Clinical Documentation for Medical Necessity (Including the FIM ® Instrument)

1. Clinical Documentation for Medical Necessity (Including the FIM® Instrument) The user-friendly UDSMR® presentation that will help you improve your interdisciplinary clinical documentation! © 2007–2009 Uniform Data System for Medical Rehabilitation. All rights reserved. FIM, Mini-FIM, UDS-PRO, UDS-PROi, UDSMR, and the UDSMR logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

2. Disclaimer The information provided in this presentation includes information provided in the IRF FY 2010 Final Rule and has been updated based on the changes to the Medicare Benefit Policy Manual Published October 23, 2009by the Centers for Medicare and Medicaid Services. Implementation of the new policy is set for January 1, 2010. This content is provided for informational purposes only. UDSMR assumes no liability or responsibility for any errors or omissions, use, or interpretation of the information contained in this presentation.

3. Objectives • Review IRF PPS policies and regulations • 60% rule • Medicare Conditions for Participation • Discuss the rehabilitation process • Pre-admission • Admission • Daily documentation • Team meeting • Discharge • Medical necessity documentation • Understanding the payment system • CMG assignment • MACs • Current IRF audits

4. Objectives • FIM® item review • 18 FIM® items with clarifications and helpful hints • Interdisciplinary documentation tips and examples that demonstrate medical necessity and support the FIM® ratings placed on the IRF-PAI • UDSMR’s database findings • Scoring inconsistencies • Practice scenario • Discussion/Q&A

5. Inpatient Rehabilitation Facility Prospective Payment System Rules and Regulations

6. Common Abbreviations ALOS: Average length of stay CMS: Centers for Medicare and Medicaid Services CMG: Case-mix group FI: Fiscal intermediary IGC: Impairment group code IRF: Inpatient rehabilitation facility IRF-PAI: Inpatient Rehabilitation Facility Patient Assessment Instrument LCD: Local coverage determination MAC: Medicare administrative contractor PPS: Prospective Payment System RAC: Recovery audit contractor UB-04: Billing form

7. CMS Policies and Regulations “In order for IRF care to be considered reasonable and necessary, the documentation in the patient’s IRF medical record must include”: • Pre-admission screening • Post-admission physician evaluation • Plan of Care • Admission Orders MBPM Section 110.2

8. CMS Policies and Regulations • At the time of admission the following criteria must be met: • Patient must require active and ongoing therapeutic interventions of multiple disciplines • OT, PT, SLP Prosthetic/orthotics • One of which must be OT or PT • Patient must require an intensive rehabilitation therapy program • 3 hours of therapy per day, at least 5 days a week • In certain, well documented cases, 15 hours of intensive therapy within a 7 consecutive day period, beginning with the date of admission MBPM Section 110.2

9. CMS Policies and Regulations • Patient must be expected to actively participate, and benefit significantly from intense therapy program • Measurable improvements of practical value to patient’s functional capacity or adaptation to impairments within a prescribed period of time • Patient requires physician supervision by a rehabilitation physician • Face to face visits at least 3 days per week throughout the patient’s stay • Medical and functional assessments • Modifications of treatments as needed MBPM Section 110.2

10. CMS Policies and Regulations • Patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation MBPM Section 110.2

11. CMS Policies and Regulations • The IRF PPS was designed to ensure that Medicare payments were accurate for this setting and that beneficiaries have access to high quality care in the most appropriate setting • Must demonstrate that services offered are designed to provide specialized rehabilitation care to patients with the most intensive needs • Patient cannot be cared for properly in a less intense setting such as SNF, subacute, or outpatient

12. A Quick Look at the 60% Rule Compliance with the 60% rule should not be confused with meeting “medical necessity,” but rather rules regarding the types of patients that we can admit to our IRFs. This is also CMS policy.

