SlideShare une entreprise Scribd logo
1  sur  112
Télécharger pour lire hors ligne
Medicare Documentation for the
Rehabilitation Patient:
Evidence of Progress
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc.
(HHI)
Presented by:
Kris Mastrangelo, OTR/L, MBA, LNHA
President & CEO
Objectives:
The learner will be able to define skilled
coverage criteria.
The learner will be able to define key
elements of Documentation.
The learner will be able to provide examples
of Rehabilitation Documentation to support
Medicare coverage criteria.
The learner will be able to provide examples
of Nursing Documentation to support
Medicare coverage criteria.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
Increase in Medicare Documentation
Reviews
Significant increase in the number of medical review
requests from Medicare Administrative Contractors
(MACs)
Lower 14
Billing inconsistencies
ICD-9 Coding triggers
Similar pattern to Medical Record Reviews within
the nursing facility setting in the early 90's
Number of "Help Letters“ was astoundingly high
Investigations into potential fraudulent billing
practices increased
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
Increase in Medicare Denials
Denials due to conflict between
Nursing Notes, MDS and Rehabilitation
documentation
Documentation by Nursing of Medical
Complexity supports need to receive
rehabilitation at a SNF level of care
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
OIG Report November 2012
In fiscal year (FY) 2012, Medicare paid $32.2 billion
for SNF services
Submission of inaccurate, medically unnecessary, and
fraudulent claims
Medicare Payment Advisory Commission has raised
concerns about SNFs’ improperly billing for therapy
to obtain additional Medicare payments
Increase and expand reviews of SNF claims
Use CMS fraud prevention system to identify SNFs
billing higher paying RUGs
Monitor compliance with therapy assessments (COT)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
OIG Report November 2012
OIG recommendations (CMS concurred):
Increase and expand reviews of SNF claims
Use CMS fraud prevention system to identify
SNFs billing higher paying RUGs
Monitor compliance with therapy assessments
(COT)
Change the current method for determining
how much therapy is needed to ensure
appropriate payments
Improve the accuracy of MDS items
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
Physician Certification
Physician Certification Frequency
Admission
14th Day
Every 30 Days (from last certification)
Addresses all skilled qualifiers
Rehab
Nursing
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
Physician Certifications
Therapy Certification
Plan of Treatment/Care
Frequency of Services
Plan
Goals
Physician Involvement
Therapy Physician Orders
Evaluation
Treatment clarification
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
“Practical Matter” Criteria
“As a practical matter, considering
economy and efficiency, the daily
skilled services can only be provided in
a skilled nursing facility”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
“Practical Matter” Criteria
1. Outpatient services are not available in
the area where the individual lives
2. Outpatient services are available in the
area where the individual lives, but
transportation to the closest facility could
cause an excessive physical hardship, be
less economical, or less effective that
placement in the skilled nursing facility
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
“Practical Matter” Criteria
3. The availability at home of a capable and
willing caregiver should be considered, but the
care can be furnished only in the skilled
nursing facility if home care would be
ineffective because there would be insufficient
assistance at home for the patient/resident to
reside there safely
4. If the use of alternative services would
adversely affect the patient/resident’s medical
condition, then as a practical matter the daily
skilled service(s) can only be provided on an
inpatient basis
“Practical Matter” Criteria
Reasons for SNF stay:
Intensity of Therapy
Medical Complexity
Deficits
Less than 24-hour care would impose
safety risks
Less than 24-hour care would result in
adverse impact on medical condition
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
“Practical Matter” Criteria
Medical Complexity
Details of skilled assessment, observation
and interventions provided by Nursing
and Rehabilitation Services
Deficits
ADL Documentation accurately reflects
assist provided to support deficits
Rehabilitation documentation reflects
deficits with tasks of increasing complexity
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
Clinical Eligibility Requirements
The need for skilled care must be
justified and documented in the
medical record
Conditions may have prompted the
initial hospitalization, but also include
the conditions that arose during
recovery in the SNF
Harmony Healthcare International, Inc. 14Copyright © 2013 All Rights Reserved
Relationship to Hospitalization
Acute Care hospitalization diagnosis
Pneumonia
Conditions identified at acute
Skin
History of conditions and diagnosis now
requiring skilled assessment, observation and
intervention
Diabetes
CHF
COPD
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
Relationship to Hospitalization
Although a deficit or problem exists, documentation
must reflect the relationship to hospitalization or
problem that arose in the SNF
Documentation should be clarified to ensure the
reviewer can see the connection
“New onset of difficulty swallowing upon return
from hospitalization”
No longer able to….
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
Therapy Documentation to Support
Related to hospitalization or problem
that arose during SNF stay:
Detail in reason for referral
Address in narrative summary
Prior level of function reflects a change
compared to prior to hospitalization
Chronic conditions:
How has the condition changed?
What is the functional impact?
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
What is Skilled Care?
Requires the skills of qualified technical or
professional health personnel such as RN, LPN, PT,
OT or SLP
Must be provided directly by or under the general
supervision of a licensed nurse or skilled rehab
personnel to assure the safety of the resident and to
achieve the medically desired result
“General supervision” requires initial direction and
periodic inspection of activity
Ordered by a physician
Services are needed and provided on a daily basis
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
Daily Basis
The patient requires these skilled
services on a daily basis (see §214.5)
Nursing 7 Days
Therapy combination PT, OT and/or SLP
5 days of 7
Supporting Documentation:
Daily Therapy Note
Daily Nursing Notes
Treatment Sheets
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
Basic Medicare Requirements
If not supported by the documentation
in the patient’s record, a stay in an SNF,
even though it might include the
delivery of daily skilled services, is not
covered
For Example: Payment for a SNF level of
care may not be made if documentation
supports a patient’s need as intermittent
rather than daily skilled service
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
Skilled Care
Skilled Rehabilitation
Direct Skilled Nursing Services
Management and Evaluation of a Care
Plan
Observation and Assessment
Teaching and Training
Medical Necessity
The services provided requires the
skills of a therapist:
Modalities (Diathermy, Ultrasound)
Assessment
Management and progression of the plan
of care
The patient is medically complex and
requires the skills of a therapist
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
Skilled Rehabilitation
Evaluations; Reevaluations
Establishment of treatment goals to
address each problem identified in the
evaluation
Design of a plan of care , including
establishing procedures to obtain goals,
determine frequency and duration of
treatment
Harmony Healthcare International, Inc. 23Copyright © 2013 All Rights Reserved
Skilled Rehabilitation
Continued assessment at regular intervals
Instruction leading to establishment of
compensatory skills
Selection of devices to replace or augment a
function
Patient and family training to augment
rehabilitative treatment or establish a
maintenance program. Education of staff and
family is ongoing through treatment and
instructions may be modified intermittently if
the patient’s status changes.
24Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Treatment Modalities
Self care training
Therapeutic activities
Mobility training
Transfer training
Neuromuscular reeducation
Gait training
Orthotic/prosthetic training
UE splinting
Manual therapy
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25Copyright © 2013 All Rights Reserved
Treatment Modalities
Balance training
Therapeutic exercise
Electrical stimulation
Ultrasound
Modalities
Wound management
Wheelchair management
Patient/caregiver education and training
Compensatory techniques
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26Copyright © 2013 All Rights Reserved
Treatment Modalities
Home management training
Community reintegration
Safety education
Adaptive equipment training
Cognitive retraining
Visual motor/ perception training
Dysphagia management
Cognitive-linguistic treatment for newly
impaired
27Harmony Healthcare International, Inc.Copyright © 2013 All Rights ReservedCopyright © 2013 All Rights Reserved
Therapy Documentation to Support
Evaluation
Decline from prior level of function
Relationship to hospitalization
Deficits
Risks without therapy
Medical Complexity
Daily Treatment Notes to Support daily
provision
MD involvement:
Signed Plan of Treatment
Physician orders
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
Therapy Documentation to Support
Documentation that the skills of a
therapist are required:
Why restorative nursing cannot address
identified issues?
Assessment and changes to the treatment
regime
Medical Complexity
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
Direct Skilled Nursing
IV (parental) medications
N/G, gastrostomy tubes, jejunostomy tubes
Application of dressing with prescription
medications and aseptic technique
Treatment of pressure ulcer grade III or worse
Initial phases of a regimen involving medical
gases such as bronchodilators and oxygen
therapy
New Colostomy Care
Bowel and Bladder Training
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
Management and Evaluation of a
Care Plan
“Constitute skilled services when, because
of the patient’s physical or mental
condition, those activities require the
involvement of technical or professional
personnel in order to meet the patient’s
needs, promote recovery and ensure
medical safety.” (Final Rule 7/31/99)
Management and Evaluation of a
Care Plan
Based on the Physician’s orders, these
services require the involvement of skilled
nursing to meet the resident’s
Medical needs
Promote recovery
Ensure medical safety
Harmony Healthcare International, Inc. 32Copyright © 2013 All Rights Reserved
This area includes
The sum total of unskilled services
Potential for serious complications
High probability of relapse
Recovery and safety
Meet medical needs
Includes resident’s overall condition
Harmony Healthcare International, Inc. 33
Management and Evaluation of a
Care Plan
Copyright © 2013 All Rights Reserved
Management and Evaluation of a
Care Plan
Although any of the required services could be
performed by a properly instructed person, that person
would not have the capability to understand the
relationship among the services and their effect on each
other. Since the nature of the patient’s condition, his
age and his immobility create a high potential for
serious complications, such an understanding is
essential to assure the patient’s recovery and safety. The
management of this plan of care requires skilled nursing
personnel until the patient’s treatment regimen is
essentially stabilized, even though the individual services
involved are supportive in nature and not require skilled
nursing personnel.
Harmony Healthcare International, Inc. 34Copyright © 2013 All Rights Reserved
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
Skilled Observation and
Assessment
Reasonable probability for
complications or potential for further
acute episodes of the patient’s changing
condition needed to identify and
evaluate the patient’s need for
modification of treatment or additional
medical procedures until his or her
condition is stabilized
Skilled Observation and
Assessment
If a patient was admitted for skilled
observation but did not develop a further
acute episode or complication, the skilled
observation services are still covered so
long as there was reasonable probability for
such a complication or further acute
episode
“Reasonable probability” means that a
potential complication or further acute
episode is a likely possibility
Harmony Healthcare International, Inc. 36Copyright © 2013 All Rights Reserved
Skills of a Therapist or a Nurse
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
Skills of a Therapist or a Nurse
