House Keeping Cell phones mute please! Sign in/out Breaks/lunch - - PowerPoint PPT Presentation
House Keeping Cell phones mute please! Sign in/out Breaks/lunch Bathrooms Booklets Special forms Attendee Information Form Course Evaluations ASHA End of day sign out, forms placement Temp 1
House Keeping
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Evidence‐based Documentation That (helps) Prevents Denials
By John Adamson, PT, MDiv, GCS adamsonenterprises1@gmail.com “John Adamson, The Rehab & Documentation Guru” YouTube channel Find me on LinkedIn 2
from Southern Seminary, Louisville, KY
Specialist (GCS)
experience
related courses
children (4 with special needs, from Ukraine)
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Objectives
therapy services.
codes
patient.
mandated intervals
discipline scope of practice 6
Why are you taking a DOCUMENTATION COURSE????
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Cost of Medicare vs. Inflation
(2018 data):
dollars, a 785% increase. (https://www.aier.org/cost‐living‐ calculator)
(1966 to 2019): 22,633%
budget‐breakdown‐3305789
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Change Medicare to a Premium Support Plan Require Drug Companies to Give Rebates or Discounts to Medicare Increase Medicare Cost‐Sharing for Home Health Care, Skilled Nursing Facility Care and Laboratory Services Generate New Revenue by Increasing the Payroll Tax Rate Increase Supplemental Plan Costs and Reduce Coverage Raise Medicare Premiums for Everyone Increase Penalties for Health Care Fraud Enroll All Beneficiaries Covered by Both Medicaid and Medicare in Managed Care
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Improved Outcomes Reduced Costs Positive Patient Experience
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legs, not all 3, at the same time
satisfaction
continue to happen and therefore we can expect
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Reasonable‐ Weighing costs with benefits, care is generally predictable in duration and intensity, based upon best clinical practice and research.
http://www.nejm.org/doi/full/10.1056/NEJMp1208386
determine the most reasonable payments by diagnostic groups and some other personal factors.
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OUTCOMES
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SOC LTG
Physical Therapist Medical Doctor Orthotist Walgreens
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Only You!
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“The service of a physical therapist, speech‐language pathologist, or
service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled
Services, and Occupational Therapy, CMS
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patient, acuity, personal factors
clinical judgment
administered by non‐skilled personnel.
“reasonable” as well
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Minimum Requirements of the POC?
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Skilled Therapy must meet the following requirements:
specialist) except in case of Certified Outpatient Rehabilitation Facilities (CORF)
intervene.
therapist’s skills, or the therapist is required to initiate/adjust a restorative maintenance program.
(scientifically supported)
(http://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/bp102c08.pdf)
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special skill/knowledge of therapist
(EBP)
and duration to accomplish goals of treatment
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Maintenance Therapy
situations in the SNF, home health, and outpatient therapy settings where, even though no improvement is expected, skilled nursing and/or therapy services to prevent or slow a decline in condition are necessary because of the particular patient’s special medical complications or the complexity of the needed services.”
restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.”
Payment/SNFPPS/Downloads/jimmo_fact_sheet2_022014_final.pdf
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Who tells you what to do…
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etc.)
decline to be treated
something
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ROM, strength, balance, etc)
effectively because of the complexity
needing skilled training
the need for skilled services, form the basis for goals and analysis, and demonstrate the need for (most) chosen interventions (CPTs)
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before needing a break
more skilled professionals (definitely within PT scope)
skilled
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distance?
measures?
non‐skilled personnel/non‐therapists, and certainly not measurable by many, or make clinical sense to but a few.
