Functional Geriatrics! Documentation and Treatment Strategies Every - - PowerPoint PPT Presentation

Documentation and Treatment Strategies Every Therapist Must Know to Improve Outcomes

Functional Geriatrics!

1

COURSE OBJECTIVES

1. Develop individualized, holistic treatment plans for any geriatric setting that sets the tone for treatment with the use

• f standardized assessment tools.

2. Administer effective treatment interventions that specifically address goals and meet the efficiency demands of managed care models. 3. Compose skilled treatment notes that justify medical necessity

• f therapy services.

4. Write comprehensive progress reports that provide an accurate analysis of function and justify the need for ongoing services. 5. Establish the necessary steps to prevent and prepare for Medicare audits, specifically targeting therapy.

2

Developing a Comprehensive Tx Plan

Who lives in the home, physical/cognitive support, employment, hobbies, responsibilities, lifestyle, access to resources. Outside: Stairs, Accessible Rails, Accessible/Preferred Entrances, Mailbox Access, Trash receptacles, Ground Type/Condition Inside: Stairs, Rails, Floor Type, Layout, Clutter, Lighting, Doorways, Preferred Seating, Bedroom and kitchen layout

3

Bathroom: Physical Setup – Pedestal or Vanity Sink, Shower stall and/or tub, Commode Type, AE, DME

Social Support Environmental Factors

“Tell a Story” of life before rehab

Prior and Current Level of Function

Obtain all essential information about the home: Bed Mobility: height of bed/mattress size Transfers: 17 inch and compliant surfaces, favorite chair Gait: Identify at least one gait deviation Stairs: Stair training with one rail only Measure ‐ Doorways, hallways, stair height

4

Prior & Current Level Of Function

5

BADL: includes set up, continence; undergarments; devices Instrumental ADL (IADL): Pet care, trash removal, item retrieval (high, low, floor), plant care/lawn care, gardening, clean up spills, carry beverage Executive Functions: Operate electronics, prepare meal/snack, manage meds, community access, care for

• thers

Speech: Voice, volume, intelligibility, auditory & reading comprehension, verbal/graphic expression Swallowing: Status, affected phase, intake‐food, liquid, meds Cognition: A&O x 1, 2, 3, or 4; follows 1,2, or 3 step directions

Prior and Current Level of Function

• ROM
• Strength
• Muscle Tone
• Motor
• Pain
• Edema
• Wounds
• Sensory

Processing

• Perceptual
• Vital Signs
• Activity

Tolerance

• Cognition
• Executive Function
• Articulation
• Voice
• Pragmatics
• Aural
• Auditory

Comprehension

• Reading

Comprehension

• Graphic Expression
• Oral

Motor/Dysphagia

6

Underlying Impairments Functional Deficits

• Alertness
• Sitting Balance
• Standing Balance
• Coordination
• BADL
• IADL
• Ambulation
• Memory
• Problem‐Solve
• Sequence
• Follow Commands
• Communication
• Swallowing

YIELDS

5

N

Holds test position against maximal resistance 4+ G+ Holds test position against moderate to strong resistance 4

G

Holds test position against moderate resistance 4‐

G‐

Holds test position against slight to moderate resistance 3+ F+ Holds test position against slight resistance 3

F

Holds test position against gravity

7

Hands on Assessment ‐ MMT

Modified from 1993 Florence P Kendall. May be reproduced

3‐ F‐ Gradual release from test position 2+ P+ Against gravity‐ Moves through partial ROM

Gravity eliminated‐Moves through complete ROM & holds against pressure

2 P Gravity Eliminated – Moves through full ROM 2‐ P‐ Gravity Eliminated ‐ Moves through partial ROM 1 T No visible movement No visible or palpable muscle contraction or movement

Note: It is acceptable to test and score within patient’s available range

Standardized Assessments

Increase inter‐rater reliability Evidence based Little to no equipment needed Administer in 5 minutes or less Many available in multiple languages

www.sralab.org/rehabilitation‐measures

formerly

www.rehabmeasures.org

8

Transfers #1) 30 Second Chair Stance

Indication: Assesses functional lower extremity strength in older adults Equipment Needed:

• Timer
• Chair with no arms, 17 inches from floor

Instructions:

Instruct patient to sit in the middle of the chair, back straight, feet shoulder width apart, slightly posterior to knees, one foot slightly in front of the other. Cross arms and hold against the chest. Demo the task both slowly and quickly. Incomplete stands do not count

Interpreting Scores: Average repetitions (moderate activity): 60‐69 = 14; 70‐79 = 12.9; 80‐89 = 11.9

9

Transfers #2) Supine to Stand Test

Indication: Assesses transitional movement from supine to standing Equipment Needed: Timer and raised mat or bed Interpreting Scores: Mean time (seconds) to complete supine to stand: 18.1 seconds Interpretations based on seniors requiring assistance with at least one ADL (t/f, ambulation, bathing, or toileting)

10

Balance #1) Four Step Square Test(FSST)

Indication: Test of dynamic balance that clinically assesses the person’s ability to step over objects in all directions Equipment Needed: 4 canes and a timer Instructions: Instruct patient, “Try to complete the sequence as fast as possible without touching the canes. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.” Demonstrate and allow a practice trial. Interpreting Scores:

• > 15 second = at risk for falls for individuals age 65 or older

11

12

Balance #2) Function in Sitting Test (FIST)

Indication:

14 item bedside assessment to assess sensory, motor, proactive, reactive and steady state balance.

Equipment Needed:

Stop watch, standard hospital bed

Instructions:

1. Instruct patient to sit edge of bed with ½ upper leg supported, hips, knees at 90°, feet flat, hands in lap unless needed for support. 2. Provide verbal cues and demonstration as needed. 3. Complete 1 trial per item: Nudge (anterior, posterior, & lateral), static sitting for 30 seconds, shake head no, close eyes for 30 seconds, lift foot 1 inch, pick up object from behind at midline, forward reach‐dominant arm, lateral reach‐dominant arm, pick up object from floor between feet, posterior scoot‐2 inches, anterior scoot‐2 inches, lateral scoot‐2 inches to dominant side.

13

Balance #2) Function in Sitting Test (FIST) Cont.