Must require, the expertise, knowledge,
clinical judgment, decision making and
abilities of a therapist or a nurse that
qualified personnel, trained caretakers
or the patient cannot provide
independently
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
Skills of a Therapist or a Nurse
Documentation must support:
Description of skilled treatment
Changes made to the plan of care due
to assessment of the patient’s needs
Medical complexity
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
Patient Education Services
Patient Education Services: Activities
which require skilled nursing or skilled
rehabilitation personnel to teach a
patient and/or family member how to
manage the patient’s treatment regimen
Skilled if the use of technical or
professional personnel is necessary to
teach a patient self-maintenance
Harmony Healthcare International, Inc. 40Copyright © 2013 All Rights Reserved
Skilled Services Categories:
Patient Education Services
Colostomy care
Insulin
administration
Prosthesis
management
Catheter care
G-tube feedings
IV access sites
Braces, splints and
orthotics
Wound dressings
and skin treatments
Medication
Management
Orthopedic
Precautions
Harmony Healthcare International, Inc. 41Copyright © 2013 All Rights Reserved
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
Universal Documentation
Guidelines
Legible
Dated
Standard abbreviations
Joint Commission is commonly used as a
standard
Facility policy
Understood by all readers
Detail-oriented
Clear
Handwriting Legibility
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
Handwriting Legibility
Documentation that is illegible or
indecipherable can result in denial of payment
Illegible handwriting is defined as the inability
of two out of three individuals not being able to
read an unfamiliar chart entry
Someone can read what you wrote on the first
attempt
Legible does not mean several people standing
around the nursing station can figure out what it
was supposed to say
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
Electronic Medical Record (EMR)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
Electronic Medical Record (EMR)
Electronic signature must meet
requirements:
Sole usage (e.g., PIN required)
Name and designation
EMR still requires the user to
understand the requirements for
Medicare
Canned documentation may not support
the services provided
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
Basics of Documentation
Clarity: Evidence of the need for further
skilled care
Content: Describe what you have done. There
is a beginning, middle and end of every good
note.
Communication:
Document any changes in the patient
Document what needs to be changed regarding
the plan of care
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
Documentation Using Skilled
Terminology
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
Acute
Beginning to respond
Description of a balance
deficit
Evaluated
Measured amount
Reddened area
Continues to progress
Difficulty with
Incapable of
Self help devices
New skills added
Techniques or strategies
Functional outcomes
Evaluate
Increased carryover
Increased generalization
Individualized
Condition is complicated
by
High risk for
Goal achieved
Documentation Using Skilled
Terminology
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
Analyzing
Establishing
Modifying
Implementing
Hierarchy of tasks
Skilled teaching or
feedback
Optimum performance
Compensatory skills
Skilled activities
Active skilled program
Significant practical
improvement
Change in living
environment
Safe and effective
Complexity of performance
Adaptive procedures
Customized
Increased consistency
Non-Supportive Documentation
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
Generalized weakness
Chronic
Stabilized
Good, fair, poor, or other
general term
Monitored
Scant, little, much, great
Slight improvement
Slightly red
Slow progress
No problem
Routine
Practice
General Conditioning
Exercises
Maintenance
Repetitious
Refuses to
Making slow progress
Unable to learn
Reinforced previously
taught..
Objective Evidence
Objective evidence consists of:
Standardized patient assessment instruments
Outcome measurements tools
Measurable assessments of functional outcome
Not required, but their use will enhance the
justification for needed therapy
Use of objective measures at:
The beginning of treatment
During and/or after treatment
Quantify progress and support justifications for
continued treatment
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
Functional Outcome Measures
CMS Referenced Instruments:
National Outcomes Measurement System
(NOMS) by the American Speech-
Language Hearing Association
Patient Inquiry by Focus On Therapeutic
Outcomes, Inc. (FOTO)
Activity Measure – Post Acute Care (AM-
PAC)
OPTIMAL by Cedaron through the
American Physical Therapy Association
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
Concept of Medical Necessity
Medical Complexity:
The service is so complex that the skills of
a therapist are required (modalities)
The patient is so complex that the services
require the skills of a therapist
Both require documentation to support
Describe why and/or how complicating
factors (complexities) affect treatment
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
Concept of Reasonable and Necessary
Services meet accepted standards of medical
practice
Specific and effective treatment for the condition
A level of complexity/sophistication or the
condition of the patient shall be such that the
services required can be safely and effectively
performed only by a qualified therapist (or
supervised PTA/OTA)
Patient’s clinical condition requires the skills of a
therapist
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
Concept of Reasonable and
Necessary
The following are not considered reasonable
and necessary:
Services provided for general exercises to promote
overall fitness and flexibility and activities to
provide diversion or general motivation, do not
constitute therapy services for Medicare purposes
Services that are not provided under a therapy
plan of care, or are provided by staff who are not
qualified or appropriately supervised, are not
covered or payable therapy services
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
Functional Impact
Skilled rehabilitative therapy occurs when,
“The skills of a therapist are necessary to
safely and effectively furnish a recognized
therapy service whose goal is improvement of
an impairment or functional limitation”
Documentation should focus on functional
abilities and deficits
Evaluation
Goals
Progress
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
Importance of Evaluation
The initial evaluation sets the stage for
all subsequent therapy services
Poor evaluation documentation risks
that ALL subsequent therapy services
will be denied
Poor evaluation limits potential goals
as therapy progresses
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
Importance of Evaluation
Just because Medicare Part A does not allow time
spent on evaluation to be counted toward RUG
minutes doesn’t mean we shouldn’t fully assess:
Get them on the mat
Full ADLs
Full meal assessment
Document reason for functional deficits in
descriptive terms
Additional data can be obtained through diagnostic
treatment
Registered therapist treats during initial visits
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
The Importance Prior Level of Function
Medicare supports skilled intervention to
assist the patient to attain their
highest/prior level of function
PLOF is vital to supporting medical
necessity for skilled rehabilitation and
support the intensity of services rendered
Evidence of a Change in Condition
Evidence of the potential to achieve a
higher level of function
How to Document PLOF
Gather as much information regarding the patient’s
functional level prior to recent illnesses. Be Specific.
Onset of illness on re-admission
Address all Goals areas:
Setting
Distance
Device
Diet
Paint a picture to portray the patients lifestyle prior to
onset of illness
Focus on function
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
Prior Level of Function
Example
Admission after an acute CVA:
PT: Independent with all mobility without a device
for unrestricted distances. Independently climbs a
flight of stairs to enter home.
OT: Independent with all ADL and IADLs without
an assistive device or adaptive equipment. Lives
alone in own home
Speech: Lives independently in own home alone
managing all medical and financial affairs.
Communicates in high level conversation with no
reported difficulty
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
Nursing Documentation Prior
Level of Function
Document information obtained from resident and
family
Admission Assessment
Weekends
Document patient reported goals
Document specific abilities prior to onset of illness
…”no longer able to wash face and comb hair”
Daughter reports the patient is lived completely
independently and did not use a device to ambulate
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
What is Rehab Potential
The patient’s potential to achieve goals set
by the therapist
Not related to medical prognosis
Goals should be achievable with good to
excellent potential to achieve
Rehab potential set to Fair, guarded or
Poor would indicate to Medicare that the
therapist does not believe in their plan
Include “Due to” or “Given the
patient’s…”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
Nursing Documentation
Rehab Potential
Focus on the potential to achieve goals
Recent onset
Intact abilities
“Given the patient’s level of intact
cognition…”
“Given the recent onset of decline, the
patient evidences good rehab potential”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
The Importance of Reason for Referral
Details the specifics of why skilled therapy
services are warranted
Clarifies the events that led to a therapy referral
Establishes the relationship to recent
hospitalization
Details the event that prompted evaluation
Clarifies the specifics of the decline in function
from prior level of function
Points the reviewer to specific areas of the
medical record
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
Reason for Referral Nursing and Therapy Examples
“Significant decline in function status post an acute
CVA on 9/1/13”
“Evidences decreased ability to safely ambulate after
a 3 week hospitalization for an MI on 9/1/13”
“..recurrent Pneumonia despite medical intervention
indicating potential Dysphagia”
“new onset of cognitive deficits impacting ability to
progress in medically necessary PT and OT ”
“change in cognitive status after resolution of ……
“New onset of slurred speech impacting ability to
communicate”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
The Importance of Measuring
Functional Deficits
Supports Medical Necessity
Establishes the physical and cognitive
baseline data necessary for assessing
expected rehabilitation potential,
setting realistic goals, and measuring
progress
Baseline from which to measure
progress
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
Level of Assist
Devices and Adaptive Equipment Assessed
Diet Textures
Number of Caregivers to Assist
Functional Levels:
Maximum Assistance: The need for 75 percent assistance by one
person to physically perform any part of a functional activity
Moderate Assistance: The need for 50 percent assistance by one
person to physically perform any part of a functional activity
Minimal Assistance: The need for 25 percent assistance by one
person to physically perform any part of a functional activity
Contact Guard: Contact Assist to provide cues or guided
maneuvering
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
Supervision
Supervision: Cueing
Reviewers may view this level of care as restorative
Ensure documentation of deficits are clearly stated
Analyze task to determine if the patient is not
receiving hands on assist for a portion of the task
Describe Cueing
Constant (max)
Frequent (mod)
Occasional (mod)
Rare (min)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70
Supervision
Describe Causes of Cueing
Technique
Sequencing
Pacing
Initiation
Describe Type of Cueing
Verbal
Tactile
Visual
How to Measure Functional Deficits
Current level of function for each functional
deficit to be addressed in therapy
Define/describe the behavior without using
min/mod/max assist if needed
Objective measures of function
Be descriptive
Amount and type
Describe underlying impairments
Reason for functional impairment/limitation
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
Reasons for Functional Limitations
Examples of reasons for functional limitation:
Lack of awareness of sensory cues
Impaired attention span
Impaired strength and or coordination
Abnormal muscle tone
Range of motion limitations
Impaired body scheme
Perceptual deficits
Impaired balance/head control
Environmental barriers
Delayed initiation of swallow
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72
Reasons for Functional Limitations
Safety Issues Related To:
Poor posture
Improper gait