13. 60% Rule (Formerly 75% Rule) • Must be a rehabilitation hospital or distinct unit that has a Medicare provider agreement • Rehabilitation services must provide to an inpatient population being treated for:

14. Final Rule Medical Conditions Stroke Spinal Cord Injury Congenital Deformity Amputation Major Multiple Trauma Hip Fracture Brain Injury Neurological Disorders Burns Active, Polyarticular Rheumatoid Arthritis, Psoriatic Arthritis, and Seronegative Arthropathies Systemic Vasculidities with joint inflammation Severe or Advanced Osteoarthritis Knee or hip replacement, if at least one of the following conditions are met: 75% RuleTransmittal 478 (2/18/05) The “HCFA 10” becomes…. “CMS 13” Change from polyarthritis to:

15. Hip and Knee ReplacementsTransmittal 478 • During an acute hospitalization immediately preceding the IRF stay and also meets one or more of the following criteria: • Patient underwent bilateral knee or bilateral hip joint replacement surgery immediately preceding the IRF admission • Patient is extremely obese with a body mass index (BMI) of at least 50 at the time of admission to the IRF • Patient is age 85 or older at the time of the admission to the IRF

16. Transmittal 478 • In order to be counted as a compliant case, one of the following in the record must match one of the codes specified in Transmittal 478 (commonly referred to as the “Change Request”): • IGC • Etiologic diagnosis • Comorbid condition (ICD-9-CM) code (presumptively compliant) • This information was updated in Transmittal 938, May 5, 2006. Transmittal 938 is still in use for determining 60% rule compliance today.

17. CHANGE REQUEST 5016 TRANSMITTAL 938MAY 5, 2006Effective date: August 7, 2006

18. Some IGCs have conditions that, when used as an etiologic diagnosis, make a case not compliant.

19. 60% Rule • On December 31, 2007, President Bush signed into law the Medicare, Medicaid, and SCHIP Extension Act of 2007 • Permanently repeals the 75% rule for IRFs • Returns the compliance threshold to 60% • Allows comorbid conditions to count toward 60% compliance threshold • Retroactive change effective July 1, 2006 BUT… this in no way lessens conditions for participation as an IRF OR medical necessity requirements!!!

20. Documentation Requirements • There must be documentation establishing appropriate medical necessityfor the inpatient services rendered to the patient. If the IRF-PAI data are recorded accurately, they form the basis for documenting the medical necessity of services provided. • Other sources (e.g., physician notes, nursing notes, therapy notes) will be used to support the accuracy of the IRF-PAI data. Reference: Fed. Register, Vol 66, No 152, page 41329

21. IRF Coverage Requirements • Medicare IRF PPS, FY 2010 Final Rule; 42 CFR 412 • Effective for discharges on or after January 1, 2010 • Provides provisions addressing IRF admissions and post-admission procedures • Developing and implementing an overall individual treatment plan for each Medicare patient • Emphasizes the role of a rehabilitation physician in ordering IRF services and providing ongoing oversight of each patient’s care

22. IRF Coverage Requirements • Provisions in the FY 2010 final rule focus on clarifying key decision points that need to be considered and documented when making a decision to admit, retain, or discharge a patient • Medicare Benefit Policy Manual • HCFAR 85-2 has been rescinded. • The new manual has been issued and provides guidance with interpretation of the new regulations MBPM 110.1.1

23. IRF Coverage Requirement Pre-Admission Screening • The pre-admission screening documentation must indicate the following: 1. Prior level of function 2. Expected level of improvement 3. Expected length of stay 4. Evaluation of patients risk for clinical complications 5. The conditions that caused the need for rehab 6. The combinations of treatments (PT, OT, SLP, prosthetics) 7. Expected frequency and duration of treatments 8. Anticipated discharge destination • Any anticipated post-discharge treatments • These rules are effective for patients discharged on or after January 1, 2010

24. IRF Coverage Requirement Pre-Admission Screening • A pre-admission screening evaluation must be conducted by a licensed or certified clinician or clinicians as long as they are qualified to perform the evaluation within their scopes of practice and training, designated by a rehabilitation physician • FY 2010 final rule (74 FR 39762 at 39791) • “…the IRF personnel involved in collecting the information for the preadmission screening must be appropriately trained and qualified to assess the patient’s medical and functional status, assess the risk for clinical and rehabilitation complications, and assess other aspects of the patient’s condition both medically and functionally.” MBPM 110.1.1

25. IRF Coverage Requirement Pre-Admission Screening • Question: How should the physician identify to Medicare who they have designated to be a preadmission screener? • CMS’s answer: The specific processes the IRF uses for designating the preadmission screener(s) are up to each individual IRF…The most important thing from our perspective is that the preadmission screening is comprehensive, complete, and accurate, and that it supports the conclusion that the IRF stay is reasonable and necessary.