Interpreting Scores:

• Score 4, 3, 2, 1 or 0 for each item.
• 4= Ind.
• 3= Verbal cues
• 2= UE support
• 1= min.
• Mod or Max A needed
• Total score out of 56
• <42 = not likely to return home without assistance

Balance #3) 360° Turn Test

Indication: A measure of dynamic balance Equipment Needed: Tape on floor to mark start position and timer Instructions: Instruct patient to turn completely in either direction. Conduct 2 trials and record the average time as the score Interpreting Scores: > 3.8 seconds = decreased independence Remember

• 3 sensory systems provide input to the cerebellum for balance
• Check proprioception with by removing vision (I.E. Romberg Test)
• Have more time? Consider Tinetti (low inter‐rater reliability), Berg

(no device), Dynamic Gait Index (incorporates head turning). BEST

• r Mini BEST (incorporates incline ramp), 2 Minute Walk Test

(Dementia)

14

ADL #1) Barthel & Modified Barthel

Indication:

Measure of physical disability used widely to assess behavior relating to activities of daily living for patients with disabling conditions. Designed to increase the sensitivity of the Barthel ADL Index Equipment Needed: Modified Barthel Assessment Tool

Instructions:

Score the patient in each ADL area based on what the patient does over past 24‐48 hours. Direct testing is not required

Interpreting Scores:

• 0‐20 = Total Dependence, 21‐60 = Severe Dependence, 61‐90 = Moderate

Dependence, 91‐99 = Slight Dependence, 100 = Independence

• <40 = dependence in mobility and care (24/7 help in home or SNF)
• 40‐60 = Some assistance with mobility and care (in home or ALF)
• 65‐80 = community living with support services
• 85‐100 = Independent community living (walking or with w/c)

15

FEEDING 2 5 8 10 ‐Dependent in all aspects and needs to be fed orally or otherwise ‐Can manipulate eating device but needs assistance during meal ‐Self feeds with supervision. Needs assistance with associated tasks such as adding milk/sugar into tea, salt/pepper, spreading butter, rotating plate or other set‐up activities ‐Independent in feeding with prepared tray except needing meat cut, milk carton opened, etc. Presence of another person is not required during the meal ‐Independently feeds self from a tray or table when someone places food within reach. May use a device to cut food, add salt and pepper, spread butter, etc.

16

Sample Barthel Assessment Item Sample Modified Barthel Assessment Item

ADL AREA SCORE DESCRIPTION FEEDING 5 10 ‐Unable ‐Needs help cutting; spreading butter, etc. or requires modified diet ‐Independent

ADL #2) ADL – KATZ Index of Independence in ADL

Indication: Assesses 6 ADL functions in seniors (bathing, dressing, toileting, transferring, continence, and feeding) Equipment Needed: Assessment Tool with scoring rubric Instructions: Score patient in each ADL area either a 0 (dependent) or 1 (Independent). Use rubric to determine most appropriate response Example: Bathing

1 POINT = Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity. 0 POINTS = Needs help with bathing more than one part of the body, getting in or

• ut of the tub or shower. Requires total bathing.

Interpreting Scores: A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

17

ADL

#3) Modified Physical Performance Test

Indication: Assesses physical function of ADL with various levels of difficulty Equipment Needed: Assessment Tool and scoring rubric, standard height chair, 7 lb book and shoulder level shelf Instructions: Assess patient’s performance of each of the 11 items. Book lift, don/doff coat, pick up penny from floor, chair rise, 360⁰ turn, 50 foot walk, flight of stairs, 4 flights of stairs, progressive Romberg Scoring: 4 points per item; maximum score is 36

18

#1) Short Blessed Test

Indication: 6 item measure of cognitive impairment Equipment: Assessment tool and scoring rubric Instructions:

Ask patient these questions and record their responses:

• 1. What year is it now? 2. What month is it now?

Repeat this phrase: John Brown, 42 Market Street, Chicago

• 3. About what time is it? (within one hour) 4. Count backwards 20 to 1
• 5. Say the months in reverse order 6. Repeat the phrase just given

Interpreting Scores:

0 ‐ 8: Normal, 9 ‐ 19: Minimal‐Moderate impairment, 20 ‐ 28: Severe impairment

19

Cognition

Cognition

#2) Executive Function Performance Test

Indication:

Examines the execution of four basic tasks that are essential for self‐ maintenance and independent living: simple cooking, telephone use, medication management, and bill payment. Assesses: Initiation,

• rganization, sequencing, judgment/safety, completion and insight

Equipment Needed:

• Assessment Tool
• Simulated utility bills (downloadable)
• Oatmeal and other food prep items as identified in assessment tool

Instructions:

• The assessment requires participants to complete the following tasks (in
• rder): Hand Washing (Assesses patient’s ability to follow directions. If

unable to complete this task, do not proceed.)

• Oatmeal Preparation, Telephone, Taking Medication, Paying Bills

Interpreting Scores:

0‐100 scoring rubric based on the amount of assistance provided to patient. 20

Cognition #3) Clock Drawing Test

Indication:

Assesses visuospatial and praxis abilities (may reflect either attention

• r executive dysfunction)

Equipment Needed: Pre‐drawn clock and scoring rubric Instructions:

• Give patient sheet of paper and indicate the top of page.
• Instruct patient to draw a large circle (unless using paper with a pre‐

drawn circle), then write numbers in the circle to make the circle look like the face of a clock and then draw the hands of the clock to read 10 after 11

• Interpreting Scores:

1‐2 = normal; 3‐6 = cognitive deficit

21

22

Functional Goal Writing: How to Write SMART Goals!

S = Specific

Goals must address the specific functional deficits and/or underlying impairments identified as a result of the onset of new condition or reason for therapy episode.

M = Measurable

Goals must contain a measurable component. I.E. level of assistance, amount

• f cuing, percentage of accuracy, etc.

A = Achievable

Goals must be written at or below the patient’s PLOF, unless there is documentation to support otherwise. Include special equipment or technique needed

R=Relevant

Goals must be relevant to the patient, diagnoses, d/c setting, lifestyle and wishes. Example: a goal for toileting from w/c is not relevant for a patient whose w/c won’t fit in the bathroom

T = Timeline

Goals must contain a specific and reasonable timeline typically measured in number of sessions, number of trials, days, weeks, months. 23

Functional Goal Writing

General Tips

• Include a legend to define levels of assist/function
• Include any special equipment or technique needed to achieve

the goal

• Remember to write patient and/or caregiver training goals
• Every short term goal should have a related long term goal
• Avoid duplicating services between disciplines: bed mobility,

transfers, wheelchair, cognition, and general static or dynamic sitting and standing balance

• Strengthening goals should be tied to a functional task
• Balance, ADL and cognition goals should include a standardized

assessment

24

Achieving Functional Goals General Tips

• Avoid documenting during active treatment

‐Patient/caregiver training is billable with patient present ‐care conferences are not billable in acute rehab settings

• Offer water during therapeutic rest breaks
• Get patients on their feet during treatment!
• Strength training should involve progressive resistance

Progressive Resistance Strength Training:

• Explain the benefits – decrease BP and arthritic pain,

increase glucose metabolism

• 8‐12 repetitions (4‐6 = body building, over 12 = endurance)
• 3 sets of each exercise, timed 1‐2 min rest break, 3‐5

x/week, per muscle group, grade each session

• Must perform to the point of failure to increase strength
• Educate patient on water intake to reduce soreness

25

SMART Goal Samples for PT

S= Specific ~ Patient will improve sit to stand t/f’s M= Measurable ~ to CGA (make contact but no weight bearing asst)

A=Achievable ~ using quad cane and articulating AFO R=Relevant ~ from sofa T=Timeline ~ 5 visits

SMART Goal = Patient will improve sit to stand t/f’s to CGA (make contact but no weight bearing asst) using a quad cane and articulating AFO from sofa in 5 visits.