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down, due to inability to pull shirt over head. (functional impairment)
impairments:
balance‐ therapist determines that patient has vestibular and/or proprioceptive issue due to 1) loss of visual input and 2) position change
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(function)
SLP (underlying impairments)
with no dentures
thus making bolus propulsion difficult
making airway closure coordination difficult
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(generally) considered reasonable that skilled care is required…
underlying impairments causing functional deficits, we will not be able to prove our particular (discipline) services are necessary…
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Bootcamp Exercise 1
Patient is a 67 y/o female with a decline in function resulting from an acute event, and is evaluated by you with the following findings. ID the functional deficits (FD) from the underlying impairments (UI). ‐cannot feed self ‐incomplete labial closure and pocketing right sulcus ‐global aphasia measured with the Boston Aphasia Battery ‐unable to walk with max assist ‐strength on dominant side is 3‐/5 UE, 3/5 LE ‐Tinetti score of 3/28, with subcomponent deficits in seated and standing balance ‐hypertonicity measured at 3+ on modified Ashworth Scale on dominant side ‐repeats “I can’t, I can’t” to everything ‐unable to don clothing LB without total assist ‐unable to complete finger‐nose‐finger dominant side, evidence of impaired proprioception and kinesthesia ‐lacks 2 point discrimination and light touch sense dominant side ‐cannot toilet by self
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effectiveness (reasonableness) of treatment
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Standardized Tests/Assessments
If you measure them, use them to enhance your:
patient.
necessary.
standardization with section GG, MIPS reporting, FLR, etc…, as part of “Value‐Based” payment model development
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identifying a disease from its signs and symptoms (Merriam‐Webster)
have a functional decline
impairments assessed
the patient…
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“There are two ways in which ICD‐10 codes will be used under
the patient’s primary diagnosis for the SNF stay. Each primary diagnosis is mapped to one of ten PDPM clinical categories, representing groups of similar diagnosis codes, which is then used as part of the patient’s classification under the PT, OT, and SLP components. Second, ICD‐10 codes are used to capture additional diagnoses and comorbidities that the patient has, which can factor into the SLP comorbidities that are part of classifying patients under the SLP component and the NTA comorbidity score that is used to classify patients under the NTA component.”
Payment/SNFPPS/Downloads/PDPM_FAQ_Final.pdf
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“A comorbidity is defined as a medical condition coexisting in addition to a principal diagnosis.
and management, and higher care costs.”
Education/Outreach/NPC/Downloads/2019‐02‐12‐PDGM‐ Presentation.pdf
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From CMS Presentation on PDGM – “Co‐Morbidities Specific to Home Health”
“A HH specific comorbidity list was developed with broad clinical categories used to group comorbidities within the PDGM:
Heart Disease Respiratory Disease
Circulatory Disease Cerebral Vascular Disease Gastrointestinal Disease Neurological Disease Endocrine Disease Neoplasms Genitourinary/Renal Disease Skin Disease Musculoskeletal Disease Behavioral Health Issues Infectious Disease
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Medical and Treatment Dx
initial analysis statement
effect relationship with the treatment diagnosis
and complexity of the patient, as long as it is relevant to the patient’s therapy case/RFR.
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Diagnosis Website
locations)
locations)
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GI issues, pneumonia, etc.
the patient’s function will improve as they recover from their illness and through nursing activities
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“…in the 2008 HH PPS final rule, we identified ‘‘muscle weakness (generalized)’’ as a nonspecific condition that represents general symptomatic complaints in the elderly
threaten to move the case‐mix model away from a foundation
appropriate for home care’’ (72 FR 49774). Specifically, the 2008 HH PPS final rule stipulated that the case‐mix system avoid, to the fullest extent possible, non‐specific or ambiguous ICD–9–CM codes, codes that represent general symptomatic complaints in the elderly population, and codes that lack consensus for clear diagnostic criteria within the medical community…”
Rules and Regulations, page 69.
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What to document in the RFR when a patient has a medical dx that should resolve when patient is medically treated…
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any insurer.
changed?” and “why now/why me?”
