FD and UI • ST • Patient cannot swallow without coughing (function) • Patient exhibits the following findings to a SLP (underlying impairments) • Poor mastication due to loss of dentition, with no dentures • Decreased tongue strength and ROM, thus making bolus propulsion difficult • Tachypnea at 35 ‐ 40 respirations/minute, making airway closure coordination difficult 31
Do you see the importance? • Without a functional deficit, it is not (generally) considered reasonable that skilled care is required… • Without assessment/analysis of underlying impairments causing functional deficits, we will not be able to prove our particular (discipline) services are necessary … 32
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 33 ‐ cannot toilet by self
Standardized Tests/Assessments • “Standardized” • Evidence ‐ Based • Psychometric parameters (examples) • Test ‐ retest reliability • Minimal Detectable Change (MDC) • Construct Validity • Age Normative Data • Etc… • Best way to track baselines and prove effectiveness (reasonableness) of treatment 34
Standardized Tests/Assessments If you measure them, use them to enhance your: • Interpretation of what is going on with the patient. • Analysis of the progress the patient is making. • Argument that your care is reasonable and necessary. • Medicare is attempting to use a form of standardization with section GG, MIPS reporting, FLR, etc…, as part of “Value ‐ Based” payment model development 35
Standardized Tests 36
Diagnoses 37
Medical and Treatment Dx • Medical Diagnosis: the art or act of identifying a disease from its signs and symptoms (Merriam ‐ Webster) • Helps answer “what” caused the patient to have a functional decline • Treatment Diagnosis: • Needs to tied in with underlying impairments assessed • Helps answer the “why” we are treating the patient… 38
PDPM (SNF Part A) “There are two ways in which ICD ‐ 10 codes will be used under PDPM. First, providers will be required to report on the MDS 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.” • https://www.cms.gov/Medicare/Medicare ‐ Fee ‐ for ‐ Service ‐ Payment/SNFPPS/Downloads/PDPM_FAQ_Final.pdf 39
PDGM (HH Part A) “A comorbidity is defined as a medical condition coexisting in addition to a principal diagnosis. • Comorbidity is tied to poorer health outcomes, more complex medical need and management, and higher care costs.” • https://www.cms.gov/Outreach ‐ and ‐ Education/Outreach/NPC/Downloads/2019 ‐ 02 ‐ 12 ‐ PDGM ‐ Presentation.pdf 40
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 41
Medical and Treatment Dx • Must be relevant – all diagnoses • Must be sufficiently explained in the initial analysis statement • Medical diagnosis must have a cause ‐ effect relationship with the treatment diagnosis • Code to the highest level of specificity and complexity of the patient, as long as it is relevant to the patient’s therapy case/RFR. 42
Diagnosis Website • www.icd10data.com • Shortness of breath R06.02 • Pain (in various specific anatomical locations) • Contractures (in various specific anatomical locations) • Speech and language deficits following other cerebrovascular disease I69.82 • Abnormal posture R29.3 • Etc… 43
Medical Dx ‐ ca caution • Medical conditions such as UTI, dehydration, GI issues, pneumonia, etc. • The assumption on Medicare’s part is that the patient’s function will improve as they recover from their illness and through nursing activities 44
M62.81 “…in the 2008 HH PPS final rule, we identified ‘‘muscle weakness (generalized)’’ as a nonspecific condition that represents general symptomatic complaints in the elderly population . We stated that inclusion of this code ‘‘would threaten to move the case ‐ mix model away from a foundation of reliable and meaningful diagnosis codes that are 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…” • Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Rules and Regulations, page 69. 45
What to document in the RFR when a patient has a medical dx that should resolve when patient is medically treated… “The patient’s functional deficits did not spontaneously resolve as a result of medical care, necessitating referral to therapy services.” 46
Diagnosis Relevance Bootcamp 2 • Primary Dx: AMI 2 weeks ago • Secondary Dx: • Parkinson’s x 4 years • DM II x 11 years • OA right knee x 5 years 47
Diagnoses 48
Initia Initial (eval) Analysis Statement • Your sales pitch to Medicare or any insurer. • Tells a brief story of “what changed?” and “why now/why me?” • Helps you get paid. 49
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 on severity of evaluation code for PT and OT) 7) A statement of medical necessity of care (benefits of care AND risks of not receiving care) 50
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 d ifficulty 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 awareness . Patient has a h/o DM with erratic blood sugar levels , >=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 home. In addition , unmonitored activity at high blood sugar levels places patient at risk for metabolic dysfunction. Patient’s BP response will need to be monitored to ensure safety during assessment and treatment. Patient’s clinical presentation is unstable because of these 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 out of room activity capability, and educate caregivers on their roll in positioning 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.” 52