26

S= Specific ~ Patient will improve glute strength M= Measurable ~ from 3+ to 4/5 A=Achievable ~ to ascend 3 stairs R=Relevant ~ at entrance of home T=Timeline ~ in 2 weeks

SMART Goal = Patient will improve glute strength from 3+ to 4/5 to ascend 3 stairs to enter home in 2 weeks.

S= Specific ~ Patient will improve strength of B UEs grossly M= Measurable ~ from 3 to 4/5 (Able to withstand moderate resistance)

A=Achievable ~ to complete sit/pivot transfer

R=Relevant ~ from wheelchair to drop‐arm commode T=Timeline ~ 2 weeks

SMART Goal = Patient will improve strength of B UEs grossly from 3 to 4/5 to complete sit‐pivot transfer from wheelchair to drop‐arm commode in 2 wks.

SMART Goal Samples for OT

S= Specific ~ Patient will dynamic balance

M= Measurable ~ evidence by functional reach of greater than 7 inches A=Achievable ~ to retrieve clothing from closet R=Relevant ~ at walker level T=Timeline ~ in 5 visits

SMART Goal = Patient will improve functional reach to greater than 7 inches to retrieve clothing from closet at walker level in 5 visits.

27

SMART Goal Samples for ST

S = Patient will consume mechanical soft diet M = with supervision (verbal cues but no touching assistance) A = sitting upright in chair

R = with a maroon spoon T = in 2 weeks

Patient will consume mechanical soft diet sitting upright in chair with a maroon spoon in 2 weeks.

S = Patient will improve executive function for bill pay M = with 100% accuracy A = using a day planner R = for ILF living

T = in 5 of 5 trials

Patient will improve executive function for bill pay with 100% accuracy using a day planner for ILF living in 5 of 5 trials.

28

Achieving Functional Goals Balance

• Falls result in over $30 billion in health care costs each

year in the US

• Balance does not improve if it is not challenged. This

means, removing patients from their comfort zone

• Single‐leg activities, balance balls, bosu balls,

rebounders, and tandem standing are all effective

• Closed chain activities improve core strength and

stability

29

• Otago is a 12 month balance program for seniors from New Zealand.

On‐line certification for $25 worth 3 CEUs. See link on APTA website.

• Figure 8’s helps to develop the body’s awareness & concentration,

and respond quickly to environmental changes (ankle strategies)

Don’t forget total body, isometric, essentric & closed chain

30

Effective Treatment Interventions

OR OR

31

OR OR

Effective Treatment Interventions

32

Effective Treatment Interventions

OR OR

33

Achieving Functional Goals Technology

• Comprehensive stroke rehab app with assessments,

tracking and exercise protocols (free with in‐app purchases)

• Gait Speed (the 6th vital sign) can be assessed easily

($0.99 app)

• Lumosity Brain Training (memory, attention,

problem solving, etc.) designed by scientists (free with in‐app purchases)

• Improve gait speed and quality, balance and

coordination with Metronome (free app)

• Create custom handouts point of service!

(free website)

34

Documenting Functional Ortho Goals

‐ Include goals to address joint pain or stiffness if these are barriers to performance ‐ Incorporate precautions, restrictions, equipment or post surgical instructions (back, hip, WB, immobilizer, etc.) ‐ Avoid strengthening goals if patient's strength is functional according to age and lifestyle. ‐ If a LE ortho condition results in upper body weakness or vice versa, explain the contributing factors

• Patients s/p Lumbar surgery typically have LE exercise restrictions
• Patients s/p cervical or thoracic surgery typically have UE exercise

restrictions.

35

Functional Orthopedic Goal Samples

• Patient will ambulate 50 feet with Mod I with erect

posture in 6 visits.

• Patient will complete stand/pivot transfers with Mod I

(extra time) with 100% adherence to NWB in 1 week.

• Patient/caregiver will demonstrate 100% understanding of

posterior hip precautions in 2 visits.

• Patient will improve dynamic balance to min fall risk by

improving from 19 sec to 15 sec on Four Step Square Test in 2 weeks.

• Patient will complete LB dressing with CGA (no wt bearing

asst) with no complaints of increased R knee pain at walker level in 4 sessions. Practice:

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

36

Documenting Functional Neuro Goals

‐ Write adjunctive (pre‐functional) goals (eye tracking, alertness, facial recognition, sitting, weight shifting, crossing midline, etc.) ‐ Use standardized assessments to write goals for measuring tone and alertness (Ashworth, Glasgow Coma Scale) ‐ Include splinting goals for joint contractures or spasticity ‐ Include goals that address anatomical alignment and joint approximation ‐ Include goals that address visual deficits ‐ ADL goals should include hemi‐techniques when applicable

37

Functional Neuro Goal Samples

• Patient will ambulate 10 feet with CGA with good toe clearance

using an AFO and hemi‐walker in 2 weeks

• Patient will decrease tone as evidenced by Modified Ashworth

score from 2/5 to 1/5 for decreased discomfort during care in 3 weeks.

• Patient will decrease pusher syndrome for improved sitting balance

by achieving 30° from midline in 14 days

• Patient will reduce delayed swallow from 8 seconds to 3 seconds

with puree trials in 2 weeks.

• Patient will sit in wheelchair for 2 hours with good joint

approximation of right upper extremity in 3 sessions.

• Patient will wear R knee extension splint for 4 hours/day to prevent

increased joint contracture in 10 sessions.

• Patient will improve LB dressing to Min A using hemi techniques in

1 week.

Practice:

________________________________________________________ ________________________________________________________ ________________________________________________________

38

Achieving Functional Neuro Goals

Hemiplegia is not a muscle problem, it’s a brain problem. Treatment should facilitate joint approximation and anatomical alignment. Pain mgmt. & ROM of hemiplegic limb

Neuro re‐ed with modalities, weight bearing/shifting, prone on elbows, quadruped, CIMT,

Joint Approximation and Anatomical Alignment Taping, splinting, and positioning, coordination of movements, inhibit/facilitate tone Transfers and Gait

Must master sit to stand and weight shifting before addressing gait; focus on the quality of gait not distance; use orthotics if indicated

ADL

Hemi‐techniques and AE to increase independence. Try YouTube!

Speech and Swallowing

Bedbound patients on thickened liquids need access to cold beverages at

• bedside. Try a small cooler with ice packs.

