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Long Term Care Updates and Documentation Strategies Tina Young, MSOT, OTR/L Older Adult MSG May 2010.

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Presentation on theme: "Long Term Care Updates and Documentation Strategies Tina Young, MSOT, OTR/L Older Adult MSG May 2010."— Presentation transcript:

1 Long Term Care Updates and Documentation Strategies Tina Young, MSOT, OTR/L Older Adult MSG May 2010

2 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

3 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

4 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

5 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!!!!

6 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

7 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”

8 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

9 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

10 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 days) Beginning after October 2010

11 Long Term Care Changes RUGS IV Beginning October 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

12 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

13 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

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

15 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

16 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

17 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

18 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

19 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?”

20 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)

21 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

22 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

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

24 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

25 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?)

26 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

27 Relevant Transmittals that affect Documentation and denials Transmittal #262 continued Dementia clients can make progress Allowed us to treat clients to their highest level

28 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

29 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

30 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

31 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,

32 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

33 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

34 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

35 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

36 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

37 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

38 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

39 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.

40 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.

41 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 1 st each year Rehab diagnosis is the impairment based diagnosis relevant to the problem to be treated.

42 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

43 Documentation: Focus is YOU ICD-9 V codes are allowed such as V43.64 THR V43.65 TKR V49.75 BKA V AEA

44 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

45 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

46 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

47 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….)

48 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

49 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

50 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

51 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

52 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

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

54 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

55 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

56 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

57 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

58 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

59 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

60 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 __

61 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

62 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.

63 Documentation: Focus is YOU Group Therapy Document why chose group therapy Write clinical benefits “Group addressed…… to improve……”

64 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

65 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

66 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

67 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

68 Documentation: Focus is YOU Consider every note having:  Strengths  Barriers to discharge or complicating factors  Goals not met- why  Teaching provided

69 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

70 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.

71 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.

72 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


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