What am I Looking For?: A Reviewer s Guide to Therapy Documentation

Transcription

1 What am I Looking For?: A Reviewer s Guide to Therapy Documentation Presented By: Cindy Krafft MS PT, COS-C Director of Rehabilitation Consulting Services President - Home Health Section APTA November 2, King Street, Suite 246 Northampton, MA fax:

2 Instructions and Handouts for: A Reviewer s Guide to Therapy Documentation Eastern Standard Time 1:00 PM to 2:00 PM Central Standard Time 12:00 PM to 1:00 PM Mountain Standard Time 11:00 AM to 12:00 PM Pacific Standard Time 10:00 AM to 11:00 AM It is very important that you have these materials printed and ready to use prior to the start of the training. In order to participate in this training you will need to do the following: 1. Dial 1 (877) at least 10 minutes prior to the start of the webinar. 2. When asked, enter Conference ID #. 3. Give your agency s name. 4. At this time you will be entered into the call and in listen mode. 5. If at any time you need assistance you may press *0 for the operator. 6. There will be a Q & A period toward the end of the session. Questions will be answered in the order in which they are received. To ask a question, press *1. You will have the opportunity to ask your question and then be returned to listen mode. Do not press *1 prior to this time. 7. To view the presentation online you must click on the link sent to you from GoToWebinar. Therapists Only: Directions to receive contact hours for the training. The process for therapy CEUs varies state to state. In order to assist therapists with getting a session approved, we have provided material that can be submitted to the state licensing board. Please check with your individual state for more specific information as to the process. More information on APTA Guide to Practice can be found at the following websites:

3 Speaker Introduction Cindy Krafft MS PT is the Director of Rehabilitation Consulting Services for Fazzi Associates, Inc. She has 15 years of home health experience ranging from PRN Clinician to the Director of Rehabilitation for a six agency home care system. She serves as the President of the Home Health Section of the American Physical Therapy Association, Chair of the NAHC Therapy Advisory Committee, and is on the NAHC Regulatory Affairs Committee. She has published a variety of articles in Caring Magazine, The Remington Report, Success in Home Care, Home Healthcare Nurse, and the Home Health Section of APTA newsletter. As well as being an expert on therapy practice in home care she also assists agencies with achieving OASIS competency. She served as the Clinical Co-Director of the Delta National OASIS-C Best Practices Project and currently acts as the Clinical Director of the Delta Excellence in Therapy Project. She is a well received speaker at both the state and national levels on the topics of OASIS, therapy documentation, program development, therapy utilization, and recruitment.

4 What am I Looking For?: A Reviewer s Guide to Therapy Documentation November 2, 2010 Cindy Krafft MS PT, COS-C Director of Rehabilitation Consulting Services Fazzi Associates, Inc. President - Home Health Section APTA Objectives Understand the recent developments that have impacted the scrutiny of therapy documentation. Discuss the components of appropriate therapy utilization as they relate to reasonable and necessary for both assessments and ongoing visits. Establish review practices that ensure compliance with documentation standards. Therapy and Reimbursement CMS attempted models could not predict therapy use. Concerns that providers would skimp on high cost services such as therapy under a PPS model. Intent to ensure services were not under provided. Fazzi Associates, Inc. 1

5 Changing Visit Patterns 10 visit threshold: 50% of high therapy ended between 10 and 13 visits Tiered model: 26% increase in episodes with 14 or more Additional Issues OASIS Functional Scores unchanged yet therapy visits increasing. More than 60% of SOC OASIS B scored ambulation at as 0 or 1 why all the need for PT? Wall Street Journal Article in April MedPac Reports. What is Medical Necessity? Necessity is defined as: An imperative requirement or need for something Indispensability Fazzi Associates, Inc. 2

6 Coverage Issue Therapy would not be covered to effect improvement or restoration of function when a patient suffered a transient and easily reversible loss or reduction of function. Documentation Expectations Objective assessments done by qualified therapists. Goals that are measureable and functional. Accepted standards of clinical practice. Chart Reviews External Audits often involve few, if any, therapists in reviewing charts. Internal reviews are often done by non -therapy staff that are concerned they do not know what they are looking for. Therapists are pulled in to review therapy documentation. Determination of reasonable and necessary should be evident to the reviewer, regardless of discipline. Issues related to orders must not be overlooked. Fazzi Associates, Inc. 3

7 The Language of Therapy It takes time to learn the specific terminology associated with therapy: Use/develop reference lists for reviewers Follow standard abbreviations If something is unclear to you, do not ignore that concern. There are no magic words that guarantee payment. Bottom line, does the document as a whole make sense. Using a Tool The approach to a review needs to be as consistent as possible. Results need to drive a course of action. Specific Providers Helps to accurately pin point issues: PT and PTA OT and COTA When you see a difference between providers, note it in the comments area. Fazzi Associates, Inc. 4

8 Reviewing Orders Orders: Evaluation Frequency and duration Number of visits completed: Do orders cover all visits All orders signed and dated correctly Documentation present for all visits: Include missed visit notes OASIS and Therapy Referrals The comprehensive assessment should support the referral. Consider the following: Ambulation Bathing Overall functional status Initial Therapy Visit What to look for: Previous functional status Rehabilitation potential Patient/caregiver reported issues Measurements of function Assessment statements outlining issues and interventions Goals that are functionally based and tied to measured deficits Fazzi Associates, Inc. 5