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How to write an Initial Analysis
1) Patient information (age, gender, etc.) 2) Referral source and Reason for Referral 3) Setting patient referred from and reason 4) The medical and Tx Dx, and how they relate. (“what changed?”) 5) Summary of the functional deficits, and the underlying impairments that cause them. (also “what changed?”) 6) Significant co‐morbidities/complexities (age, severity of condition(s), acuity, social circumstances) that may impede progress/impact therapy. (Impact
7) A statement of medical necessity of care (benefits of care AND risks of not receiving care)
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Sample PT Initial Analysis
“Patient is a 78 y/o male hospitalized from ____ to _____ due to left CVA on ____ (date), resulting in right dominant hemiparesis. Patient was referred to PT to be provided in ______ setting by ____ due to patient exhibiting difficulty performing bed mobility, transfers, and level ambulation and being unable to safely transition to home due to spouse unable to meet needs in home setting. These functional deficits were caused by significant weakness of right LE, hypertonicity, decreased balance, high blood pressure with activity, and poor safety
>=250 inconsistently through day, placing patient at risk for ketoacidosis, and increasing risk that care by a non‐licensed professional will not be safe nor effective due to impact of hyperglycemia. Skilled PT is necessary to improve bed mobility, transfers, and ambulation, and restore patient to level of functionality that his spouse can manage at home. Without therapy, patient is at risk for falls, further immobility, dependence upon caregivers, and failure to return
places patient at risk for metabolic dysfunction. Patient’s BP response will need to be monitored to ensure safety during assessment and
concerns.” 51
Sample OT Initial Analysis
“91 y/o female with Alzheimer’s Disease, referred by nursing and MD for a seating
consult secondary to patient sliding in current geri‐chair x several weeks. Nursing efforts have been unsuccessful in addressing this problem. Due to sliding, patient has developed recurrent stage 3 pressure ulcers with tunneling along ischial tuberosities (a clinical sign of sheer), which necessitates patient being kept in bed on pressure relief mattress, prohibiting out of room activities. Due to cognition rated at 2.6 on Allen Cognitive Level Assessment (ACL), patient will not initiate movement to relieve pressure and is not trainable. Patient presents to OT with difficulty maintaining seated balance, hypertonicity, limited initiation of movement to pressure relieve, decreased strength, poor safety awareness, limited social interaction, abnormal posture, and notable bilateral UE and LE contractures. PMH includes PAD, with brachial‐ankle index of 0.73 bilateral LE, indicating patient is at significant risk for LE wound development without proper positioning. These factors contribute to an unstable clinical presentation. Prior to becoming intermittently bed bound due to skin issues, patient was able to sit by nurses’ station, attend music time, and enjoyed sitting outside during warm weather, which caused patient to smile, and be more alert per nursing staff. Skilled OT is necessary to determine most appropriate seating system, improve underlying impairment limitations impacting seating and positioning, and increase
improvement, as well as FMP/RNP. Without therapy, patient is at risk for falls out of chair, further contractures, acquired pressure ulcers, decreased socialization, increased dependency upon caregivers, and decreased quality of life. OT is expected to restore patient’s safety in a seating system, and improve these risk factors.”
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Sample ST Initial Analysis
“42 y/o male in MVA with closed head injury with significant h/o dysphagia three years ago, who has been on mechanical soft diet with nectar thickened liquids since his accident without incident. Patient’s caregiver noted approximately 1 week ago significant coughing with drinks and loss of food from mouth. Recently, MD increased Baclofen dosage and some psychotropic medications to manage tone and some behavioral issues, and will not adjust medications at this time, so there are no pharmacological avenues to utilize to address the functional decline at this time. Nursing/MD decreased diet to pureed/honey thickened liquids, but patient is requesting dietary upgrade and has lost weight since diet consistency change, losing 14 pounds in one month and falling to 94% ideal body weight. Patient presents to ST with oral‐pharyngeal dysphagia, with decreased labial closure, decreased bolus propulsion, decreased airway protection, delayed swallow response, and decreased arousal. Skilled ST is necessary to improve patient’s swallow function to allow return to prior level of dietary consistency to assist in maintenance of
penetration/aspiration with associated complications, potentially including death. ST is expected to improve patient’s swallow function to PLOF.”