Weak grip, arthritis
Dysphagia
Poor communication skills
Paralysis/paresis
Perceptual deficits
Vestibular disorder
Cognitive disorder
COPD, emphysema
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73
How to Measure Functional Deficits
Standardized Measurement Tools
Borg Scale= 5 (Severe Breathlessness)
Berg Functional Balance Scale 39/56
(Medium Fall Risk)
Western Aphasia Battery(WAB) 29.9/100
(Moderate to Severe Broca’s Aphasia)
Functional Outcome Measures
Composite Scale
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
Complexity of Task
Environment
In room
In dining room
Distraction
Patient Condition
End of the day versus beginning
With pain (how often does this occur?)
With shortness of breath (how often does this
occur?)
Sequence
Dressing after rising from bed and toileting
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75
Nursing Documentation of Function
Focus on:
Functional tasks requiring assist
Partial task completion by caregivers
Complex tasks that pose a challenge
Functional impact of pain, dyspnea, anxiety etc.
Risk assessment outcomes
“Patient ambulated to the dining room with Limited
Assist for the first time since returning from the
hospital”
Patient with limited ability to prticipate in ADLs due
to increased pain with movement”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
The Importance of Summarizing
Findings
Supports Medical Necessity
Evidences the critical thinking process
Don’t leave it up to the reviewer to
determine
Tell a story
Evidences individualization of the plan
of care
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
How to Summarize Findings
Be descriptive
Chart your thinking
Guide the reviewer
State the obvious
It may only be obvious to you!
Focus on the relevant
Individualize
Avoid canned phrases
Avoid negative statements
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
The Importance of Functional
Rehabilitation Goal Writing
Guides the reviewer through progress
Reflects the logical plan of care based on
the evaluation findings
Supports medical necessity
“The skills of a therapist are necessary to
safely and effectively furnish a recognized
therapy service whose goal is
improvement of an impairment or
functional limitation”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80
What is a Measurable Rehabilitation Goal
Long-Term Goals
Level you expect patient to be at discharge
Short-Term Goals (2 to 4 weeks)
Incremental steps toward the long term goals.
Think beyond diet texture, transfers, ambulation,
and ADLs
Based on deficits identified on assessment
and in nursing documentation
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81
Performance Skills
Motor skills: moving and interacting
with task, objects, and environment
Posture
Mobility
Coordination
Strength
Effort
Energy
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82
Performance Skills
Process Skills: managing and modifying
action when completing tasks
Energy
Knowledge
Temporal organization
Organizing space and objects
Adaptation
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83
Performance Skills
Communication Skills: conveying
intention and need and coordinating
social behaviors
Physicality
Information exchange
Relations
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
Duplication of Services
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85
Duplication of Services
Rehab goals can appear to be demonstrating a
duplication of services. High risk of denial.
Commonly seen goal areas:
Bed mobility (PT/OT)
Functional transfers (PT/OT)
Functional mobility/Ambulation (PT/OT)
Cognition (OT/ST)
Safety (PT/OT/ST)
Standing balance (PT/OT)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86
Duplication of Services
The goals must be written to differentiate
the skilled area to be addressed by each
discipline
High Risk of Denial
Most reviewers are NOT therapists
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
Duplication of Services
PT Goal:
Pt. will demonstrate Good Functional Balance
Better Stated As:
Pt. will be able to I ambulate around obstacles
in their room without loss of balance
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
Duplication of Services
OT Goal:
Pt. will demonstrate Good Functional Balance
for ADLs
Better Stated As:
Pt. will I complete Grooming task standing at
sink without loss of balance
The Importance of Progress Reports
Required for Payment
Justifies outcome of skilled therapy
intervention
Supports the need to continue skilled
therapy intervention
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
What is a Progress Report
The minimum Progress Report Period is at least once
on or before the 10th treatment day
No later than 30 days
Recommended weekly
The beginning of the first reporting period is the first
day of the episode of treatment
Service provided on the first day of treatment is the
evaluation, re-evaluation or treatment.
The Progress Report Period requirements are met
when both the Progress Report and the Therapist’s
active participation in treatment have been
documented
Copyright © 2013 All Rights Reserved 90Harmony Healthcare International, Inc.
Assistants and Progress Reports
The PT, OT or SLP clinician must write a
Progress Report during each Progress Report
Period regardless of whether the assistant
writes other reports. Must provide treatment.
Reports written by assistants are not complete
Progress Reports
Physical Therapist Assistants or Occupational
Therapy Assistants may write elements of the
Progress Report dated between clinician reports
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
How to Write a Progress Note
Each report should compare and contrast
the prior level of function and describe
specific areas which reflect improvement
Within each level of function include
specific performance tasks that the patient
can demonstrate as a result of skilled
intervention
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
How to Write a Progress Note
Include:
Assessment of improvement and extent of
progress (or lack thereof) toward each goal
Plans for continuing treatment, reference to
additional evaluation results, and/or treatment
plan revisions
Changes to long or short-term goals, discharge or
an updated plan of care that is sent to the
physician/NPP for certification of the next
interval of treatment
How to Write a Progress Note
Avoid:
Simply listing CPT code descriptors
Stating general treatment interventions
(Ther Ex, strengthening, balance activities)
Reflecting repetitive exercises that an
unskilled care giver or restorative could
provided
Endurance training
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
How to Write a Progress Note
Include:
That the patient’s condition has the
potential to improve or is improving in
response to therapy
That maximum improvement is yet to be
attained
That there is an expectation that the
anticipated improvement is attainable in a
reasonable and generally predictable
period of time
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
How to Write a Progress Note
Summary:
1) Skilled services provided since previous
report to progress towards goals
2) Current Status
3) Specific progress towards each short term
goal
4) Ongoing impairments to be addressed to
progress towards long-term goals
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
Supportive Skilled Documentation
Patient at high risk for
Skilled assessment of
Reasonable
probability
Potential for
recurrence
Monitoring for
consistency
The medical regimen
is not essentially
stabilized
Patient continues to
require daily skilled
rehab for
Patient requires daily
skilled evaluation of
the plan of care
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
Non-Supportive Skilled
Documentation
Plateau in progress
Still requires
Patient is unable to follow directions
Patient has poor rehab potential
Patient refuses to participate in therapy (without
documentation of root of refusal)
Within normal limits
“Slow, steady gains” described in progress notes but
comparison of function is without change from one
week to the next
Non-Supportive Skilled
Documentation
Quoted statements from patient refusing
therapy and asking to end the therapy
sessions/program, yet services continued
without documented improvement
Monitor or observed at meals versus
assessed
Focus on behaviors versus what skills of a
therapist were required to manage
Copyright © 2013 All Rights Reserved 99Harmony Healthcare International, Inc.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
Progress Report Examples
On evaluation, patient required max verbal
and tactile cueing for initiation of upper
body bathing while seated at the sink. At this
time the patient only requires min verbal
cueing and no tactile cueing to initiate upper
body bathing.
Progression of hip/glut strengthening
exercises to now include weighted resistance
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
Progress Report Examples
The patient initiated use of their prior
level device of a cane for mobility this
week. The patient required minimal
assist to ambulate 45 to 50 feet at the
beginning of the reporting period. The
patient has improved to ambulate 45 –
50 feet with CGA with the cane at the
end of the reporting period.
Progress Report Examples
The patient tolerated nectar thick liquids for
all meals with no evidence of aspiration. The
patient was assessed with thin liquids with
overt signs and symptoms of aspiration on
10% of trials. Aspiration was eliminated with
patient utilization of a chin tuck with
continual minimal tactile cues during the
meal. Patient and care giver education was
provided on use of the chin tuck
compensatory swallow strategy.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
Nursing Documentation of Progress
Focus on:
New functional abilities
Partial task completion
Increased initiation attempts
Lesser levels of care
Decreased Number of assist or symptoms
“Initiated participation in care as evidenced
by….”
No signs or symptoms of aspiration with diet
upgrade to thin liquids on 10/1/13
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
Monthly Progress Report
These are completed every 30 days and
include components of weekly progress
noted while also requiring:
Updated goals and treatment plan with
identification of significant improvement in
functional skills
“Significant” means a generally measurable and
substantial increase in the patient’s present level
of functional independence, and competence
compared to the level of function at the time
treatment was initiated. HIM 12, 544.
Copyright © 2013 All Rights Reserved 104Harmony Healthcare International, Inc.
Monthly Progress Report
Any change in treatment plan would
require physician clarification orders
The completion of clarification orders to
communicate the expected treatment
plan with the physician and receive
verbal approval for the treatment to
continue
Copyright © 2013 All Rights Reserved 105Harmony Healthcare International, Inc.
Discharge Progress Report
The discharge note is a Progress Report
written by the clinician upon completion
of each program
Supports outcome of therapy intervention
for all payors
Copyright © 2013 All Rights Reserved 106Harmony Healthcare International, Inc.
Discharge Progress Report
It is important to give a thorough
synopsis beginning with a comparison
between the initial level of function and
discharge status
The clinician should consider the
discharge note the last opportunity to
justify the medical necessity of the entire
treatment episode for review purposes
Copyright © 2013 All Rights Reserved 107Harmony Healthcare International, Inc.
108
Discharge Progress Report
List all techniques and methods trialed even
failed attempts
Discharge setting with cues for re-referral for
skilled therapy
Unanticipated discharge:
Data related to discharge not noted in the previous
Progress Report will require the clinician writing the
final note to rely on treatment notes and verbal reports
of the assistant or qualified personnel
Summary of progress is still needed to support
services provided
Copyright © 2013 All Rights Reserved 108Harmony Healthcare International, Inc.
Nursing Discharge Documentation
Supplement with:
Functional Goals achieved
Medical diagnosis and conditions
that have resolved
Patient Education
Reoccurrence of UTI
Fall Risk
Home Safety and Home Exercise Program
developed by therapy
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 109
Skilled Coverage Criteria
There is no such thing as a “Rehab” or
“Nursing Patient
One patient
One medical record
One claim billed
One set of Medicare coverage criteria
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
References
Medicare Benefit Policy Manual
Chapter 8 - Coverage of Extended Care
(SNF) Services Under Hospital
Insurance (Rev. 161, 10-26-12)
CMS MDS 3.0 RAI Manual v1.11
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
Questions/Answers
Harmony Healthcare International, Inc. 112112Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Harmony Healthcare International
1 (800) 530 – 4413
kmastrangelo@harmony-healthcare.com
www.harmony-healthcare.com