Use diagnostic like mobile MBSW and FEES to make diet recommendations. E‐stim to facial muscles can be effective for improving swallowing function, speech and facial symmetry. Oral motor movement helps maintain swallow function. Unintelligible speech ok

39

Achieving Functional Neuro Goals

Givmohr Sling LEMA Strap Carbon Fiber AFO Toe off Anti‐subluxation sling Pant Clip 40

‐ Include work‐simplification/energy conservation goals to help manage chronic conditions ‐ Utilize Borg or Modified Borg Scale of exertion, COPD Questionnaire, or similar assessment tools to write subjective activity tolerance goals ‐ Include objective data like oxygen saturation levels, respirations, etc. in goals ‐ If patient is on oxygen, incorporate the need to manage

• xygen during gait and ADL in goal writing

‐ Include donning/doffing compression garments in dressing goals

41

Documenting Functional Cardio‐pulmonary Goals

Functional Cardio‐pulmonary Goal Samples

• Patient will stand for 2 minutes with no loss of balance to

safely complete daily weight in 2 sessions.

• Patient will demonstrate 100% accuracy with following

written recipe instructions in 1 week.

• Patient will ambulate 50 feet with Min A for transporting
• xygen in 5 of 5 trials.
• Patient will complete shower routine with set up using

shower chair and hand held shower head, maintaining o2 saturation above 90% in 6 visits.

• Patient/Caregiver will demonstrate 100% understanding
• f energy conservation techniques in 2 weeks.
• Patient will complete LB dressing, including compression

stockings with set up in 1 week. Practice:

___________________________________________________________ ___________________________________________________________ ___________________________________________________________

42

Achieving Functional Cardio‐pulmonary Goals

• Teach Energy Conservation/Work simplification techniques & assess vitals

and o2 sats throughout tx

• Teach relaxation, diaphragmatic breathing, pursed lip breathing,

positioning and posture to increase lung expansion and capacity

• These patients are often frail, high anxiety and slow moving. They need

more tx time, not less.

ADL

• Teach patient to examine LEs with a long handled mirror due to increased

risk for cellulitis and edema

• Nutrition is typically compromised so incorporate strategies for meal prep
• f fresh foods instead of processed

Speech, Swallowing, Cognition

• Speech and swallowing therapy should incorporate breathing, and

relaxation techniques

• Assess vitals and o2 sats as well during swallowing and cognitive tx
• Cognitive therapy should incorporate patient self‐assessment (perceived

exertion) 43

Achieving Functional Cardio‐pulmonary Goals

Strengthening & Gait

• 6 Minute Walk Test, 2 Minute Walk Test and TUG are good

assessment and treatment options

• If patient is on oxygen, treatment should incorporate

management of o2 concentrator and tubing during gait training

• Time therapeutic rest breaks and assess

patient’s recovery throughout

• Tip: if patient is not a candidate for a

rollator, try a 2‐wheeled walker with seat

44

Documenting Functional Dementia Goals

‐ Incorporate goals that also target the caregiver ‐ If patient has new learning ability, be sure that it is evident based on your standardized assessment and write goals accordingly. ‐ It is acceptable to eval and treat for one or more visits to determine a baseline of function and establish a functional maintenance program. ‐ Utilize Global Deterioration Scale (GDS) of Dementia to help determine and justify appropriate goals and tx options.

45

46

Stage V Moderate Dementia Moderately severe cognitive decline; may not recall address or phone number; may forget names of grandchildren; difficulty with orientation to place, time, reality; can no longer survive alone; needs verbal but not physical assist with ADL; can learn new things with repetition

STAGE VI Moderately Severe Dementia

Severe cognitive decline; may forget name of spouse; needs physical A with ADL; unaware of surrounds, year, season; may exhibit delusional behavior; may begin to speak gibberish; downward gaze; shuffling gait

STAGE VII Severe Dementia

Very severe cognitive declined; all verbal abilities decline; total assistance with ADL; incontinent; deficient neurologic reflexes ; basic psychomotor skills decline; often w/c or bed bound

STAGE CLINICAL MAIFESTATIONS of GDS Stage I No memory deficits Stage II Age Related Very mild, age associated memory decline; forget name of familiar person, place or thing. No deficits on cognitive assessment Stage III Mild Cognitive Impairment Mild cognitive decline; deficits will appear on assessments; others may notice < work performance; may get lost going to familiar place; may retain very little from written passage.; denial and mild anxiety may manifest; still lives independently Stage IV Mild Dementia Moderate cognitive decline; mild dementia; decline in knowledge of some personal history; decline in performance of executive functions and complex tasks; anger, denial, withdrawal and/or depression may manifest; may live alone with good social support & compensatory strategies

46

Functional Dementia Goal Samples

• Patient will locate bathroom with 90% accuracy with the use of visual

aides in 2 weeks

• Caregiver will demo medication administration strategy with 100%

accuracy to maximize PO intake in 2 sessions .

• Patient will decrease falls as evidenced by improved 2 Minute walk

test from 12 meters (@39 ft) to 26 meters (@85 ft) in 2 weeks.

• Patient will improve ADL as evidenced by increased Modified Barthel

score from 40/100 to 60/100 for ALF placement in 6 weeks.

• Patient will improve self feeding to SBA [close enough to assist if

necessary] for 75% of meal in 1 week [with caregiver training on effective cuing strategies]. Practice:

__________________________________________________ __________________________________________________ __________________________________________________

47

Achieving Functional Dementia Goals

• If the patient has new learning ability ensure that

treatment supports this through the use of objective assessment tools and GDS

• If patient has little to no new learning ability, treatment

interventions should be focused on the following: 1. Adapt environment – signs, decluttering, shadow box, nostalgia 2. Caregiver training – handling cruise diners, aggression, resisting care, wandering, hoarding 3. Following simple instructions or mimicking for strength and balance training with advanced Dementia 4. Incorporate a ball into treatment interventions for patients who have trouble following instructions

*See supplemental materials for useful treatment strategies dementia

48

Write a SMART goal for this scenario:

Problem: Mary presents to the ED on Friday with a subdural hematoma s/p a fall in the bathroom while attempting to t/f into the bathtub. She was found by her sister Esther who called 911. The EMS respondent noticed Mary’s medications (blood pressure pill, multi‐vitamin, and Aricept) on the sink. All bottles appeared to be full. Upon assessment, Mary was disoriented required min A to stand and walk. PLOF/Environmental factors: Mary is a 100 year old female, never married, no children residing in a 2 story home with B rails inside; 1 step to enter with no rail. Her 2 sisters Esther (95) and Ruth (90), reside with her. All 3 ladies are retired nuns from their local parish. Mary ambulated 150 feet between rooms with a single point cane and took baths daily using a standard tub/shower combo with no hand held shower head and no DME with Mod I. All 3 bedrooms and the only full bathroom is located

• upstairs. There is a ½ bathroom (powder room) downstairs.

Social support: Volunteers from their local church come by every Sunday to clean the home and provide meals for the week. They also come by as needed throughout the week to take the ladies to their MD appointments and other errands. Ruth heats meals in the microwave and makes tea daily. Esther handles the bills. All 3 ladies present at a stage IV on the GDS and have refused to consider an emergency response system stating “That’s for old people”. PMH: Mild OA of B knees; hypoglycemia, and Hypotension

49

50

Audit Proofing

Justification of Skilled Services through Treatment Encounter Notes

Audit Proofing

Does this treatment require the skills of a licensed therapist?