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What are examples of poor poor RFRs?
recommendation of decreased transfer
for gait. Therapy recommended.”
fitting hand, and requires this for feeding and
with wrist splint applied to ankle.”
pureed diet.”
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Writing a strong initial analysis (continued)
improving…
Parkinson’s meds and is moving much more freely…
patient can achieve a higher practicable level of function, and that it is necessary we provide services.
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Writing a strong Initial Analysis (continued)
Medicare) have access to rehabilitation purely for the purpose of:
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for determination of
cannot address
your goals are attainable, your prognosis will be good/excellent.
rights? PLOF? Our scope of practice?
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STGs
thorough analysis of patient progress
patient within the minimum reporting period (i.e., 10 treatment days/30 calendar days, whichever is first).
specific
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the patient to be like when we are all done with him/her.
care/ Discharge, but can be for the end of a certification period.
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using to achieve the goal‐ goals are independent of therapist intervention‐e.g., putting application of ES in a goal.
progress/ill defined objectives
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with SBA due to right knee flexion ROM >=95 degrees by (DATE).”
University Sitting Balance Assessment to allow bilateral UE usage in seated dressing to don/doff of shirt SBA by (DATE).”
spillage on 9/10 trials as evidence of improved labial closure, to improve bolus cohesion, by (DATE).”
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>=20/28 to reduce fall risk and demonstrate 1 standard deviation improvement in gait/balance by ________ (DATE).”
shoe horn to don shoes mod IND due to lack of ability to bend trunk forward without significant DOE measured at <=4/10 RPE by (DATE).”
techniques prior to verbal output as evidenced by <=1 repetition of syllables per sentence, to improve speech intelligibility by (DATE).”
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improved ability to go from room <> dining room by (DATE).”
5/5 to allow IND UB dressing by (DATE).”
to 90% in order to function more safely in d/c environment by (DATE).”
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maintenance of function (assuming skills of therapist are necessary to maintain)
extension bilaterally (UI) to prevent posterior pelvic tilting in wheelchair, to allow sitting 2 hours without repositioning for meals and activities (FD) by (DATE).”
have an underlying impairment and a functional deficit.
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underlying impairment:
(underlying impairment) to measurement of _____ to allow ______ (functional capability).”
underlying impairment less impactful upon the function.
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patient makes up for an underlying impairment that he/she cannot improve with a compensation:
with left hand, lipped plate, and enhanced grip utensils secondary to R UE weakness by (DATE).”
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accommodate an underlying impairment for which the patient can neither improve or compensate for, thus improving function:
good alignment by caregiver 3/3 presentations, to allow patient to complete assisted meal and attend activity for time to digest food, with report of pain <=3/10 by (DATE).”
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are improvable, nor will all patients be able to compensate for the deficit.
goals, it limits the amount of acceptable therapeutic interventions that you can deliver to the patient.
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an issue in the reason for referral, you had better have a goal for it…
an identified problem, there is a word for that…_______________.
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Goals…
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Choosing Appropriate Interventions (CPT codes)
impairments (mostly) and functional deficits (sometimes) that you are addressing.
something you might want to address in future.
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not supported by objective measurements.
(from the John Adamson Abridged Dictionary)
compliance
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Ways to demonstrate ongoing medical necessity:
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clear, objective, and timely improvement (goes back to reasonable criteria of care).
same functional and underlying impairment criteria.
burden on skilled analysis, skilled interventions, and adjustments to care.
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How to make it read sim simply ly for reviewers
GOAL Last Note Today’s Fxn 3+/5 strength to allow modified IND 2+/5 Max assist 3/5 Min assist 2+/5 Modified IND 3+/5 Max assist
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What word is “change in function” associated with?
_______________________
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into goals
underlying impairments that may be impacting function/barriers to progress
why continued skilled service is necessary
progress.