26. IRF Coverage Requirement Pre-Admission Screening • Must be completed in person when onsite or through a review of the acute medical records as long as the records contain the necessary assessments to make a reasonable determination. • A preadmission screening conducted entirely by telephone will not be accepted without transmission of the patient’s medical records from referring hospital to the IRF and review of those records by licensed or certified clinical staff. • Must be performed within the 48 hours immediately preceding the IRF admission MBPM 110.1.1

27. IRF Coverage Requirement Pre-Admission Screening • At a minimum, documentation about the patient should include or indicate the following: • Evidence that medical conditions are sufficiently stable to allow the patient to actively participate in an intense rehabilitation program • Therapy needs appropriate for an IRF level of care • The patient requires active and ongoing therapy intervention from multiple disciplines • OT, PT, SLP, or prosthetic/orthotics (one must be OT or PT)

28. Pre-Admission Screening “If the physician’s reasonable expectation prior to admission is not realized once the patient is admitted to the IRF, we are allowing the IRF to begin making arrangements to transfer the patient to another setting of care and to receive the short stay outlier payment for the IRF stay of 3 days or less (instead of having the entire stay denied), as long as the reason for the change in the patient’s status before and after admission are well-documented in the patient’s medical record.” —Federal Register 42 CFR Part 412,effective for patients discharged on or afterJanuary 1, 2010

29. Pre-Admission ScreeningAdmission Criteria • Potential patients must demonstrate the following: • Primary rehabilitation impairment • Stable medical problems, without complications that may interfere with intensive rehabilitation • Need for daily physician monitoring • Need for rehabilitation nursing care

30. Pre-Admission ScreeningAdmission Criteria • Potential patients must demonstrate the following (continued): • Functional problems affecting at least two of the following areas: • Self-care • Mobility (includes locomotion and transfers) • Motor dysfunction • Bowel/bladder management • Pain management • Safety • Cognitive functioning • Communication

31. Pre-Admission ScreeningAdmission Criteria • Potential patients must demonstrate the following (continued): • Deficits requiring an intense level of rehabilitation care • Able to participate in a minimum of 3 hours of therapy a minimum of 5 days/week • Require at least two therapies (PT, OT, SLP, prosthetics/orthotics) • Unique services that cannot be provided in a less intense or alternate level of care

32. Pre-Admission ScreeningAdmission Criteria • Potential patients must demonstrate the following (continued): • Viable community discharge plan • Anticipated social support • Patient/family plan and goals • Achievement of goals within a reasonable time frame

33. Pre-Admission ScreeningSuggestions • Track acceptance/denial rates • Use of Mini-FIM® assessment tool to predict CMG and ALOS for potential patient • Tool in UDS-PRO® and UDS-PROi® software • Predicted IGC • Ratings for seven (7) specific FIM® items: • Eating • Toileting • Bowel Management • Transfers: Bed, Chair, Wheelchair • Locomotion: Walk, Wheelchair • Expression • Memory

34. Pre-Admission Screen

35. Admission Documentation

36. Admission AssessmentsSupporting Medical Necessity • Documentation at admission should support the following: • Need for close medical supervision • Need for rehabilitation nursing provided by nurses with experience or training in rehabilitation • Need for, and ability to participate in, a relatively intense level of services • Expectation of significant practical improvement • Need for an interdisciplinary team approach and coordinated program of care to achieve rehabilitation goals • Development of realistic goals

37. IRF Coverage RequirementsPost-Admission Physician Evaluation 1. Must be performed by a rehabilitation physician 2. Patients status on admission—compare it to the pre-admission screen 3. Begin developing patient’s expected course of treatment 4. Report any relevant changes since the Preadmission screen 5. Patients prior and current medical, function conditions and comorbidities 6. Must be completed within the first 24 hours of admission • If there is a drastic change—marked improvement or an inability to meet demands—the IRF must immediately begin the process of discharging the patient to another setting. Any IRF services provided after the third day will not be considered reasonable or necessary. • These polices go into effect for patients discharged on or after January 1, 2010