51

Justification of Skilled Services

Recumbent Bikes

• aid in cardiovascular endurance (not strength)
• Skill: Verbal, visual, tactile cues for isolating target muscle

groups, full excursion, ROM through entire plane of mm, inhibiting compensation, reciprocal movement patterns, coordination of agonist/antagonist muscle groups, assessing vitals & o2 throughout session

• Use of recumbent bikes for 5 minute warm up (tx set up) to

increase blood flow and warm tissue in preparation for therapy does not need to demonstrate further skill.

• UE recumbent bikes may be more effective with backward

pedaling for improved scapular mobility (and prevention of winging).

• Avoid documenting while patients are on recumbent bikes

52

Justification of Skilled Services

Task Analysis:

• A list of all steps involved in a sequence. Helps to show progress

during treatment and can be encouraging for the patient. Example: Gait Cycle (Rancho Terminology) Stance phase – 60% of gait cycle: 1) initial contact, 2) load response 3)mid‐stance, 4) terminal stance/Pre‐swing Swing phase – 40% of gait cycle: 1. initial swing, 2. mid swing,

• 3. terminal swing

Activity Analysis:

• Assess performance of each ADL task and design interventions to

address the underlying impairments noted. Example: Design activities to address limitations in internal rotation

• f the UE causing UB dressing deficits

53

Task Segmentation:

• Breaking an entire task into segments and addressing one

segment at a time. Example: Segmenting UB dressing into donning undergarment, donning pull‐over shirt and donning sweater or jacket

Chaining:

Breaking down a multi‐step or complex skill into smaller steps

• Backward Chaining ‐ Chain the entire task except last step.

Ideal when patients can more successfully perform tasks at the end of the chain. Example: therapist dons the shirt except for the last sleeve

• Forward Chaining ‐ Teaching a task beginning with the first

step, allowing the patient to perform the first step of the task independently Example: patient dons the shirt except the last sleeve

Justification of Skilled Services

54

Justification of Skilled Services Through Treatment Encounter Notes

What is a skilled statement?

• Demonstrates skills of a licensed therapist
• Substantiates the number of treatment minutes billed
• Reflects the type of intervention provided and the rationale
• Includes subjective and objective patient information
• Summarizes outcome of treatment intervention

How to write

SPECIAL

treatment notes

55

Non‐skilled Words:

• Critique
• Direct
• Instruct
• Educate
• List
• Individualize
• Create
• Train
• Challenge
• Organize
• Plan
• Stabilize
• Formulate
• Administer
• Adapt
• Assess
• Grade
• Develop
• Differentiate
• Classify
• Compare
• Distinguish
• Analyze
• Describe
• Demonstrate
• Modify
• Problem Solve
• Trial

56

Skilled Words:

• Slow Progress
• Unable to Learn
• General
• Patient seen
• Encourage
• Helped
• Practice
• Monitor
• Unmotivated
• Assisted
• Passive Participation

SPECIAL Treatment Notes

SPECIAL Treatment Notes

Pertinent to Medical Dx and/or reason for therapy

Ordinary: Patient completed LB dressing with reacher Special: Instructed patient on use of 32” Reacher to don pants due to trunk flexion restriction s/p R THA. Educated patient on risk for hip dislocation due to weak abductor muscles. Pertinent to medical diagnosis ‐ R THA

SPECIAL Treatment Notes

Equipment & its Effectiveness

Ordinary: Patient seen for adaptive equipment for feeding. Special: Implemented scoop plate to increase accuracy of food transfer from plate to fork to compensate for limited wrist supination with gross grasp. Spillage reduced by 50% with this intervention. Equipment – scoop plate Effectiveness – 50% less spillage

57

SPECIAL Treatment Notes

Customized for patient’s own unique story Ordinary: Patient ambulated 25 ft with rolling walker with Min A and mod verbal cues for safety. Instructed patient in LE ther ex in all planes to improve functional mobility. Special: Facilitated gait training with RW, 25 ft w/Min A for scissoring & mod v/c to widen BOS. Assessed gait quality. Will continue PRS of abductors to minimize scissoring & improve balance. Customized – scissoring and narrow BOS

SPECIAL Treatment Notes

State the underlying Impairments and resulting functional deficits Ordinary: Pt was given an appointment book for recording upcoming

• appointments. Patient responded well to tx. Continue with established POC.

Special: Patient completed cognitive training in short‐term memory. Provided patient with a 3‐step process in recording appointments in pocket calendar. Patient was trained with trial appointments until patient replicated the 3 steps with 100% accuracy with minimal verbal cues. Underlying Impairment‐ cognition Functional Deficits– short term memory 58

SPECIAL Treatment Notes

Assess the patient’s level of function, as related to underlying

• impairments. Use Standardized Assessments to justify ongoing services

Ordinary: Patient seen for balance assessment. See Berg report and progress report for details. Special: Graded balance training program to challenge patient outside base

• f support. Administered Berg balance assessment to quantify
• improvements. Patient scored 46/56 ‐ lowest fall risk category.

Collaborated with PT regarding d/c of skilled services in 2 sessions. Focus next session will be HEP training

Assessment – Berg, lowest fall risk

SPECIAL Treatment Notes

Level of performance, pain, & improvements from the interventions Ordinary: gave patient mechanical soft tray w/thin liquids. Fed patient 100% of meal. Pt tolerated well w/no s/s of aspiration noted. Special: Downgraded diet from regular to mech soft with due to pneumonia w/questionable aspiration. Assessed swallow. Trained pt on Masaco Maneuver to build spindle muscle fibers at base of tongue, and a lingual sweep q 3 bites to clear oral cavity & improve A‐P transfer.

Level of performance – Mod v/c (50%) with Masaco Maneuver, lingual sweep, and effortful swallow. 59

SPECIAL Daily Notes Practice

Why can’t a caregiver provide verbal cues? Ordinary: Patient ambulated 50 feet with CGA and Min v/c’s for safety Write an improved daily note

What is the gait deviation(s): ___________________________ Reason for making contact: _____________________________ Specific unsafe actions: ________________________________

Why can’t the patient go Planet Fitness for strengthening exercises? Ordinary: Patient seen for LE strengthening ther ex, completed 3 sets of 10 hip extension with min verbal cues to increase strength and function. Special: Upgraded PRT program 3 sets of 10 ‐ hip extension w/2 min therapeutic rest break between each. Rationale: strengthen glute max and medius for stabilizing pelvis during stair climbing. Write a daily note to justify UE ther ex…

What muscle groups are being strengthened? _______________ For what specific functional task? _____________________________ 60