9 Assessment Clinical judgment that examines the objective data. Opportunity to summarize the functional concerns and support the need for therapy in a concise way. Watch for repetitive statements: Patient tolerated well Patient progressing toward goals Key Assessment Areas Physical Therapy: Gait more than distance, device, and level of assistance Occupational Therapy: ADLs and IADLS should not be assessed as a group of tasks Speech Therapy: Clarity of functional impact of testing Bottom Line quantity AND quality of patient performance. Therapy Common Ground Transfers. Strength/ROM tied to functional issues. Endurance/Activity Tolerance. Pain/Dyspnea/Vital Signs Watch for: Duplication Out of scope Does the measurement make sense to you? Fazzi Associates, Inc. 6

10 Initial Examination / Evaluation: Examination: History Systems Review Tests and Measures Evaluation: Problem list/statement of assessment Diagnosis: Prognosis Plan of Care/Goals APTA Defensible Documentation for Patient/Client Management Tests and Measures Standardized: Must follow the directions Validated: Assess research behind the tool Value in repeating over course of care: Support ongoing need and impact of care Components of Well Written Goals Identification of person who is receiving therapy and will carry out the program. Description of the movement or activity that the patient will perform. A connection of the movement/activity to a specific function. Physical Therapy Reimbursement News, Volume 13, Number 3 Fazzi Associates, Inc. 7

11 Components of Well Written Goals Continued Specific conditions in which the activity will be performed. Factors for measuring performance. Time Frame for achieving goal. Physical Therapy Reimbursement News, Volume 13, Number 3 Goal Examples Improve balance and gait. Independent/SBA ambulation with/ without an assistive device. Improve ROM and strength. Improve overall strength and conditioning. Patient to demonstrate cognitive skills. Self management. Assisted ambulation with ADLs. Better Examples Patient will demonstrate upper extremity strength of 4/5 as seen in decreased assistance needed for bathing and dressing. Patient will complete lower body dressing using reacher with supervision. Patient will ambulate 200 feet with walker independently to be able to get to mailbox in apt complex. Fazzi Associates, Inc. 8

12 Better Examples Patient will achieve a Tinetti score of 25/28 indicating a decreased fall risk. Patient will complete three syllable word recognition o with 90% accuracy acy to improve her safety with her medication regime. Patient will correctly write a check with no assistance. Discharge Goals Met Very common to see goals met on final therapy visit, but are they really? There should be evidence in the notes that the goal tasks s were e completed during the course of care. Therapy Interventions What is Training? : Gait Transfer ADL Oral Motor Fazzi Associates, Inc. 9

13 Keep in Mind! Are these visits reasonable in number compared to the plan? Can I see that the care was indispensable to the patient and could not be done by anyone else? Would I pay for the visits? Need for the Visit? Amb 50 feet X 3. Patient advanced ambulation to 35 with walker. Patient amb 45 feet with walker, CGA and 50% verbal cues to increase step length on the right. Patient completed shower activity. Standing ex X 10 reps each. Ther ex per flow sheet X 10 reps with VC needed 80% of the time for correct technique. Follow Up Visits Patient or caregiver report. Interventions provided including (as appropriate): Frequency Intensity Time Patient response to treatment. APTA Defensible Documentation for Patient/Client Management Fazzi Associates, Inc. 10

14 Follow Up Visits Continued Communication/collaboration with other providers/family/patient as applicable/indicated. Factors that modify frequency or intensity of intervention and progression within the plan of care. Plan for next visit including interventions with objectives, progression parameters and precautions if indicated within the plan of care. APTA Defensible Documentation for Patient/Client Management Independent Use of this term can be a red flag that therapy is not needed or has reached set goals and further visits are not warranted: Think like OASIS Consistency between disciplines Documentation Tools Tools need to facilitate good documentation. Paper versus electronic??? The responsibility will always remain with the therapy professional. Fazzi Associates, Inc. 11

15 Documentation and Clinical Practice From the first visit to the last, determine why the patient is being seen. If that question does not have a clear answer, e,the epa plan of caes care should oudbe reassessed. Chart Audit Tool Orders Section. Evaluation clearly outlines patient issues. Measurements are tied to function. Goals align with evaluation findings. Interventions correlate to goals. Visits indicate indispensability of therapy. Number of visits that are medically necessary. Documentation References Functional Outcomes Documentation for Rehabilitation: By Lori Quinn and James Gordon Published by Saunders APTA - Defensible Documentation for Patient/Client Management. Fazzi Associates, Inc. 12

16 Helpful Resources American Physical Therapy Association: Home Health Section State Level Associations American Occupational Therapy Association: American Speech and Hearing Association: ww.asha.org National Association of Home Care. State Home Care Associations. fazzi.com Therapy Services Available Documentation Audit: Detailed analysis of trends and risks Includes a conference call to discuss findings Case Management Training. Program Assessment: Opportunities for growth and development OASIS Training. Fazzi Associates, Inc. 13