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 optimal weight. Without skilled interventions, patient is at risk of penetration/aspiration with associated complications, potentially including death. ST is expected to improve patient’s swallow function to PLOF.” 53
What are examples of poor poor RFRs? • “PT evaluated patient per nursing recommendation of decreased transfer ability. Patient also noted to require assist for gait. Therapy recommended .” • “Patient demonstrates difficulty with splint fitting hand, and requires this for feeding and ADLs. Patient was found in chair yesterday with wrist splint applied to ankle.” • “Patient referred to ST for recent weight loss of 10 lbs. in 3 weeks. Patient is currently on pureed diet.” 54
Writing a strong initial analysis (continued) • Can be hard to do when patient is improving … • Patient received modification to Parkinson’s meds and is moving much more freely … • Prove it is reasonable that the patient can achieve a higher practicable level of function, and that it is necessary we provide services. 55
Writing a strong Initial Analysis (continued) • Patients do not (according to Medicare) have access to rehabilitation purely for the purpose of: • Recreation • Vocation 56
Initial Analysis 57
GOALS 58
Goal Writing Goal writing should demonstrate… • A correlation between functional deficits and underlying impairments. • Objective benchmarks. • Skilled analysis , and basis for further analysis. 59
60
Documenting Goals • SMART… • Specific ‐ area of function ‐ be specific ‐ allows for determination of • Measurable ‐ if it is not measurable, you cannot address • Attainable ‐ is it something we can achieve ‐ If your goals are attainable, your prognosis will be good/excellent. • Relevant ‐ does it have bearing on patient rights? PLOF? Our scope of practice? • Time ‐ constrained ‐ There is an end in sight 61
Goals continued • STGs • Medicare does not necessarily require STGs • However , STGs allow more specific and thorough analysis of patient progress • There should be attainable goals for any patient within the minimum reporting period (i.e., 10 treatment days/30 calendar days, whichever is first). • Point to LTGs and are generally more specific 62
Goals ‐ continued • LTGs • Are required • Need to be measurable functionally • Give the picture of what the end result of care will look like ‐ what we envision the patient to be like when we are all done with him/her. • Generally are geared for the end of care/ Discharge, but can be for the end of a certification period. 63
Mechanics of writing a good goal • Very simple… • Functional deficit • Underlying impairment • SMART format 64
What should not not be in the goal • The skilled intervention you are using to achieve the goal ‐ goals are independent of therapist intervention ‐ e.g., putting application of ES in a goal. • Vague descriptors of patient progress/ill defined objectives 65
What should not be in goal ‐ “vague descriptors” • Least restrictive • Maximize function • Maximize level • Highest level attainable • “endurance” or “functional endurance” or “activity tolerance” • These are not skilled activities 66
“Exercises to promote overall fitness, flexibility, endurance (in absence of a complicated patient condition), aerobic conditioning, or weight reduction, are not covered... “ • Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) 67
Examples of Goals • “Patient will perform sit to stand transfers with SBA due to right knee flexion ROM >=95 degrees by (DATE).” • “Patient will demonstrate 3+ grade Kansas University Sitting Balance Assessment to allow bilateral UE usage in seated dressing to don/doff of shirt SBA by (DATE).” • “Patient will demonstrate no anterior spillage on 9/10 trials as evidence of improved labial closure, to improve bolus cohesion, by (DATE).” 68
Examples of goals ‐ continued • “Patient will achieve a Tinetti POMA score of >=20/28 to reduce fall risk and demonstrate 1 standard deviation improvement in gait/balance by ________ (DATE).” • “Patient will demonstrate use of long handled 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).” • “Patient will be IND with self ‐ relaxation techniques prior to verbal output as evidenced by <=1 repetition of syllables per sentence, to improve speech intelligibility by (DATE).” 69
Examples of weak weak goals • “Patient will ambulate 150 ft to allow improved ability to go from room <> dining room by (DATE).” • “Patient will increase UE strength to 5/5 to allow IND UB dressing by (DATE).” • “Patient will improve safety/judgment to 90% in order to function more safely in d/c environment by (DATE).” 70
M.I.C.E. 71
M .I.C.E. • M aintain Impairments ‐ the goal is simply maintenance of function (assuming skills of therapist are necessary to maintain) • “Patient will maintain ‐ 70 degrees knee extension bilaterally (UI) to prevent posterior pelvic tilting in wheelchair, to allow sitting 2 hours without repositioning for meals and activities (FD) by (DATE).” • Notice – the goal is still SMART , and still have an underlying impairment and a functional deficit. 72
M. I .C.E. • I mprove Impairments ‐ improving the underlying impairment: • “Patient will improve _____ (underlying impairment) to measurement of _____ to allow ______ (functional capability).” • The focus of this goal is making the underlying impairment less impactful upon the function. 73
M.I. C .E. • C ompensate for Impairments : The patient makes up for an underlying impairment that he/she cannot improve with a compensation: • “Patient will demonstrate IND feeding with left hand, lipped plate, and enhanced grip utensils secondary to R UE weakness by (DATE).” 74