38. IRF Coverage RequirementsPost-Admission Physician Evaluation • Ensure that the patient is seen by the attending physician (with the necessary experience and knowledge) within the first 24 hours of admission

39. IRF Coverage RequirementsPost-Admission Physician Evaluation • The attending physician is responsible for completing the post-admission physician evaluation, which includes: • Admission H&P • Validation of the patient’s status on admission, compared to pre-admission screening documentation • Beginning development of the patient’s expected course of treatment • Providing guidance as to whether it is safe to initiate the patient’s therapy program • Support of the medical necessity of the IRF admission

40. Physician H&P • In addition to the post-admission physician evaluation, the physician H&P must still be completed and must include the following: • IGC (primary reason for the patient’s admission) • Etiologic diagnosis (explains primary impairment) • Comorbid conditions (current conditions impacting the rehabilitation stay in addition to the primary reason for admission) • Not past medical history! • Medical conditions • Functional deficits • Synopsis of events leading to IRF admission

41. Physician H&P • Patient history • Functional (premorbid) • Mobility, ADLs, community access, cognition, communication • Psychosocial • Family/friend support, living situation, finances, vocation, leisure, mental health, sexual history • Medication and allergies • Prescription, OTC (over the counter), homeopathic • Diet history (premorbid) • Appropriateness for current condition • Past medical and surgical history

42. Physician H&P • Review of systems • Physical assessment • Support identified IGC and current comorbid conditions

43. Physician H&P • As rehabilitation team leader, give direction to the rehabilitation team by identifying the following: • Initial problem list • Functional deficits • Medical/surgical problems • Initial treatment plan • Discipline-specific recommendations • Realistic goals • Barriers to discharge • ELOS • Discharge plan

44. H&P Plan Example: Discipline-Specific Direction • 67 y.o. male with impairment of right BKA • PT: Mobility deficits, independence in W/C activities until ready for prosthesis, ambulation with walker or crutches for short distances, transfer skills and increasing endurance. Pre-prosthetic training, residual limb shaping. • OT: Upper limb strengthening and endurance, independence in ADLs and living skills at W/C level, desensitization techniques, use of gutter splint, prep for driving with assistive devices. • Rehab nursing: Skin integrity, wound healing, diabetes management, pain control, CHF and HTN stability, bowel and bladder management, patient/family education. • Dietician: Diabetic diet for weight loss.

45. Rehabilitation Nursing Admission Assessment • Collect patient health data • Identify conditions requiring nursing management and intervention • Medical, functional, and psychosocial • Current comorbid conditions • Barriers to discharge • Education needs • Identify rehabilitation nursing diagnoses • Unique services provided at this level of care • Initiate nursing care plan • Contribute to interdisciplinary plan of care • Discharge planning

47. Therapy Admission Assessment • The required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF (therapy evaluations count) • Collect patient data, including primary impairment, etiologic diagnosis, and current comorbid conditions, from the physician’s H&P • Consult the physician’s plan for direction • Complete physical assessment of patient’s current functional level • Identify functional conditions requiring therapeutic management, and link functional deficits to interventions that will be implemented • Identify current medical conditions and their anticipated impact on therapeutic interventions MBPM 110.2.2

48. Therapy Admission Assessment • Identify barriers to discharge, including information about the patient’s discharge living setting, any environmental barriers, and the patient’s family support system • Contribute to interdisciplinary plan of care

49. Therapy Evaluation OT/PT

50. IRF Coverage RequirementsIndividualized Overall Plan of Care • Completed by the rehabilitation physician within the first 4 days of the patients IRF admission • Completed with input from the interdisciplinary team: • A rehabilitation physician with specialized training or experience in rehabilitation • A registered nurse with specialized training or experience in rehabilitation • A social worker or case manager (or both) • A licensed or certified therapist from each therapy discipline involved in treating the patient • Must be retained in the medical record MBPM 110.1.3