Girling Reviewer Training: Session 1. Therapy Practice in 2011: What the Reviewers Need to Know. May 10, 2011

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1 Girling Reviewer Training: Session 1 Therapy Practice in 2011: What the Reviewers Need to Know May 10, 2011 Presented by: Nancy Buseth RN, PT Senior Rehabilitation Consultant Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA Fax:

2 Therapy Practice in 2011: What the Reviewers Need to Know Presented by: Nancy Buseth RN, PT Senior Rehabilitation Consultant Fazzi Associates, Inc. Therapy Visits and Payment M2200: In the plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech pathology visits combined)? Changing Visit Patterns 10 visit threshold: 50% of therapy episodes ended between 10 and 13 Tiered model: 2008: 26% increase in episodes with : Additional 20% increase in 14 + AND 30% increase in 20+ Source: MedPAC analysis of home health standard analytical file 1

3 Documentation Implications The tiered system will make each and every therapy visit note a critical piece in keeping the level of reimbursement earned. Key areas: 6, 14, and 20+ Documentation Implications Reassessment documentation requirements for 13 and 19 visits, or minimally every 30 days. Patients Getting Therapy Episodes 1 or % Episodes 3 or more 24.6% All Episodes 53.1% Source: Abt Associates Inc analysis of Home Health Datalink file 2

4 What is Medical Necessity? Necessity is defined as: An imperative requirement or need for something Indispensability Reasonable Amount of therapy: Frequency & duration Areas of concern include: Low example: 1 time per week High example: 5 times per week Same freq. /duration on every patient Average length of visit Does the amount make sense given the plan of care? Necessary = Indispensible Speaks to the need for a skilled therapist to be involved with the care. Patient progress does not automatically support necessity: Is it occurring because of unique and specific interventions or by accident? Could it have occurred without the therapist being involved? 3

5 Prior Level of Care Considerations Acute Care. Transitional Care. Rehabilitation Unit. Skilled Nursing Facility. Nothing Not Just Clinical Issues Additional issues include: Therapy services not properly authorized Services not provided as ordered Medical records incomplete Not Properly Authorized Plan of care/orders not dated by the physician. Orders dated after the final bill. Orders not signed by physician. Order did not specify frequency or duration. 4

6 Incomplete Medical Records Missing visit documentation and physician orders: 15 billed visits 2 missing notes = 13 and a down code of the claim 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, and no magic words that guarantee denials. Chart Audit Tool OASIS review. Orders Section. Evaluation clearly outlines patient issues using tests/measures. Measurements are tied to function. Goals align with findings. 5

7 Chart Audit Tool Interventions correlate to goals. Visits indicate indispensability of therapy. Number of visits that are medically necessary. Using a Tool The approach to a review needs to be as consistent as possible. Results need to drive a course of action. Reassessments completed within timeframe. Specific Clinicians Helps to accurately pinpoint issues: PT and PTA OT and COTA When you see a difference between clinicians, note it in the comments area. Work closely with clinical managers/supervisors for follow up. 6

8 OASIS Review Functionally Driven Items (M1800 series): Grooming Dressing Bathing Toileting Toileting Hygiene Transfers Ambulation Meal Preparation Other OASIS Items to Consider Hospitalization Risk. Living Situation. Ability to Hear. Ability tounderstand Verbal Content. Speech/Expression of Language. Interfering Pain. Pressure Ulcer Risk. Dyspnea. Incontinence. Cognitive Issues. Anxiety. Depression. Medication Management. PPS 2011 Documentation Expectations Objective assessments done by qualified therapists. Goals that are measureable and functional. Accepted standards of clinical practice. 7

9 Assessments Create the foundation of the entire therapy plan of care. Prior level of function (PLOF) is NOT optional. Critical to begin to answer the question, Why is therapy indispensible to this patient? 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 Independent The patient is able to safely complete the task whenever they want with no need for assistance of any kind. Why would they need therapy? WFL (within functional limits) for Strength and ROM then why would they be doing an exercise program? 8

10 Physical Therapy: Issues by Discipline 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. Issues by discipline PT Ambulates with rolling walker 100 feet on a variety of surfaces. Needs mod assist with transfers. Standing exercises of X 10 reps with cues. Sit to stand x4 with SBA. Patient/caregiver education. Issues by discipline OT Needs mod assist with dressing LE. Able to shower with supervision. Min assist with ADLs. Balance during transfers is fair/good. Educated on energy conservation techniques. 9

11 Issues by discipline ST Improved swallowing noted. Components of Well Written Goals Description of the movement or activity that the patient will perform. A connection of the movement/activity to a specific function. Specific conditions in which the activity will be performed. Factors for measuring performance. Physical Therapy Reimbursement News, Volume 13, Number 3 Measureable AND Meaningful Goals Patient will ambulate 300 feet independently over driveway surface with walker, to allow access to mailbox and vehicle. Patientwill shower with intermittent SBAand use of a transfer bench. Patient will demonstrate independent ability to utilize thickener to maintain nectar consistency for safe intake of liquids. 10

12 Measureable AND Meaningful Goals Patient will ambulate with 4ww 25 feet independently, to get to golf cart in garage. Patient will be able to stand for 10 minutes at kitchen counter, to be able to knead and bake bread. Patient will amb ind 165 feet, with no device, on sidewalk to son s house 2 doors down. Patient will be able to use sentences to call pharmacy to reorder meds. Patient will be able to do car transfer with supervision to get to face to face encounter with physician. Selecting Interventions The assessment findings set the expectations for the areas to be addressed over the course of care. One size should not fit all. Only select ones that will be implemented and update as needed. Every intervention does not have to be done at every visit. Intervention = Interference = What did the Therapist do? Gait Training. Transfer Training. ADL Training. Oral Motor Training. Home Programs. Caregiver Ed. 11

13 Amb 50 feet X 3. Need for the Visit? Patient advanced ambulation to 35 feet 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 Medical necessity needs to be evident in each visit note. Progress is not an automatic confirmation of skill. Therapist intervention/interference needs to be evident in every visit note. Tests/measures need to be repeated. 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 12

14 Reassessment Timeframes Minimally every 30 days. Key areas around 13 and 19 total therapy visits. Doneby qualified therapist who actually participates in the assessment directly. Done as part of a treatment visit. If One Therapy Providing Care Reassessment required minimally every 30 days. If completing more than 13 visits, the reassessment is required on the 13th visit. If continuing on to more than 19 visits, the reassessment is required on the 19th visit. Exceptions and 17 19: Rural area Circumstances outside the control of the therapist If More Than One Therapy Reassessment required minimally every 30 days. If completing more than 13 visits the reassessment is required by all continuing services close to the 13 th visit. If continuing on to more than 19 visits the reassessment is required by all continuing services close to the 19 th visit. Exceptions: Rural area Circumstances outside the control of the therapist 13

15 Reassessment Documentation Objective assessments. Effectiveness of therapy in relation to the goals. Clinically supported statement of expectation that the patient can continue to progress, or resume progress after plateau or regression. Plans to continue or discontinue: Refer to clinical findings and treatment plan revisions Changes in goals or an updated plan of care MD signature required. Delta Excellence in Therapy Forum Over 80 physical, occupational, and speech therapists met in Chicago for two days to develop meaningful recommendations for home health agencies. Documentation References Functional Outcomes Documentation for Rehabilitation: By Lori Quinn and James Gordon Published by Saunders APTA Defensible Documentation for Patient/Client Management. 14

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. 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. nbuseth@fazzi.com fazzi.com

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