M.I.C. E . • E nvironmental adaptations ‐ the environment or caregiver’s behavior is modified to accommodate an underlying impairment for which the patient can neither improve or compensate for, thus improving function: • ”Patient will be set up in wheelchair with 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).” 75
M.I.C.E. ‐ continued • Why is ICE important to consider: • Not all patients’ underlying impairments are improvable, nor will all patients be able to compensate for the deficit. • If treatment focuses just on improvement goals, it limits the amount of acceptable therapeutic interventions that you can deliver to the patient. • It has a direct impact on patient prognosis. 76
One more thing about goals… • If you stated that something was an issue in the reason for referral, you had better have a goal for it… • If you do not do something about an identified problem, there is a word for that…_______________. 77
Goals… 78
Choosing Appropriate Interventions (CPT codes) • CPTs are determined based upon underlying impairments (mostly) and functional deficits (sometimes) that you are addressing. • CPTs should correlate with your Tx Dx . • CPTs should not be chosen to cover something you might want to address in future. 79
Avoid “CP “CPT Po Potpourri” • A mixture of CPT codes, some of which are not supported by objective measurements. (from the John Adamson Abridged Dictionary) • Dangers of CPT Potpourri: • Lack of compliance with orders from MD • Lack of professional standards of practice compliance 80
We are done formulating the Plan of Care… So now onto Progress Reports 81
Progressing with treatment • Plans of care/initial evals cover medical necessity of care until first required reporting of progress (10 treatment days/30 calendar days) • Demonstrate the continued medical necessity of care. 82
Ways to demonstrate ongoing medical necessity: • Change in function • Skilled Analysis • Skilled Interventions • Adjustments to care • Continued frequency and duration 83
Change in Function • Each progress note should demonstrate clear, objective, and timely improvement (goes back to reasonable criteria of care). • Goals should be documented upon with same functional and underlying impairment criteria. • If no change occurs , this will put greater burden on skilled analysis, skilled interventions, and adjustments to care. • Objective Data – the basis for analysis 84
How to make it read sim simply ly for reviewers GOAL Last Note Today’s Fxn 3+/5 strength 2+/5 3/5 to allow Max assist Min assist modified IND 2+/5 Modified IND 3+/5 Max assist 85
What word is “change in function” associated with? Reasonable OR Necessary? _______________________ 86
Skilled Analysis • Based upon (specific/measurable) data entered into goals • Demonstrates critical/clinical thinking • Gives opportunity to explain lack of progress • Allows for further assessment/analysis of underlying impairments that may be impacting function/barriers to progress • If patient is on skilled maintenance , can discuss why continued skilled service is necessary • Answers the “why?” progress/”why not?” progress. 87
The Blueprint for a Solid Analysis 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? 88
Skilled Analysis ‐ starter phrase for progress • “ Patient has demonstrated progress functionally in (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. Barriers that impact the rate and extent of progress include (ENTER), which are being 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).” 89
Skilled Analysis – starter phrase for lack of progress • “The rate and extent of progress has been 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.” 90
What is an analysis statement? • A parable • An easy to follow story, but with a deeper meaning 91
What is an analysis statement? Analysis Reasonable Necessary 92
Analysis words to avoid • “Patient has plateaued …” • “ Slow and steady progress…” • “Patient is not compliant …” • Informed consent • Right to refuse • “Patient has achieved maximum therapy benefit …” (if continuing care) • “Patient tolerated treatment well…” 93
Dealing with Non ‐ Compliance • Mentally competent patient • Mentally/psychologically incompetent patient 94
Analysis ‐ Boot Camp 3 • “Patient demonstrates improved stair climbing ability to min A with 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.” • “Patient shows improved strength right UE from 3/5 for shoulder to 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.” • “Patient demonstrates 90% accuracy with word retrieval and naming, 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 .” 95
Change in Function/Analysis 96
Skilled Interventions • Charges entered by therapist as CPTs 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 organizations. (http://searchhealthit.techtarget.com/definition/Current ‐ Procedural ‐ Terminology ‐ CPT) 97
Use the right tool for the job – including therapy! 98
CPT Documentation • It is important that all CPTs have a clear relationship to the underlying impairments/functional deficits/treatment diagnoses. • All CPTs that were billed during the interval between last to current documentation should be explained. Any that are not explained should not be billed. 99
Skilled Interventions are are not… not… • …a description of what the patient did (though this may be part of it) • Example: • “Patient performed 3 sets of 10 reps shoulder flexion with 3# weighted dowel.” 100
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