SPECIAL Daily Notes Practice

Why can’t a caregiver assist with ADL? Ordinary: Patient seen for entire ADL shower routine this day. Gathered patient’s items and a shower chair. Patient required set up and supervision for UB bathing and min A for LB bathing while seated on shower chair. Assisted patient to chair for dressing. Patient required set up and supervision for UB dressing and min A for LB dressing in chair. Mod verbal cues provided throughout session for safe technique. Special: Facilitated self‐care mgmt training to teach LB bathing and dressing skills w/energy conservation techniques. Trialed a shower chair due to low activity tolerance from COPD. Trained pt in diaphragmatic breathing & pursed lip breathing to maintain open

• airway. With this intervention, patient improved from max A to

min A with LB bathing in shower. Pt ambulated to chair at rollator level and was trained in tripod position for 3 points of support during rest breaks for dressing w/min A with LB dressing in chair, w/o2 sats maintaining >90%. Pt maintains s/u (plof) for UB ADL. Patient recalled COPD mgmt techniques with 75% accuracy. 61

Justification of Skilled Services: Progress Reports

• Incorporate the patient (point of service) when possible
• Provide status update on all STGs (and LTGs if applicable)

~Pt has met 3 of 5 STGs with skilled PT, OT, ST in gait/toileting/swallow function.~

• Provide a clinical impression of patient’s overall progress &

justification for continued tx; include gains outside of therapy

~pt is motivated; has good family support; pain is well managed; attention span improving; strength improved 1/2 grade; BP stabilized; spouse now able to t/f pt. ~

• Provide a summary of skilled interventions & missed visits that
• interim. If you document daily, simply refer reader to daily notes.

~see encounter notes for a summary of skilled services provided each day~

• Provide details about updates to treatment plan, approach, new

goals, d/c’d goals, etc. Avoid “continue with POC as indicated.”

~STG for transfer upgraded; c/p with family scheduled; c/g training to begin next interim; progress to ADL training at walker level; advancing to trials of mechanical soft; gait training to progress to uneven surfaces; will initiate HEP next visit~ 62

Progress Reports

• If significant progress has not been made, explain the barriers and what’s

being done about them.

~Pt has declined due to pain at surgical site/nausea/increased confusion with UTI/reports of sadness; Pharmacology/psych/family/MD has been consulted to address barrier(s); With _____ intervention(s) it is expected that patient will progress toward goals next interim~

• Provide specific details regarding pt/cg training, handouts, HEP, etc.

~spouse trained in hand over hand technique/ nursing trained in techniques for minimizing agitation/caregiver trained in sternal precautions/weight bearing status. Developed HEP and trained pt/spouse in program; a handout summarizing training was provided~

• If you plan to d/c provide a rationale. Avoid “max potential” or “plateau”

~No return in hemiplegic limb; cognition prevents carryover of techniques taught; pt has esophageal stricture; pts desire to participate not improving with interventions; skills of a therapist are no longer needed~

• If continuing, provide a statement about remaining underlying

impairments and functional deficits and why services should continue.

~Pt still has limitations in ROM against gravity/proprioception/bolus manipulation /delayed

recall/pain in involved limb/ activity tolerance; and without ongoing tx, pt is at risk for skin breakdown/pain/contractures/SNF placement/caregiver burden/hospital readmission~

63

Your excuses for not providing me coverage have been denied!

Why All The Fuss?

Health Care Reform

I’ll have someone come in and prep you for the bill. 64

Health Care Reform: Managed Care

It’s not a bad thing. Understanding can reduce frustration

• Many patients have Medicare replacement plans (also called

Medicare Advantage or Medicare part C)

• Case managers (often RNs) follow the patients throughout the

episode of care

• Regular updates must be provided to the case managers via

progress notes, special forms, verbal updates, or peer to peer reviews

• Many HMOs and PPOs also have case managers who oversee

rehab services and follow CMS guidelines (Centers for Medicare & Medicaid)

• Often no part B cap
• 3 night hospital stay often waived for SNF placement
• Many offer additional follow‐up services for patients after

episode of care

• Not to be confused with Medigap which is a separate Medicare

supplement used with traditional Medicare only

65

Health Care Reform Bundle Payments for Care Improvement (BPCI)

A form of consolidated billing (as opposed to fee‐for‐service models) implemented by the federal government to:

• Ensure financial and performance accountability of health care

entities

• Maximize quality, efficiency and coordination of health care

services

• Goal is to reduce hospital re‐admissions and Medicare

expenditure

• Healthcare organizations that are either appointed or elect to the

program enter into payment arrangements

• CMS obtained extensive data on DRGs (Diagnostic Related Groups)

to determine BPCI guidelines ‐ 48 clinical episodes

• Providers of choice are 3 star or better
• Government continues to assess and modify the bundle programs

nationwide.

66

2017 2018

67

2020 2017

Health Care Reform

ZPIC/UPIC Audits

68

ZPIC = Zone Program Integrity Contractor UPIC = Unified Program Integrity Contractor

• Unlike other audits, they target therapy and DME

claims

• Focused reviews when fraud or abuse is suspected
• Claim‐by‐claim overpayment: detailed review of

claim to determine medical necessity

• SVRS Overpayment (Statistically Valid Random

Sample): An audit triggered by outliers

• Investigates and determines the

factual basis of allegations of fraud made by beneficiaries, providers, CMS, OIG, and other sources.

• May impose denied or suspended

payments to providers if there is reliable evidence of fraud.

• Refers cases to appropriate

enforcement entities for consideration

• f civil and criminal prosecution

and/or application of administrative sanctions.

• Audit formats: Phone interview,

documentation review, site or home visit, treatment observation, face‐to‐ face interviews (staff, patients, family members)

69

ZPIC/UPIC Audits

Audit Proofing

What a ZPIC or UPIC auditor may look for or ask?

• How do you determine frequency/duration of your treatment plan?
• Do you round your minutes up or down?
• How is it that all of your evaluations are exactly 15 minutes?
• Do you ever treat 2 patients simultaneously? Why or why not?
• If you bill unattended e‐stim do you treat another patient

simultaneously?

• Do you bill for your documentation?
• Do you bill for therapy services that are provided away from line of

site of your patient?

• How many minutes do you bill when a patient refuses or is unable to

participate after spending significant time trying to engage the patient?

