation Strategies

Tina Young, MSOT, OTR/L

Older Adult MSG

May 2010

objectives
Objectives
  • Introduction to the upcoming changes:

RAC, MDS 3.0 and RUGS IV

How they will affect OT practice?

  • Documentation strategies with emphasis on the therapist rather than the client:

Medical necessity, skilled services, measurable progress/goals, coding and more

goals
Goals
  • Therapists will be able to state 2 upcoming changes in October 2010
  • 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
  • Therapists will realize documentation is about the therapists’ skills, not just the client’s progress
long term care changes
Long Term Care Changes
  • RAC

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

long term care changes5
Long Term Care Changes
  • RAC continued

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!!!!

long term care changes6
Long Term Care Changes
  • RAC continued

Documentation can only use approved JCAHO abbreviations

2014 all documentation must be electronic nationwide

Claims could be for illegibility or incorrectly spelled words

long term care changes7
Long Term Care Changes
  • RAC continued

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”

long term care changes8
Long Term Care Changes
  • RAC continued

Transfer services from PRN therapists on evals

Errors procedure must include: single line through item, word “error”, initials and date on each entry

long term care changes9
Long Term Care Changes
  • RAC continued

“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

long term care changes10
Long Term Care Changes
  • MDS 3.0

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

long term care changes11
Long Term Care Changes
  • RUGS IV

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

long term care changes12
Long Term Care Changes
  • RUGS IV continued

Nursing will have more brief interview section for cognition (MMSE)

SLP will document signs/symptoms of swallowing deficits

long term care changes13
Long Term Care Changes
  • Extension of Cap most likely beyond 12/31/10 deadline
  • Section 6121 mandates dementia care and abuse training for all SNF employees by 3/2011
  • Incentives for prevention and wellness
  • Monitor readmissions to hospitals 1/2013
  • CLASS Program developed rollout 2012
long term care changes14
Long Term Care Changes
  • What do these 3 changes mean?

Increase in Audits

And Denials

medicare denials audit process
Medicare Denials/Audit Process
  • Appeal process:

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

medicare denials audit process16
Medicare Denials/Audit Process

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

medicare denials audit process17
Medicare Denials/Audit Process
  • Recommendations:

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

medicare denials audit process18
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
medicare denials audit process19
Medicare Denials/Audit Process

To Ensure Payment

  • Paint a Picture of the Patient with content not fluff
  • Be specific, clear and concise
  • Don’t write defer/refer to…..
  • Don’t leave blanks
  • Ask a therapist “can I read the note and know what to do next?”
medicare denials audit process20
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)
medicare denials audit process21
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

medicare denials audit process22
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

medicare denials audit process23
Medicare Denials/Audit Process
  • Addressing group therapy documentation

Reason why for group, write clinical benefits, group addressed…… to improve…….

medicare denials audit process24
Medicare Denials/Audit Process
  • My recent experience with ADRs:

Dementia diagnoses are most common

Lack of cognitive scores

UI treatment

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

relevant transmittals that affect documentation and denials
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?)

relevant transmittals that affect documentation and denials26
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

relevant transmittals that affect documentation and denials27
Relevant Transmittals that affect Documentation and denials
  • Transmittal #262 continued

Dementia clients can make progress

Allowed us to treat clients to their highest level

relevant transmittals that affect documentation and denials28
Relevant Transmittals that affect Documentation and denials
  • Transmittal #262 continued

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

documentation focus is you
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
documentation focus is you30
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?

Did YOU say that?

Why are you needed (skills) vs. CNA”?

HCR CEU

documentation focus is you31
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,

documentation focus is you32
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

documentation focus is you33
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

documentation focus is you34
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
documentation focus is you35
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
documentation focus is you36
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
documentation focus is you37
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
documentation focus is you38
Documentation: Focus is YOU
  • Explain results of tests: i.e. MMT below 3/5, patient is unable to utilize UE for feeding successfully without assistance or would be unable to assist with bathroom transfers
documentation focus is you39
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.
documentation focus is you40
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.

documentation focus is you41
Documentation: Focus is YOU
  • ICD-9

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.

documentation focus is you42
Documentation: Focus is YOU
  • ICD-9
  • Try to use exception codes and complicating Co morbidities (CC) codes, they will qualify a client for caps and exceptions
  • Be sure to include all of the applicable codes
  • Some instances the medical diagnosis has an inherent correlation to rehab services i.e. MS
  • Some diagnosis is associated with the medical diagnosis i.e. CVA
documentation focus is you43
Documentation: Focus is YOU
  • ICD-9
  • V codes are allowed such as V43.64 THR

V43.65 TKR

V49.75 BKA

V 49.66 AEA

documentation focus is you44
Documentation: Focus is YOU
  • POC (Plan of Care)

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

documentation focus is you45
Documentation: Focus is YOU
  • POC (Plan of Care) continued

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

documentation focus is you46
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

documentation focus is you47
Documentation: Focus is YOU
  • POC (Plan of Care) continued

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….)

documentation focus is you48
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

documentation focus is you49
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

documentation focus is you50
Documentation: Focus is YOU
  • Treatment Encounter Notes

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

documentation focus is you51
Documentation: Focus is YOU
  • Treatment Encounter Notes continued

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

documentation focus is you52
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

documentation focus is you53
Documentation: Focus is YOU
  • CPT Coding

Consider which service is more intricate, intense and/or highly skilled

documentation focus is you54
Documentation: Focus is YOU
  • CPT Coding

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

documentation focus is you55
Documentation: Focus is YOU
  • Progress Notes/Reports

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

documentation focus is you56
Documentation: Focus is YOU
  • Progress Notes/Reports continued

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

documentation focus is you57
Documentation: Focus is YOU
  • Progress Notes/Reports continued

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

documentation focus is you58
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

documentation focus is you59
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

documentation focus is you60
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 __

documentation focus is you61
Documentation: Focus is YOU
  • Cognition Aspects:

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

documentation focus is you62
Documentation: Focus is YOU
  • Cognition Aspects:

Example: if __cue is not used, the client’s success rate drops to __. __cues enhance ADL task, allowing percentage

of function/independence .

documentation focus is you63
Documentation: Focus is YOU
  • Group Therapy

Document why chose group therapy

Write clinical benefits

“Group addressed…… to improve……”

documentation focus is you64
Documentation: Focus is YOU
  • General things to consider when treating and then documenting:

Use percentages

Describe level of functioning

Speed of response/response latency

Appropriateness of response

Describe successive approximations

HCR CEU 2010

documentation focus is you65
Documentation: Focus is YOU
  • General things to consider when treating and then documenting:

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

documentation focus is you66
Documentation: Focus is YOU
  • General things to consider when treating and then documenting:

Knowing that change occurred, what will you

do now?

What would you do more of?

What would you do less of?

What would you do differently?

HCR CEU 2010

documentation focus is you67
Documentation: Focus is YOU

Consider every note having:

  • Statement of some progress
  • Types of modalities provided and why
  • Potential for future progress
  • Plan for following week
  • Use quotes from protocols and regulations
  • Use standardized tests
documentation focus is you68
Documentation: Focus is YOU

Consider every note having:

  • Strengths
  • Barriers to discharge or complicating factors
  • Goals not met- why
  • Teaching provided
documentation focus is you69
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

documentation focus is you70
Documentation: Focus is YOU
  • Example

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.

documentation focus is you71
Documentation: Focus is YOU
  • Example

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.

resources
Resources
  • OOTA CEUs, Board meetings and Older Adult MSG Roundtable discussions
  • 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