Contenu connexe

Tendances

Hospital business plan new
Hospital business plan newHospital business plan new
Hospital business plan newTom Jose
 
FINAL PROJECT OF JCI DOCUMENTATION
FINAL PROJECT OF JCI DOCUMENTATIONFINAL PROJECT OF JCI DOCUMENTATION
FINAL PROJECT OF JCI DOCUMENTATIONKaustav Deb
 
Ambulance management system
Ambulance management systemAmbulance management system
Ambulance management systemHari Om sharma
 
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARD
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARDHospital administration by mahboob ali khan MHA CPHQ USA HARVARD
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARDHealthcare consultant
 
Emergency Department/Hospital Inpatient Initiative
Emergency Department/Hospital Inpatient InitiativeEmergency Department/Hospital Inpatient Initiative
Emergency Department/Hospital Inpatient InitiativeGroup Health Cooperative
 
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...Healthcare consultant
 
6 patients' rights & responsibilities
6 patients' rights & responsibilities6 patients' rights & responsibilities
6 patients' rights & responsibilitiespatientsafetyalliance
 
To study the process of patient discharge in corporate hospital
To study the process of patient discharge in corporate hospitalTo study the process of patient discharge in corporate hospital
To study the process of patient discharge in corporate hospitalRameez Shah
 
Importance of Measuring Patient Satisfaction
Importance of Measuring Patient SatisfactionImportance of Measuring Patient Satisfaction
Importance of Measuring Patient SatisfactionZonkaFeedback
 
Overview of Patient Experience Definitions and Measurement Tools
Overview of Patient Experience Definitions and Measurement ToolsOverview of Patient Experience Definitions and Measurement Tools
Overview of Patient Experience Definitions and Measurement ToolsInnovations2Solutions
 
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...Healthcare consultant
 
project on patient satisfaction
project on patient satisfactionproject on patient satisfaction
project on patient satisfactionAnkurAnkit3
 
NABH 5th edition hospital std april 2020
NABH  5th edition hospital std april 2020NABH  5th edition hospital std april 2020
NABH 5th edition hospital std april 2020anjalatchi
 
outpatient satisfaction survey
outpatient satisfaction surveyoutpatient satisfaction survey
outpatient satisfaction surveyAAYUSHI SAHA
 
Hospital and its classification
Hospital and its classificationHospital and its classification
Hospital and its classificationlekhasree9
 
Various departments of the hospital
Various departments of the hospitalVarious departments of the hospital
Various departments of the hospitalanjalatchi
 
Prevention of Patient Falls - A Case Study
Prevention of Patient Falls - A Case StudyPrevention of Patient Falls - A Case Study
Prevention of Patient Falls - A Case StudyApollo Hospitals
 

Tendances (20)

Hospital business plan new
Hospital business plan newHospital business plan new
Hospital business plan new
 
FINAL PROJECT OF JCI DOCUMENTATION
FINAL PROJECT OF JCI DOCUMENTATIONFINAL PROJECT OF JCI DOCUMENTATION
FINAL PROJECT OF JCI DOCUMENTATION
 
Ambulance management system
Ambulance management systemAmbulance management system
Ambulance management system
 
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARD
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARDHospital administration by mahboob ali khan MHA CPHQ USA HARVARD
Hospital administration by mahboob ali khan MHA CPHQ USA HARVARD
 
Emergency Department/Hospital Inpatient Initiative
Emergency Department/Hospital Inpatient InitiativeEmergency Department/Hospital Inpatient Initiative
Emergency Department/Hospital Inpatient Initiative
 
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...
 
Hospital management system
Hospital management systemHospital management system
Hospital management system
 
6 patients' rights & responsibilities
6 patients' rights & responsibilities6 patients' rights & responsibilities
6 patients' rights & responsibilities
 
To study the process of patient discharge in corporate hospital
To study the process of patient discharge in corporate hospitalTo study the process of patient discharge in corporate hospital
To study the process of patient discharge in corporate hospital
 
Importance of Measuring Patient Satisfaction
Importance of Measuring Patient SatisfactionImportance of Measuring Patient Satisfaction
Importance of Measuring Patient Satisfaction
 
Overview of Patient Experience Definitions and Measurement Tools
Overview of Patient Experience Definitions and Measurement ToolsOverview of Patient Experience Definitions and Measurement Tools
Overview of Patient Experience Definitions and Measurement Tools
 
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...
IMPORTANT COMMITTEE LIST for a hospital going for NABH /JCI by Dr.Mahboob ali...
 
project on patient satisfaction
project on patient satisfactionproject on patient satisfaction
project on patient satisfaction
 
NABH 5th edition hospital std april 2020
NABH  5th edition hospital std april 2020NABH  5th edition hospital std april 2020
NABH 5th edition hospital std april 2020
 
outpatient satisfaction survey
outpatient satisfaction surveyoutpatient satisfaction survey
outpatient satisfaction survey
 
Hospital and its classification
Hospital and its classificationHospital and its classification
Hospital and its classification
 
Various departments of the hospital
Various departments of the hospitalVarious departments of the hospital
Various departments of the hospital
 
Nabh
NabhNabh
Nabh
 
QUALITY NURSE job description
QUALITY NURSE job descriptionQUALITY NURSE job description
QUALITY NURSE job description
 
Prevention of Patient Falls - A Case Study
Prevention of Patient Falls - A Case StudyPrevention of Patient Falls - A Case Study
Prevention of Patient Falls - A Case Study
 

En vedette

Differences between inpatient rehabilitation & skilled nursing care
Differences between inpatient rehabilitation & skilled nursing careDifferences between inpatient rehabilitation & skilled nursing care
Differences between inpatient rehabilitation & skilled nursing carejulenemcalister
 
Methods of nursing documentation final
Methods of nursing documentation finalMethods of nursing documentation final
Methods of nursing documentation finalTaghreed Hawsawi
 
Chapter 39 Rehabilitation
Chapter 39 RehabilitationChapter 39 Rehabilitation
Chapter 39 Rehabilitationbholmes
 
Good documentation practice
Good documentation practiceGood documentation practice
Good documentation practicePharmaceutical
 
Rehabiltation.ppt
Rehabiltation.pptRehabiltation.ppt
Rehabiltation.pptShama
 
Community Based Rehabilitation CBR
Community Based Rehabilitation CBRCommunity Based Rehabilitation CBR
Community Based Rehabilitation CBRAhmed-Refat Refat
 
What is rehabilitation
What is rehabilitationWhat is rehabilitation
What is rehabilitationalayalewis
 
Types of Rehabilitation
Types of RehabilitationTypes of Rehabilitation
Types of Rehabilitationalayalewis
 
Fdar charting
Fdar chartingFdar charting
Fdar chartingkataliya
 
Ejercicios en_cama_en_artroplastia_de_cadera_
 Ejercicios en_cama_en_artroplastia_de_cadera_ Ejercicios en_cama_en_artroplastia_de_cadera_
Ejercicios en_cama_en_artroplastia_de_cadera_Israel Kine Cortes
 

En vedette (20)

ADL's
ADL'sADL's
ADL's
 
Documenting the Care you Provide ADL Accuracy
Documenting the Care you Provide ADL AccuracyDocumenting the Care you Provide ADL Accuracy
Documenting the Care you Provide ADL Accuracy
 
Top Ten Missed Opportunities in the Skilled Nursing Facility
Top Ten Missed Opportunities in the Skilled Nursing FacilityTop Ten Missed Opportunities in the Skilled Nursing Facility
Top Ten Missed Opportunities in the Skilled Nursing Facility
 