70

Health Care Reform

Other Audits

RAC Audits (Recovery Audit Contractor)

• Created in 2003 (limited) and expanded to all 50 states in 2006
• Auditors are paid on contingency and receive a percentage of monies

recouped “claw back” MAC Audit (Medicare Administrative Contractor)

• Processes Medicare Part A and Part B and Durable Medical Equipment

(DME) claims for Medicare Fee‐For‐Service (FFS) beneficiaries and review records for selected claims

• Compile audit provider cost reports
• Handle redetermination requests (1st stage appeals process)
• Respond to provider inquiries
• Educate providers about Medicare FFS billing requirements
• Establish Local Coverage Determinations (LCD’s)

71

NAME OF A / B MAC CONTACT INFORMATION STATES & TERRITORIES SERVICED

Noridian Healthcare Solutions

https://med.noridianmedicare.com/ Noridian SMRC PO Box 6711 Fargo, ND 58108‐6711 833‐860‐4133 (M‐F 7:30 am – 5 pm CT) Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands

Novitas Solutions

https://www.novitas‐solutions.com Novitas Solutions, Inc. Attention: _________ 2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 communications@guidewellsource.com 855‐252‐8782 Arkansas, Colorado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas, District of Columbia

National Government Services, Inc.

https://www.ngsmedicare.com/ National Government Services, Inc. P.O. Box 6131 Indianapolis, IN 46206‐6131 877‐702‐0990 (M‐F 8am‐4pm CT) Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin

Medicare Administrative Contractors

2020

72

NAME OF A / B MAC CONTACT INFORMATION STATES AND TERRITORIES SERVICED

Palmetto GBA, LLC

https://www.palmettogba.com/ Palmetto GBA, LLC 17 Technology Circle Columbia, South Carolina 29203 (803) 735‐1034

Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia, West Virginia

WPS Government Health Administrators

https://wpshealthsolutions.com/ 1717 W. Broadway P.O. Box 8190 Madison, WI 53708‐8190 J5 Part A and B: (866) 518‐3285 J8 Part A and B: (866) 234‐7331

Indiana, Iowa, Kansas, Michigan, Missouri, Nebraska

First Coast Service Options, Inc.

https://www.fcso.com/ 532 Riverside Ave, Jacksonville, FL 32202 (866) 454‐9007

Florida, Puerto Rico, US Virgin Islands

CGS Administrators, LLC

https://www.cgsadmin.com/ CGS Administrators, LLC 2 Vantage Way, Nashville, TN 37228 (615) 244‐5600

Kentucky, Ohio

73

Audit Proofing

Avoid The Easy Denials!

74

• For post hospital rehab, all involved disciplines must reflect the

same reason for a hospital stay

• Telephone orders must be completed, signed and dated
• ICD and CPT codes on orders must match plan of care
• Late documentation must include the effective date
• Avoid using incorrect or retired ICD and CPT codes
• Home health claims must avoid unacceptable codes (vague or

descriptors of symptoms

• Acute Rehab (IRF) claims must

detail a clear, realistic d/c plan

Audit Proofing – CPT Codes

Complexity Codes for OT 97165 – OT Low Complexity

• brief medical history and occupational profile is needed to

ascertain the issues relating to the presenting problem.

• 1‐3 performance deficits (physical, cognitive, psychosocial) impact

the patient.

• Clinical decision making of low complexity: Analysis of the
• ccupational profile, examination of data from the problem‐

focused assessment, the available treatment options are minimal, no co‐morbidities impact occupational performance, and during the evaluation

• No need to modify tasks, provide physical or verbal assistance

during the evaluation. If one or more of these factors applies, you must select this code Note: Generally, about 30 minutes of face‐to‐face time with the patient and/or family is needed.

75

97166 – OT Moderate Complexity

• More extended review of the occupational profile, medical and

therapy history is needed to complete the evaluation; including additional review history related to current functional performance deficits

• 3‐5 performance deficits (physical, cognitive, psychosocial skills)

impact the patient

• Clinical decision making of moderate complexity: This might

include analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment

• ptions. Patient has comorbidities that affect occupational

performance.

• Minimal to moderate modification of tasks or assistance is

needed to complete the evaluation (physical or verbal). If one or more of these factors applies, and no low complexity factors apply, you must select this code

Generally, about 45 minutes of face‐to‐face time with the patient and/or family is needed. 76

97167 – OT High Complexity

• An extensive review of the occupational profile, medical and therapy

history is needed to complete the evaluation.; including additional review of physical, cognitive, or psychosocial history related to current functional performance deficits;

• 5 or more performance deficits (physical, cognitive, or psychosocial

skills) are identified

• Clinical decision‐making is of high complexity: This might include

analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with multiple comorbidities that affect occupational performance.

• Significant modification of tasks or assistance (physical or verbal) is

necessary to enable patient to complete evaluation component. If all of these factors apply, then this is the most appropriate code Generally, 60 minutes of face‐to‐face with the patient and/or family

Resources: AOTA.org, CMS.org

77

Complexity Codes ‐ Additional guiding factors for OT

• Performance deficits are not ADL areas. They are as follows:

Physical – Underlying Impairments of body structures or function (e.g., mobility, strength, balance, activity tolerance, fine or gross motor coordination, sensation, dexterity). Cognitive – Ability to think, understand, problem solve, sequence, attend to a task, remember, and learn new things and carry out occupational tasks safely and efficiently. The need for cues or modification of task would indicate deficits. Psychosocial ‐ Habits, routines, coping mechanisms, interpersonal skills, and the emotional ability to participate in everyday social situations

• Time is a factor to consider but it should not be the only determining factor

78

97161 – PT Low Complexity

• The clinical presentation is stable and predictable
• Clinical decision making is of low complexity
• Personal factors and comorbidities do not affect the plan
• f care
• There are less than 3 body structures or functions

identified that affect the plan of care (also consider activity limitations and/or participation restrictions)

If one or more of these factors applies, you must select this code Note: Generally, 20 minutes of face‐to‐face time is needed

Audit Proofing

Complexity Codes for PT

79

97162 – PT Moderate Complexity

• The clinical presentation is evolving but not unstable
• Clinical decision making is of moderate complexity
• Less than 3 personal factors and comorbidities that affect POC
• Less than 4 body structures or functions affect the POC

If one or more of these factors applies, you must select this code Note: Generally, 30 minutes of face‐to‐face time is needed

97163 – PT High Complexity

• The clinical presentation is unstable
• Clinical decision making is of high complexity
• 3 or more personal factors and comorbidities affect the POC
• 4 or more body structures or functions affect the POC

Generally, about 45 minutes of face‐to‐face time is needed If all of these factors apply, then this is the most appropriate code Note: time is a factor to consider but it should not be the only determining factor.

80

Complexity Codes ‐ Additional Guiding Factors for PT

Body Systems (structures or functions):

Cardiovascular/pulmonary system: assessment of heart rate, respiratory rate, blood pressure, and edema Integumentary system: assessment of pliability (texture), presence of scar formation, skin color, and skin integrity Musculoskeletal system: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight Neuromuscular system: general assessment of gross coordinated movement (e.g., balance, gait, locomotion, transfers) and motor function & learning Communication: affect, cognition, language, and learning style/barriers; ability to make needs known, consciousness, orientation (person, place, and time), expected emotional/behavioral responses, and education)

• Personal Factors: include sex, age, coping styles, social background,

education, profession, past and current experience, overall behavior pattern, character, and other factors that influence how disability is experienced by the individual. Personal factors could exist but may or may not negatively impact the POC.

• Also consider: coordination, consultation, and collaboration of care with

physicians, other qualified health care professionals, or agencies is provided consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.