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1) Comparison of remaining functional deficits and underlying impairments 2) Discussion of positive impact outside of therapy (patient/caregiver reports) 3) Barriers to progress patient is facing (new illness, cog/psych status, etc., that impact rate/extent of progress) AND what you can do about it. 4) Necessity of ongoing therapy – why would it be neither safe nor effective to discharge the patient at present? Why is continued therapy reasonable and necessary? Why could a non‐skilled person not continue progress on goals?
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Skilled Analysis‐ starter phrase for progress
(ENTER) due to (ENTER underlying impairments OR learned compensation strategies OR caregiver training). Patient/caregiver has noted (ENTER) benefit as a result of therapy. Further analysis reveals (ENTER) underlying impairments that impact functionality, and will be
addressed by therapist through (ENTER). Skilled therapy is still reasonable and necessary due to (ENTER). (OR) D/C at this time is neither safe nor effective due to (ENTER).”
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Skilled Analysis – starter phrase for lack of progress
impeded by (ENTER, with rationale). Skilled therapy services were still reasonable and necessary due to (ENTER). Patient is expected to resume progress due to (ENTER). The patient did demonstrate progress in (ENTER functions/sub‐functions) due to (ENTER progress in underlying impairments OR compensatory strategies OR caregiver training), demonstrating the efficacy of therapy services.”
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Reasonable Necessary
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Analysis words to avoid
therapy benefit…” (if continuing care)
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patient
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use of handrail on right side, though progress was not made on level surfaces with FWW. Patient can perform steps with spouse assisting, spouse requiring min A for correct foot placement. It is necessary for spouse to complete 100% safely and effectively for discharge to patient’s split level home.”
3+/5. Patient is unable to adequately perform HEP with 75% cuing with visual demo required for effective completion to effectively continue, and demonstrates continued significant increased scapulothoracic movement with elevation.”
which has resulted in improved communication with nursing staff and family, with no verbal outbursts/behaviors noted this week due to communication issues. Patient requires continued therapy.”
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CPT‐ Current Procedural Terminology (CPT) is a code set that is used to report medical procedures and services to entities such as physicians, health insurance companies and accreditation
(http://searchhealthit.techtarget.com/definition/Current‐ Procedural‐Terminology‐CPT)
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Use the right tool for the job – including therapy!
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relationship to the underlying impairments/functional deficits/treatment diagnoses.
interval between last to current documentation should be explained. Any that are not explained should not be billed.
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Skilled Interventions are are not… not…
did (though this may be part of it)
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Blueprint for Documenting Skill
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Documenting Skilled Skilled patient/caregiver training:
learn – relate to your knowledge
carryover by patient/caregiver
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facilitated normalization of scapulothoracic rhythm during resisted open chain shoulder exercises, to strengthen scapular plane abduction for functional tasks of dressing and grooming, by cuing for scapular retraction, to decrease risk of glenohumeral
____ degrees AROM to ____ before substitution occurred.”
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modified, adapted, instructed, upgraded, progressed, incorporated, inhibited, facilitated, modeled, normalized, coordinated, explained, promoted, guided, focused/refocused, etc…
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More examples…
determining how strength gains in hip extension have improved cadence and gait speed, and addressed gait components of ______ with manual cues.”
right LE due to terminal extension lag, at 50 Hz on symmetrical biphasic waveform, at pulse duration of 200 microseconds, 10 seconds on/50 off, with manual and verbal cues to facilitate >50% effort during on‐phase for increased motor recruitment.”
setting to iliopsoas muscle group, followed by low load stretching with manual cues to maintain appropriate alignment for effectiveness, which has led to additional 20 degrees hip extension, allowing patient to go from step‐to gait to step‐through gait.”
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More examples…
awareness of, and determined how postural and extremity weakness impact advanced bathing activities. OT applied PRE’s to develop triceps, upper and lower back strength for bathing due to poor postural control of thoracic kyphosis and scapular stabilization problems. As a result of treatment during this reporting period, patient maintains upright posture while on tub seat with only verbal cuing now.”
grooming according to cognitive level and trained direct caregivers in application of these cues during routine care, to provide consistency in training and progress patient towards carryover, as evidenced by ACL level of 3.8. Caregivers demonstrate consistently 50% application of strategies to enhance patient’s IND with these tasks, and are not able presently to effectively maintain patient performance.”