Skilled Rehab Services: Avoiding Denied Claims
Skilled Rehab Services:  Avoiding Denied ClaimsSkilled Rehab Services:  Avoiding Denied Claims
Skilled Rehab Services: Avoiding Denied Claims
 
Documenting the Long-term Care You Provide
Documenting the Long-term Care You ProvideDocumenting the Long-term Care You Provide
Documenting the Long-term Care You Provide
 
Nursing Skills: Charting
Nursing Skills: ChartingNursing Skills: Charting
Nursing Skills: Charting
 
Differences between inpatient rehabilitation & skilled nursing care
Differences between inpatient rehabilitation & skilled nursing careDifferences between inpatient rehabilitation & skilled nursing care
Differences between inpatient rehabilitation & skilled nursing care
 
Methods of nursing documentation final
Methods of nursing documentation finalMethods of nursing documentation final
Methods of nursing documentation final
 
Chapter 39 Rehabilitation
Chapter 39 RehabilitationChapter 39 Rehabilitation
Chapter 39 Rehabilitation
 
Good documentation practice
Good documentation practiceGood documentation practice
Good documentation practice
 
MDS 3.0: A Guide to Coding Accuracy
MDS 3.0: A Guide to Coding AccuracyMDS 3.0: A Guide to Coding Accuracy
MDS 3.0: A Guide to Coding Accuracy
 
Rehabiltation.ppt
Rehabiltation.pptRehabiltation.ppt
Rehabiltation.ppt
 
Community Based Rehabilitation CBR
Community Based Rehabilitation CBRCommunity Based Rehabilitation CBR
Community Based Rehabilitation CBR
 
What is rehabilitation
What is rehabilitationWhat is rehabilitation
What is rehabilitation
 
Types of Rehabilitation
Types of RehabilitationTypes of Rehabilitation
Types of Rehabilitation
 
Fdar charting
Fdar chartingFdar charting
Fdar charting
 
Ejercicios en_cama_en_artroplastia_de_cadera_
 Ejercicios en_cama_en_artroplastia_de_cadera_ Ejercicios en_cama_en_artroplastia_de_cadera_
Ejercicios en_cama_en_artroplastia_de_cadera_
 
Facebook for Home Care Marketing!
Facebook for Home Care Marketing!Facebook for Home Care Marketing!
Facebook for Home Care Marketing!
 
Glossary of Recreation Therapy and Occupational Therapy
Glossary of Recreation Therapy and Occupational TherapyGlossary of Recreation Therapy and Occupational Therapy
Glossary of Recreation Therapy and Occupational Therapy
 
Thinking Out of the Box: Treatment Planning Outside the Gym
Thinking Out of the Box: Treatment Planning Outside the GymThinking Out of the Box: Treatment Planning Outside the Gym
Thinking Out of the Box: Treatment Planning Outside the Gym
 

Similaire à Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

Patient Resource: Medicare Observation Versus Admit Days
Patient Resource: Medicare Observation Versus Admit DaysPatient Resource: Medicare Observation Versus Admit Days
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
 
RACs, MACs and MICs
RACs, MACs and MICsRACs, MACs and MICs
RACs, MACs and MICsSelectData
 
ALH 151 Health Insurance Chap 1-5 4
ALH 151 Health Insurance Chap 1-5 4ALH 151 Health Insurance Chap 1-5 4
ALH 151 Health Insurance Chap 1-5 4Sheretta Moore MBA
 

Similaire à Medicare Documentation for the Rehabilitation Patient: Evidence of Progress (20)

ADR Process for the SNF: Medicare Part B Claims
ADR Process for the SNF: Medicare Part B ClaimsADR Process for the SNF: Medicare Part B Claims
ADR Process for the SNF: Medicare Part B Claims
 
Medicare Denied Claims: How the Appeal Letter Can Make or Break You
Medicare Denied Claims: How the Appeal Letter Can Make or Break YouMedicare Denied Claims: How the Appeal Letter Can Make or Break You
Medicare Denied Claims: How the Appeal Letter Can Make or Break You
 
Medicare Denied Claims - How the Appeal Letter Can Make or Break You
Medicare Denied Claims - How the Appeal Letter Can Make or Break YouMedicare Denied Claims - How the Appeal Letter Can Make or Break You
Medicare Denied Claims - How the Appeal Letter Can Make or Break You
 
Unusual Weather We Are Having: The Medicare Audit Climate
Unusual Weather We Are Having: The Medicare Audit ClimateUnusual Weather We Are Having: The Medicare Audit Climate
Unusual Weather We Are Having: The Medicare Audit Climate
 
RAC Audit Strategic Road Map for Leaders
RAC Audit Strategic Road Map for LeadersRAC Audit Strategic Road Map for Leaders
RAC Audit Strategic Road Map for Leaders
 
ABCs of Care Planning
ABCs of Care PlanningABCs of Care Planning
ABCs of Care Planning
 
How to Review Medicare Appeals in the SNF
How to Review Medicare Appeals in the SNFHow to Review Medicare Appeals in the SNF
How to Review Medicare Appeals in the SNF
 
FY 2014 Final Rule and MDS 3.0 Updates
FY 2014 Final Rule and MDS 3.0 UpdatesFY 2014 Final Rule and MDS 3.0 Updates
FY 2014 Final Rule and MDS 3.0 Updates
 
The RAI Process: CAAs, Care Planning and Beyond
The RAI Process: CAAs, Care Planning and BeyondThe RAI Process: CAAs, Care Planning and Beyond
The RAI Process: CAAs, Care Planning and Beyond
 
Medicare Part B Program Development in the Age of Compliance
Medicare Part B Program Development in the Age of ComplianceMedicare Part B Program Development in the Age of Compliance
Medicare Part B Program Development in the Age of Compliance
 
Hospital Readmission Roullette
Hospital Readmission RoulletteHospital Readmission Roullette
Hospital Readmission Roullette
 
Challenging the Improvement Standard: Jimmo v. Sebelius
Challenging the Improvement Standard: Jimmo v. SebeliusChallenging the Improvement Standard: Jimmo v. Sebelius
Challenging the Improvement Standard: Jimmo v. Sebelius
 
The Cost of Non-Compliance: Is it in Your Budget?
The Cost of Non-Compliance: Is it in Your Budget?The Cost of Non-Compliance: Is it in Your Budget?
The Cost of Non-Compliance: Is it in Your Budget?
 
Patient Resource: Medicare Observation Versus Admit Days
Patient Resource: Medicare Observation Versus Admit DaysPatient Resource: Medicare Observation Versus Admit Days
Patient Resource: Medicare Observation Versus Admit Days
 
Denials Management from ADR to ALJ
Denials Management from ADR to ALJDenials Management from ADR to ALJ
Denials Management from ADR to ALJ
 
Vertelogics MR.ES
Vertelogics MR.ESVertelogics MR.ES
Vertelogics MR.ES
 
RACs, MACs and MICs
RACs, MACs and MICsRACs, MACs and MICs
RACs, MACs and MICs
 
Top Ten Tips for a Successful ALJ Hearing
Top Ten Tips for a Successful ALJ HearingTop Ten Tips for a Successful ALJ Hearing
Top Ten Tips for a Successful ALJ Hearing
 
Fall 2012: Arkfeld Notes
Fall 2012: Arkfeld NotesFall 2012: Arkfeld Notes
Fall 2012: Arkfeld Notes
 
ALH 151 Health Insurance Chap 1-5 4
ALH 151 Health Insurance Chap 1-5 4ALH 151 Health Insurance Chap 1-5 4
ALH 151 Health Insurance Chap 1-5 4
 

Plus de Harmony Healthcare International (HHI)

SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesSNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesHarmony Healthcare International (HHI)
 
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyWhy, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyHarmony Healthcare International (HHI)
 
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsMedicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsHarmony Healthcare International (HHI)
 

Plus de Harmony Healthcare International (HHI) (16)

SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesSNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
 
Interpreting Your 2014 SNF PEPPER
Interpreting Your 2014 SNF PEPPERInterpreting Your 2014 SNF PEPPER
Interpreting Your 2014 SNF PEPPER
 
Incorporating PEPPER Into Your SNF Compliance Program
Incorporating PEPPER Into Your SNF Compliance ProgramIncorporating PEPPER Into Your SNF Compliance Program
Incorporating PEPPER Into Your SNF Compliance Program
 
How Safe is Your Patient Data?
How Safe is Your Patient Data?How Safe is Your Patient Data?
How Safe is Your Patient Data?
 
Steps Towards a Successful Regulatory Survey
Steps Towards a Successful Regulatory SurveySteps Towards a Successful Regulatory Survey
Steps Towards a Successful Regulatory Survey
 
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyWhy, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
 
Top 5 Ways to Prevent Falls
Top 5 Ways to Prevent FallsTop 5 Ways to Prevent Falls
Top 5 Ways to Prevent Falls
 
Quality Assurance Performance Improvement: 12 Steps to Excellence!
Quality Assurance Performance Improvement: 12 Steps to Excellence!Quality Assurance Performance Improvement: 12 Steps to Excellence!
Quality Assurance Performance Improvement: 12 Steps to Excellence!
 
OM(I)G! New York Medicaid Case Mix Audit Success
OM(I)G! New York Medicaid Case Mix Audit SuccessOM(I)G! New York Medicaid Case Mix Audit Success
OM(I)G! New York Medicaid Case Mix Audit Success
 
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsMedicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
 
Measure Up with Standardized Assessments
Measure Up with Standardized AssessmentsMeasure Up with Standardized Assessments
Measure Up with Standardized Assessments
 
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
 
Management of the Non-Traditional Rehabilitation Patient
Management of the Non-Traditional Rehabilitation PatientManagement of the Non-Traditional Rehabilitation Patient
Management of the Non-Traditional Rehabilitation Patient
 
M is for Miscoding
M is for MiscodingM is for Miscoding
M is for Miscoding
 
Is Antipsychotic Medication Reduction Making You Crazy?
Is Antipsychotic Medication Reduction Making You Crazy?Is Antipsychotic Medication Reduction Making You Crazy?
Is Antipsychotic Medication Reduction Making You Crazy?
 