*See supplemental materials for a convenient handout

Resources: APTA.org, CMS.org

81

Audit Proofing

CPT Codes

RETIRED CODE CODING UPDATE NOTE 97532: Development of cognitive skills– untimed service‐based code. 97127: cognitive function (attention, memory, executive function, pragmatics) and compensatory training. Untimed (service‐based) GO515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training). Time‐based code (each 15 min.) 97129: Therapeutic interventions that focus on cognitive function & compensatory strategies 97130: Therapeutic interventions that focus on cognitive function & compensatory strategies 97129 – first 15 minutes or less of treatment 97130 – second and each subsequent 15 minutes of treatment

82

Audit Proofing

CPT Codes

RETIRED CODE CODING UPDATE NOTE

97760: orthotic mgmt. & training Add “initial encounter” to descriptor 97761: Prosthetic training Add “initial encounter” to descriptor 97762: Orthotic/prosthetic checkout 97763: orthotic/prosthetic

• mgmt. and/or training

(subsequent encounter) Replaces 97762, Orthotic/Prosthetic checkout

83

Audit Proofing

Cognitive Evaluation CPT Codes

96125 (Standardized cognitive performance testing, per hour)

 Completion of standardized cognitive test of at least 31 minutes, including: ‐ evaluation ‐interpreting results ‐write‐up of report

(Subtests of standardized test may be used if they are also standardized)

Assessments to consider: ABCD – Arizona Battery for Communication of Disorders of Dementia FAVRES – Functional Assessment of Verbal Reasoning and Executive Strategies SCATBI – Scales of Cognitive Ability for Traumatic Brain Injury RIPA G I and II – Ross Information Processing Assessment ‐ Geriatric

92523 (Speech and sound production and language evaluation)

 Assessment of cognitive skills using non‐standardized assessments + full speech and language evaluation. Speech‐language must be primary focus 84

Audit Proofing – Reimbursement Changes

Part B Cap

• On February 9th, 2018, a budget bill was passed that included

a permanent repeal of the cap on Medicare outpatient therapy

• services. However, there is a 2‐tiered threshold
• Tier 1: $2040 for OT and $2040 for PT & ST combined
• Tier 2: $3000 for OT and $3000 for PT & St combined
• Treatment over these thresholds is allowed as long as the

services are medically necessary, require the skills of a therapist, & the documentation supports it.

• The KX Modifier must be applied to claims once service costs

meets these thresholds

85

Services provided by Assistants:

• Budget bill also includes provisions that make changes to

home health payments in 2020 and another that to reduce reimbursement for services provided by PTAs & OTAs

• Beginning in 2022 (85% of total fee per service) will be paid
• Modifiers must be applied beginning 2020.
• Modifier CQ: more than 10% of services provided by a PTA
• Modifier CO: more than 10% of services provided by an OTA

Audit Proofing – Reimbursement Changes

86

Value Based Purchasing (VPS)

• Hospital reimbursement is reduced by 2% and this amount is

allocated to participating hospitals based on TPS

• TPS = Total performance Score (quality, efficiency, outcomes,

safety, patient/caregiver experience, etc.).

• HHA & SNF VBP have similar guidelines with withholdings of

up to 8%Estimated pool for 2019 = 1.9 billion

• Outcomes, Hospital readmissions, value (resource mgmt) and

patient satisfaction are primary TPS measures

Audit Proofing – Reimbursement Changes

87

Audit Proofing – Reimbursement Changes

Maintenance Therapy

Jimmo vs. Sebelius

• 2013 lawsuit challenging Medicare’s “improvement”

standard for coverage determinations Outcome: 1. As long as the treatment rendered require the skill, knowledge or judgment of a nurse or therapist OR 2. the patient’s condition is so complex and sophisticated,

• nly a licensed nurse or therapy professional can render

the services to prevent medical and/or physical decline, then the criteria for skilled coverage would be met despite not making functional gains.

• Documentation must support this need
• Applies to SNF, HH and Outpatient settings

88

Impact – APTA Private Practice Section

89

Audit Proofing

Modes of Treatment Delivery as defined by CMS

Treatment Set‐Up

• Billable for all payors except Medicare Part B.
• Set up may be performed by a therapist, assistant or rehab aide

(only billable rehab aide service) Co‐Treatment (all payors except Medicare part B):

• Two licensed therapy professionals from different disciplines

treating one patient at the same time with different tx

• If clinically appropriate, both may bill the entire tx
• Daily treatment note must reflect the co‐treatment and each

disciplines purpose/involvement. Concurrent Treatment (all payors except Medicare part B):

• Treating 2 patients, performing different activities at the same

time, both in line of sight of the therapist.

• Must bill total time of tx session & total con‐current time.

90

Group Therapy (all payors except Medicare Part B):

• Tx of 2‐6 patients at the same time with same or similar tx.
• Group and concurrent minutes cannot account for more than

25% of total minutes on the claim for each discipline.

Group Therapy for Medicare Part B:

• Tx of 2 or more patients at the same time performing similar or

different activities.

• Medicare credits ¼ of the minutes toward the claim.

Group Therapy for Medicare Part A and B:

• Total individual time and total time in group must be recorded.
• Encounter note should provide a rationale for this mode of tx

and demonstrate it’s benefit to the patient

• Group CPT code must be included in the physician’s orders and
• n the signed POC.

91

Audit Proofing

Modes of Treatment Delivery – UPD UPDATED TED FO FOR PDPM PDPM!

Re Rehab Gr Gradua aduati tion!

• n!

92

Effective Discharge Planning to Avoid Hospital Re‐admissions and Ensure Reimbursement

• Collaborate with Social Services as needed for efficient

coordination of services.

• Therapy departments should hold regular team meetings

to discuss patient cases and brainstorm challenges.

• Recommend appropriate Medical DME

*See supplemental materials for DME documentation guide

• Recommend appropriate support programs and services:

93  Caregiver Support Groups  VA Aid & Attendance  Medicaid, CAPS, Grants  Alternative Care Settings  Non‐medical, in‐home care  Senior Care Advisers  Emergency medical alert system  Meal Delivery Services  Adult Day Centers (Senior Club)  ALF (All inclusive, Adult Retirement Community)  Long‐term Care Insurance

Walker with adjustable tray

94

Furniture Risers

Recommending inexpensive non‐medial equipment can help facilitate a safe discharge!

Adhesive Light or touch lamp Retractable keychain Hanging shoe organizer Rolling laundry basket

Life After Rehab…

95

1. Provides patient/caregivers with a summary of status level, care needs, and tips for maintaining 2. Helps to quickly identify functional declines for appropriate and timely future therapy referrals. 3. Helps to prevent hospital readmissions!

Functional Maintenance Programs help to:

So…

There is no need to change careers from Therapist to Barista!

“Functional Geriatrics” We can meet the demands of Healthcare Reform and still provide excellent rehab! info@therapystrategiesplus.com

Thank You!

Email:

With

96