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More examples…
management, therapeutic diet upgrade trials, compensatory strategies (pacing, full oral clearance, cyclic ingestion, relaxation technique for controlled breathing) and discharge counseling. Pt currently has orders for mechanical soft with thin liquids x 2 meals (breakfast/lunch) but remains on puree at dinner. Significantly reduced swallow safety noted in evening due to increased cognitive‐ behavioral changes associated with sun‐downing. Pt and his wife educated re: compensatory swallow strategies to improve safe and efficient swallowing with 100% return demonstration of strategies by his wife. SLP educated pt. and family on the need to implement relaxation strategies while eating due to pt. experiencing anxiety during meal times.”
through the steps of recording appointments in her pocket calendar. She practiced with trial appointments until she replicated the 3 steps with 100% accuracy with minimal verbal cues.”
Care‐for‐Medicare‐Beneficiaries/
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Poor
interventions…
ft with FWW.”
technique, but requires further training.”
swallow, chin tucks, and lingual sweeps.”
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Importance of “Continuing Education” on Skilled Documentation
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assessment
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non‐skilled person could eventually likely perform
person could not be trained in maintenance
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keep HR <60% predicted max during bed mobility, indicating patient’s more appropriate cardiac response.”
thumb, indicating splint is not providing proper contact with digit, therefore further assessment and adjustment is indicated to hand splint prior to patient being d/c’d to caregiver for application.”
interventions from 5 days to 3 days per week due to improvement in ____. With improved caregiver carryover of facilitation of ____.”
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indicates that she is ready for progression to ____ consistency trials, however due to significant h/o pharyngeal dysphagia will not be safe for pleasure feedings until determined safe with ST treatment.”
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progressions/modifications of care
documentation
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Frequency, Intensity and Duration
in weeks
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When pressured to give more therapy than medically necessary, you should say…
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deficits…”
impairments…”
address the areas of function outside the patient’s control…”
a complexity of care such that only a therapist can safely and effectively perform the maintenance program…”
to…”
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necessary)
impairment
dependent”)
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Compensation for Underlying Impairments
adult brain
compensations… “Am I needed to do all the training, or could I train a level 6 person to repetitively practice the training with the patient?”
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Frequency, Intensity, and Duration
adaptations, or caregiver ed (hopefully dealing with executive level functioning caregivers), only a few sessions should be needed to analyze needs, make adjustments/perform training, and arrange carryover of training/equipment usage.
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reasonable and predictable time period.
practice in addressing patient needs.
capability to carry out maintenance.
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progression, or am I the limiting factor?”
given their complexity/co‐morbidities?”
he/she still need my special skills?”
narrow/broad, or not focused on the right underlying impairment(s)?”
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insufficient to do anything else for the patient?”
interventions I am doing be enhanced by another?”
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skilled interventions?
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D/C environment and patient/caregiver capability to carry out maintenance
LOS?”
someone else (non‐licensed caregiver and/or patient) that allows them to safely and effectively maintain or improve the patient’s function?”
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Adaptations for it?
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patient’s functional state/burden of further care.
D/C (focus on modifications/evolution of care)
has been put in place to safely and effectively prevent regression of the patient.
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D/C
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Referral?
relevant?
_____________.
and knowledge of a _______________.
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Putting it all together…(continued)
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Putting it all together…(continued)
are determined by…
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Putting it all together…(continued)
change
detailing each one of the CPT codes
necessarily patient medical status/ability to restore only.
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Putting it all together…(continued)
some…
to D/C
therapist’s SOP has been exhausted to address all patient needs, unless another reason than therapist decision has caused discharge.
non‐skilled.
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Questions???????
Thank you for being so attentive and participating in boot‐camp‐ you are now ready to face anything Medicare throws at you! (Applause, kudos, and dark chocolate all appreciated!)
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