Design and Delivery of Therapy Treatment for the Complex SNF Patient
Design and Delivery of Therapy Treatment for the Complex SNF PatientDesign and Delivery of Therapy Treatment for the Complex SNF Patient
Design and Delivery of Therapy Treatment for the Complex SNF Patient
 

Dernier

ACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousKR_Barker
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal TutorNehaKewat
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareratilalthakkar704
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychologyshantisphysio
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsIris Thiele Isip-Tan
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborHealth Catalyst
 
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYCECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYRMC
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfhezamzaki1
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementIris Thiele Isip-Tan
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdfDolisha Warbi
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsNeha Sharma
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadAlex Clapson
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLyons Health
 
Identifying Signs of Mental Health Presentation (1).pptx
Identifying Signs of Mental Health Presentation (1).pptxIdentifying Signs of Mental Health Presentation (1).pptx
Identifying Signs of Mental Health Presentation (1).pptxsandhulove46637
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxMUKESH PADMANABHAN
 

Dernier (20)

ACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the CuriousACCA Version of AI & Healthcare: An Overview for the Curious
ACCA Version of AI & Healthcare: An Overview for the Curious
 
SCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATIONSCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATION
 
Painting Rats White Angers Them to No End
Painting Rats White Angers Them to No EndPainting Rats White Angers Them to No End
Painting Rats White Angers Them to No End
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal Tutor
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCare
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychology
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and Labor
 
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHYCECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
CECT NECK NECK ANGIOGRAPHY CAROTID ANGIOGRAPHY
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes Management
 
The Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdfThe Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdf
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common Locations
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion instead
 
Annual Training
Annual TrainingAnnual Training
Annual Training
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
 
Identifying Signs of Mental Health Presentation (1).pptx
Identifying Signs of Mental Health Presentation (1).pptxIdentifying Signs of Mental Health Presentation (1).pptx
Identifying Signs of Mental Health Presentation (1).pptx
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptx
 

Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

  • 1. Medicare Documentation for the Rehabilitation Patient: Evidence of Progress HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Kris Mastrangelo, OTR/L, MBA, LNHA President & CEO
  • 2. Objectives: The learner will be able to define skilled coverage criteria. The learner will be able to define key elements of Documentation. The learner will be able to provide examples of Rehabilitation Documentation to support Medicare coverage criteria. The learner will be able to provide examples of Nursing Documentation to support Medicare coverage criteria. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  • 3. Increase in Medicare Documentation Reviews Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) Lower 14 Billing inconsistencies ICD-9 Coding triggers Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's Number of "Help Letters“ was astoundingly high Investigations into potential fraudulent billing practices increased Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  • 4. Increase in Medicare Denials Denials due to conflict between Nursing Notes, MDS and Rehabilitation documentation Documentation by Nursing of Medical Complexity supports need to receive rehabilitation at a SNF level of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  • 5. OIG Report November 2012 In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF services Submission of inaccurate, medically unnecessary, and fraudulent claims Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments Increase and expand reviews of SNF claims Use CMS fraud prevention system to identify SNFs billing higher paying RUGs Monitor compliance with therapy assessments (COT) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
  • 6. OIG Report November 2012 OIG recommendations (CMS concurred): Increase and expand reviews of SNF claims Use CMS fraud prevention system to identify SNFs billing higher paying RUGs Monitor compliance with therapy assessments (COT) Change the current method for determining how much therapy is needed to ensure appropriate payments Improve the accuracy of MDS items Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  • 7. Physician Certification Physician Certification Frequency Admission 14th Day Every 30 Days (from last certification) Addresses all skilled qualifiers Rehab Nursing Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  • 8. Physician Certifications Therapy Certification Plan of Treatment/Care Frequency of Services Plan Goals Physician Involvement Therapy Physician Orders Evaluation Treatment clarification Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  • 9. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9 “Practical Matter” Criteria “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility”
  • 10. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10 “Practical Matter” Criteria 1. Outpatient services are not available in the area where the individual lives 2. Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility
  • 11. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11 “Practical Matter” Criteria 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/resident to reside there safely 4. If the use of alternative services would adversely affect the patient/resident’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis
  • 12. “Practical Matter” Criteria Reasons for SNF stay: Intensity of Therapy Medical Complexity Deficits Less than 24-hour care would impose safety risks Less than 24-hour care would result in adverse impact on medical condition Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  • 13. “Practical Matter” Criteria Medical Complexity Details of skilled assessment, observation and interventions provided by Nursing and Rehabilitation Services Deficits ADL Documentation accurately reflects assist provided to support deficits Rehabilitation documentation reflects deficits with tasks of increasing complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  • 14. Clinical Eligibility Requirements The need for skilled care must be justified and documented in the medical record Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF Harmony Healthcare International, Inc. 14Copyright © 2013 All Rights Reserved
  • 15. Relationship to Hospitalization Acute Care hospitalization diagnosis Pneumonia Conditions identified at acute Skin History of conditions and diagnosis now requiring skilled assessment, observation and intervention Diabetes CHF COPD Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  • 16. Relationship to Hospitalization Although a deficit or problem exists, documentation must reflect the relationship to hospitalization or problem that arose in the SNF Documentation should be clarified to ensure the reviewer can see the connection “New onset of difficulty swallowing upon return from hospitalization” No longer able to…. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  • 17. Therapy Documentation to Support Related to hospitalization or problem that arose during SNF stay: Detail in reason for referral Address in narrative summary Prior level of function reflects a change compared to prior to hospitalization Chronic conditions: How has the condition changed? What is the functional impact? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  • 18. What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result “General supervision” requires initial direction and periodic inspection of activity Ordered by a physician Services are needed and provided on a daily basis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  • 19. Daily Basis The patient requires these skilled services on a daily basis (see §214.5) Nursing 7 Days Therapy combination PT, OT and/or SLP 5 days of 7 Supporting Documentation: Daily Therapy Note Daily Nursing Notes Treatment Sheets Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  • 20. Basic Medicare Requirements If not supported by the documentation in the patient’s record, a stay in an SNF, even though it might include the delivery of daily skilled services, is not covered For Example: Payment for a SNF level of care may not be made if documentation supports a patient’s need as intermittent rather than daily skilled service Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  • 21. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21 Skilled Care Skilled Rehabilitation Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training
  • 22. Medical Necessity The services provided requires the skills of a therapist: Modalities (Diathermy, Ultrasound) Assessment Management and progression of the plan of care The patient is medically complex and requires the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  • 23. Skilled Rehabilitation Evaluations; Reevaluations Establishment of treatment goals to address each problem identified in the evaluation Design of a plan of care , including establishing procedures to obtain goals, determine frequency and duration of treatment Harmony Healthcare International, Inc. 23Copyright © 2013 All Rights Reserved
  • 24. Skilled Rehabilitation Continued assessment at regular intervals Instruction leading to establishment of compensatory skills Selection of devices to replace or augment a function Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family is ongoing through treatment and instructions may be modified intermittently if the patient’s status changes. 24Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 25. Treatment Modalities Self care training Therapeutic activities Mobility training Transfer training Neuromuscular reeducation Gait training Orthotic/prosthetic training UE splinting Manual therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25Copyright © 2013 All Rights Reserved
  • 26. Treatment Modalities Balance training Therapeutic exercise Electrical stimulation Ultrasound Modalities Wound management Wheelchair management Patient/caregiver education and training Compensatory techniques Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26Copyright © 2013 All Rights Reserved
  • 27. Treatment Modalities Home management training Community reintegration Safety education Adaptive equipment training Cognitive retraining Visual motor/ perception training Dysphagia management Cognitive-linguistic treatment for newly impaired 27Harmony Healthcare International, Inc.Copyright © 2013 All Rights ReservedCopyright © 2013 All Rights Reserved
  • 28. Therapy Documentation to Support Evaluation Decline from prior level of function Relationship to hospitalization Deficits Risks without therapy Medical Complexity Daily Treatment Notes to Support daily provision MD involvement: Signed Plan of Treatment Physician orders Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  • 29. Therapy Documentation to Support Documentation that the skills of a therapist are required: Why restorative nursing cannot address identified issues? Assessment and changes to the treatment regime Medical Complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  • 30. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30 Direct Skilled Nursing IV (parental) medications N/G, gastrostomy tubes, jejunostomy tubes Application of dressing with prescription medications and aseptic technique Treatment of pressure ulcer grade III or worse Initial phases of a regimen involving medical gases such as bronchodilators and oxygen therapy New Colostomy Care Bowel and Bladder Training
  • 31. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31 Management and Evaluation of a Care Plan “Constitute skilled services when, because of the patient’s physical or mental condition, those activities require the involvement of technical or professional personnel in order to meet the patient’s needs, promote recovery and ensure medical safety.” (Final Rule 7/31/99)
  • 32. Management and Evaluation of a Care Plan Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s Medical needs Promote recovery Ensure medical safety Harmony Healthcare International, Inc. 32Copyright © 2013 All Rights Reserved
  • 33. This area includes The sum total of unskilled services Potential for serious complications High probability of relapse Recovery and safety Meet medical needs Includes resident’s overall condition Harmony Healthcare International, Inc. 33 Management and Evaluation of a Care Plan Copyright © 2013 All Rights Reserved
  • 34. Management and Evaluation of a Care Plan Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel. Harmony Healthcare International, Inc. 34Copyright © 2013 All Rights Reserved
  • 35. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35 Skilled Observation and Assessment Reasonable probability for complications or potential for further acute episodes of the patient’s changing condition needed to identify and evaluate the patient’s need for modification of treatment or additional medical procedures until his or her condition is stabilized
  • 36. Skilled Observation and Assessment If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services are still covered so long as there was reasonable probability for such a complication or further acute episode “Reasonable probability” means that a potential complication or further acute episode is a likely possibility Harmony Healthcare International, Inc. 36Copyright © 2013 All Rights Reserved
  • 37. Skills of a Therapist or a Nurse Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  • 38. Skills of a Therapist or a Nurse Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
  • 39. Skills of a Therapist or a Nurse Documentation must support: Description of skilled treatment Changes made to the plan of care due to assessment of the patient’s needs Medical complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  • 40. Patient Education Services Patient Education Services: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen Skilled if the use of technical or professional personnel is necessary to teach a patient self-maintenance Harmony Healthcare International, Inc. 40Copyright © 2013 All Rights Reserved
  • 41. Skilled Services Categories: Patient Education Services Colostomy care Insulin administration Prosthesis management Catheter care G-tube feedings IV access sites Braces, splints and orthotics Wound dressings and skin treatments Medication Management Orthopedic Precautions Harmony Healthcare International, Inc. 41Copyright © 2013 All Rights Reserved
  • 42. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42 Universal Documentation Guidelines Legible Dated Standard abbreviations Joint Commission is commonly used as a standard Facility policy Understood by all readers Detail-oriented Clear
  • 43. Handwriting Legibility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  • 44. Handwriting Legibility Documentation that is illegible or indecipherable can result in denial of payment Illegible handwriting is defined as the inability of two out of three individuals not being able to read an unfamiliar chart entry Someone can read what you wrote on the first attempt Legible does not mean several people standing around the nursing station can figure out what it was supposed to say Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  • 45. Electronic Medical Record (EMR) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  • 46. Electronic Medical Record (EMR) Electronic signature must meet requirements: Sole usage (e.g., PIN required) Name and designation EMR still requires the user to understand the requirements for Medicare Canned documentation may not support the services provided Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
  • 47. Basics of Documentation Clarity: Evidence of the need for further skilled care Content: Describe what you have done. There is a beginning, middle and end of every good note. Communication: Document any changes in the patient Document what needs to be changed regarding the plan of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  • 48. Documentation Using Skilled Terminology Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48 Acute Beginning to respond Description of a balance deficit Evaluated Measured amount Reddened area Continues to progress Difficulty with Incapable of Self help devices New skills added Techniques or strategies Functional outcomes Evaluate Increased carryover Increased generalization Individualized Condition is complicated by High risk for Goal achieved
  • 49. Documentation Using Skilled Terminology Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49 Analyzing Establishing Modifying Implementing Hierarchy of tasks Skilled teaching or feedback Optimum performance Compensatory skills Skilled activities Active skilled program Significant practical improvement Change in living environment Safe and effective Complexity of performance Adaptive procedures Customized Increased consistency
  • 50. Non-Supportive Documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50 Generalized weakness Chronic Stabilized Good, fair, poor, or other general term Monitored Scant, little, much, great Slight improvement Slightly red Slow progress No problem Routine Practice General Conditioning Exercises Maintenance Repetitious Refuses to Making slow progress Unable to learn Reinforced previously taught..
  • 51. Objective Evidence Objective evidence consists of: Standardized patient assessment instruments Outcome measurements tools Measurable assessments of functional outcome Not required, but their use will enhance the justification for needed therapy Use of objective measures at: The beginning of treatment During and/or after treatment Quantify progress and support justifications for continued treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  • 52. Functional Outcome Measures CMS Referenced Instruments: National Outcomes Measurement System (NOMS) by the American Speech- Language Hearing Association Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO) Activity Measure – Post Acute Care (AM- PAC) OPTIMAL by Cedaron through the American Physical Therapy Association Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
  • 53. Concept of Medical Necessity Medical Complexity: The service is so complex that the skills of a therapist are required (modalities) The patient is so complex that the services require the skills of a therapist Both require documentation to support Describe why and/or how complicating factors (complexities) affect treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  • 54. Concept of Reasonable and Necessary Services meet accepted standards of medical practice Specific and effective treatment for the condition A level of complexity/sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist (or supervised PTA/OTA) Patient’s clinical condition requires the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  • 55. Concept of Reasonable and Necessary The following are not considered reasonable and necessary: Services provided for general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes Services that are not provided under a therapy plan of care, or are provided by staff who are not qualified or appropriately supervised, are not covered or payable therapy services Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  • 56. Functional Impact Skilled rehabilitative therapy occurs when, “The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation” Documentation should focus on functional abilities and deficits Evaluation Goals Progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  • 57. Importance of Evaluation The initial evaluation sets the stage for all subsequent therapy services Poor evaluation documentation risks that ALL subsequent therapy services will be denied Poor evaluation limits potential goals as therapy progresses Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  • 58. Importance of Evaluation Just because Medicare Part A does not allow time spent on evaluation to be counted toward RUG minutes doesn’t mean we shouldn’t fully assess: Get them on the mat Full ADLs Full meal assessment Document reason for functional deficits in descriptive terms Additional data can be obtained through diagnostic treatment Registered therapist treats during initial visits Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  • 59. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59 The Importance Prior Level of Function Medicare supports skilled intervention to assist the patient to attain their highest/prior level of function PLOF is vital to supporting medical necessity for skilled rehabilitation and support the intensity of services rendered Evidence of a Change in Condition Evidence of the potential to achieve a higher level of function
  • 60. How to Document PLOF Gather as much information regarding the patient’s functional level prior to recent illnesses. Be Specific. Onset of illness on re-admission Address all Goals areas: Setting Distance Device Diet Paint a picture to portray the patients lifestyle prior to onset of illness Focus on function Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  • 61. Prior Level of Function Example Admission after an acute CVA: PT: Independent with all mobility without a device for unrestricted distances. Independently climbs a flight of stairs to enter home. OT: Independent with all ADL and IADLs without an assistive device or adaptive equipment. Lives alone in own home Speech: Lives independently in own home alone managing all medical and financial affairs. Communicates in high level conversation with no reported difficulty Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  • 62. Nursing Documentation Prior Level of Function Document information obtained from resident and family Admission Assessment Weekends Document patient reported goals Document specific abilities prior to onset of illness …”no longer able to wash face and comb hair” Daughter reports the patient is lived completely independently and did not use a device to ambulate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  • 63. What is Rehab Potential The patient’s potential to achieve goals set by the therapist Not related to medical prognosis Goals should be achievable with good to excellent potential to achieve Rehab potential set to Fair, guarded or Poor would indicate to Medicare that the therapist does not believe in their plan Include “Due to” or “Given the patient’s…” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  • 64. Nursing Documentation Rehab Potential Focus on the potential to achieve goals Recent onset Intact abilities “Given the patient’s level of intact cognition…” “Given the recent onset of decline, the patient evidences good rehab potential” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  • 65. The Importance of Reason for Referral Details the specifics of why skilled therapy services are warranted Clarifies the events that led to a therapy referral Establishes the relationship to recent hospitalization Details the event that prompted evaluation Clarifies the specifics of the decline in function from prior level of function Points the reviewer to specific areas of the medical record Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  • 66. Reason for Referral Nursing and Therapy Examples “Significant decline in function status post an acute CVA on 9/1/13” “Evidences decreased ability to safely ambulate after a 3 week hospitalization for an MI on 9/1/13” “..recurrent Pneumonia despite medical intervention indicating potential Dysphagia” “new onset of cognitive deficits impacting ability to progress in medically necessary PT and OT ” “change in cognitive status after resolution of …… “New onset of slurred speech impacting ability to communicate” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  • 67. The Importance of Measuring Functional Deficits Supports Medical Necessity Establishes the physical and cognitive baseline data necessary for assessing expected rehabilitation potential, setting realistic goals, and measuring progress Baseline from which to measure progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  • 68. Level of Assist Devices and Adaptive Equipment Assessed Diet Textures Number of Caregivers to Assist Functional Levels: Maximum Assistance: The need for 75 percent assistance by one person to physically perform any part of a functional activity Moderate Assistance: The need for 50 percent assistance by one person to physically perform any part of a functional activity Minimal Assistance: The need for 25 percent assistance by one person to physically perform any part of a functional activity Contact Guard: Contact Assist to provide cues or guided maneuvering Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  • 69. Supervision Supervision: Cueing Reviewers may view this level of care as restorative Ensure documentation of deficits are clearly stated Analyze task to determine if the patient is not receiving hands on assist for a portion of the task Describe Cueing Constant (max) Frequent (mod) Occasional (mod) Rare (min) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
  • 70. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70 Supervision Describe Causes of Cueing Technique Sequencing Pacing Initiation Describe Type of Cueing Verbal Tactile Visual
  • 71. How to Measure Functional Deficits Current level of function for each functional deficit to be addressed in therapy Define/describe the behavior without using min/mod/max assist if needed Objective measures of function Be descriptive Amount and type Describe underlying impairments Reason for functional impairment/limitation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
  • 72. Reasons for Functional Limitations Examples of reasons for functional limitation: Lack of awareness of sensory cues Impaired attention span Impaired strength and or coordination Abnormal muscle tone Range of motion limitations Impaired body scheme Perceptual deficits Impaired balance/head control Environmental barriers Delayed initiation of swallow Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72
  • 73. Reasons for Functional Limitations Safety Issues Related To: Poor posture Improper gait Weak grip, arthritis Dysphagia Poor communication skills Paralysis/paresis Perceptual deficits Vestibular disorder Cognitive disorder COPD, emphysema Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73
  • 74. How to Measure Functional Deficits Standardized Measurement Tools Borg Scale= 5 (Severe Breathlessness) Berg Functional Balance Scale 39/56 (Medium Fall Risk) Western Aphasia Battery(WAB) 29.9/100 (Moderate to Severe Broca’s Aphasia) Functional Outcome Measures Composite Scale Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
  • 75. Complexity of Task Environment In room In dining room Distraction Patient Condition End of the day versus beginning With pain (how often does this occur?) With shortness of breath (how often does this occur?) Sequence Dressing after rising from bed and toileting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75
  • 76. Nursing Documentation of Function Focus on: Functional tasks requiring assist Partial task completion by caregivers Complex tasks that pose a challenge Functional impact of pain, dyspnea, anxiety etc. Risk assessment outcomes “Patient ambulated to the dining room with Limited Assist for the first time since returning from the hospital” Patient with limited ability to prticipate in ADLs due to increased pain with movement” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
  • 77. The Importance of Summarizing Findings Supports Medical Necessity Evidences the critical thinking process Don’t leave it up to the reviewer to determine Tell a story Evidences individualization of the plan of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
  • 78. How to Summarize Findings Be descriptive Chart your thinking Guide the reviewer State the obvious It may only be obvious to you! Focus on the relevant Individualize Avoid canned phrases Avoid negative statements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  • 79. The Importance of Functional Rehabilitation Goal Writing Guides the reviewer through progress Reflects the logical plan of care based on the evaluation findings Supports medical necessity “The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  • 80. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80 What is a Measurable Rehabilitation Goal Long-Term Goals Level you expect patient to be at discharge Short-Term Goals (2 to 4 weeks) Incremental steps toward the long term goals. Think beyond diet texture, transfers, ambulation, and ADLs Based on deficits identified on assessment and in nursing documentation
  • 81. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81 Performance Skills Motor skills: moving and interacting with task, objects, and environment Posture Mobility Coordination Strength Effort Energy
  • 82. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82 Performance Skills Process Skills: managing and modifying action when completing tasks Energy Knowledge Temporal organization Organizing space and objects Adaptation
  • 83. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83 Performance Skills Communication Skills: conveying intention and need and coordinating social behaviors Physicality Information exchange Relations
  • 84. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84 Duplication of Services
  • 85. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85 Duplication of Services Rehab goals can appear to be demonstrating a duplication of services. High risk of denial. Commonly seen goal areas: Bed mobility (PT/OT) Functional transfers (PT/OT) Functional mobility/Ambulation (PT/OT) Cognition (OT/ST) Safety (PT/OT/ST) Standing balance (PT/OT)
  • 86. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86 Duplication of Services The goals must be written to differentiate the skilled area to be addressed by each discipline High Risk of Denial Most reviewers are NOT therapists
  • 87. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87 Duplication of Services PT Goal: Pt. will demonstrate Good Functional Balance Better Stated As: Pt. will be able to I ambulate around obstacles in their room without loss of balance
  • 88. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88 Duplication of Services OT Goal: Pt. will demonstrate Good Functional Balance for ADLs Better Stated As: Pt. will I complete Grooming task standing at sink without loss of balance
  • 89. The Importance of Progress Reports Required for Payment Justifies outcome of skilled therapy intervention Supports the need to continue skilled therapy intervention Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  • 90. What is a Progress Report The minimum Progress Report Period is at least once on or before the 10th treatment day No later than 30 days Recommended weekly The beginning of the first reporting period is the first day of the episode of treatment Service provided on the first day of treatment is the evaluation, re-evaluation or treatment. The Progress Report Period requirements are met when both the Progress Report and the Therapist’s active participation in treatment have been documented Copyright © 2013 All Rights Reserved 90Harmony Healthcare International, Inc.
  • 91. Assistants and Progress Reports The PT, OT or SLP clinician must write a Progress Report during each Progress Report Period regardless of whether the assistant writes other reports. Must provide treatment. Reports written by assistants are not complete Progress Reports Physical Therapist Assistants or Occupational Therapy Assistants may write elements of the Progress Report dated between clinician reports Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
  • 92. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92 How to Write a Progress Note Each report should compare and contrast the prior level of function and describe specific areas which reflect improvement Within each level of function include specific performance tasks that the patient can demonstrate as a result of skilled intervention
  • 93. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93 How to Write a Progress Note Include: Assessment of improvement and extent of progress (or lack thereof) toward each goal Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions Changes to long or short-term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment
  • 94. How to Write a Progress Note Avoid: Simply listing CPT code descriptors Stating general treatment interventions (Ther Ex, strengthening, balance activities) Reflecting repetitive exercises that an unskilled care giver or restorative could provided Endurance training Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94
  • 95. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95 How to Write a Progress Note Include: That the patient’s condition has the potential to improve or is improving in response to therapy That maximum improvement is yet to be attained That there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time
  • 96. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96 How to Write a Progress Note Summary: 1) Skilled services provided since previous report to progress towards goals 2) Current Status 3) Specific progress towards each short term goal 4) Ongoing impairments to be addressed to progress towards long-term goals
  • 97. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97 Supportive Skilled Documentation Patient at high risk for Skilled assessment of Reasonable probability Potential for recurrence Monitoring for consistency The medical regimen is not essentially stabilized Patient continues to require daily skilled rehab for Patient requires daily skilled evaluation of the plan of care
  • 98. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98 Non-Supportive Skilled Documentation Plateau in progress Still requires Patient is unable to follow directions Patient has poor rehab potential Patient refuses to participate in therapy (without documentation of root of refusal) Within normal limits “Slow, steady gains” described in progress notes but comparison of function is without change from one week to the next
  • 99. Non-Supportive Skilled Documentation Quoted statements from patient refusing therapy and asking to end the therapy sessions/program, yet services continued without documented improvement Monitor or observed at meals versus assessed Focus on behaviors versus what skills of a therapist were required to manage Copyright © 2013 All Rights Reserved 99Harmony Healthcare International, Inc.
  • 100. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100 Progress Report Examples On evaluation, patient required max verbal and tactile cueing for initiation of upper body bathing while seated at the sink. At this time the patient only requires min verbal cueing and no tactile cueing to initiate upper body bathing. Progression of hip/glut strengthening exercises to now include weighted resistance
  • 101. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101 Progress Report Examples The patient initiated use of their prior level device of a cane for mobility this week. The patient required minimal assist to ambulate 45 to 50 feet at the beginning of the reporting period. The patient has improved to ambulate 45 – 50 feet with CGA with the cane at the end of the reporting period.
  • 102. Progress Report Examples The patient tolerated nectar thick liquids for all meals with no evidence of aspiration. The patient was assessed with thin liquids with overt signs and symptoms of aspiration on 10% of trials. Aspiration was eliminated with patient utilization of a chin tuck with continual minimal tactile cues during the meal. Patient and care giver education was provided on use of the chin tuck compensatory swallow strategy. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
  • 103. Nursing Documentation of Progress Focus on: New functional abilities Partial task completion Increased initiation attempts Lesser levels of care Decreased Number of assist or symptoms “Initiated participation in care as evidenced by….” No signs or symptoms of aspiration with diet upgrade to thin liquids on 10/1/13 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  • 104. Monthly Progress Report These are completed every 30 days and include components of weekly progress noted while also requiring: Updated goals and treatment plan with identification of significant improvement in functional skills “Significant” means a generally measurable and substantial increase in the patient’s present level of functional independence, and competence compared to the level of function at the time treatment was initiated. HIM 12, 544. Copyright © 2013 All Rights Reserved 104Harmony Healthcare International, Inc.
  • 105. Monthly Progress Report Any change in treatment plan would require physician clarification orders The completion of clarification orders to communicate the expected treatment plan with the physician and receive verbal approval for the treatment to continue Copyright © 2013 All Rights Reserved 105Harmony Healthcare International, Inc.
  • 106. Discharge Progress Report The discharge note is a Progress Report written by the clinician upon completion of each program Supports outcome of therapy intervention for all payors Copyright © 2013 All Rights Reserved 106Harmony Healthcare International, Inc.
  • 107. Discharge Progress Report It is important to give a thorough synopsis beginning with a comparison between the initial level of function and discharge status The clinician should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode for review purposes Copyright © 2013 All Rights Reserved 107Harmony Healthcare International, Inc.
  • 108. 108 Discharge Progress Report List all techniques and methods trialed even failed attempts Discharge setting with cues for re-referral for skilled therapy Unanticipated discharge: Data related to discharge not noted in the previous Progress Report will require the clinician writing the final note to rely on treatment notes and verbal reports of the assistant or qualified personnel Summary of progress is still needed to support services provided Copyright © 2013 All Rights Reserved 108Harmony Healthcare International, Inc.
  • 109. Nursing Discharge Documentation Supplement with: Functional Goals achieved Medical diagnosis and conditions that have resolved Patient Education Reoccurrence of UTI Fall Risk Home Safety and Home Exercise Program developed by therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 109
  • 110. Skilled Coverage Criteria There is no such thing as a “Rehab” or “Nursing Patient One patient One medical record One claim billed One set of Medicare coverage criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
  • 111. References Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 161, 10-26-12) CMS MDS 3.0 RAI Manual v1.11 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
  • 112. Questions/Answers Harmony Healthcare International, Inc. 112112Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Harmony Healthcare International 1 (800) 530 – 4413 kmastrangelo@harmony-healthcare.com www.harmony-healthcare.com