Therapy Documentation: Beyond Reasonable and Necessary

Transcription

1 Therapy Documentation: Beyond Reasonable and Necessary August 30, 2012 Presented by: Cindy Krafft PT, MS Director of Rehabilitation Consulting Services Fazzi Associates 243 King Street, Suite 246 Northampton, MA Fax:

2 Instructions and Handouts for: Therapy Documentation: Beyond Reasonable and Necessary Eastern Central Mountain Pacific Standard Time Standard Time Standard Times Standard Time 1:00 PM to 2:30 PM 12:00 PM to 1:30 PM 11:00 AM to 12:30 PM 10:00 AM to 11:30 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: Dial at least 10 minutes prior to the start of the webinar. 1. When asked, enter Passcode # 2. Give your agency s name. 3. At this time you will be entered into the call and in listen mode. 4. If at any time you need assistance you may press *0 for the operator. 5. 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. 6. To view the presentation online you must click on the link sent to you from GoToWebinar.

3 Therapy Documentation: Beyond Reasonable and Necessary August 30, 2012 Cindy Krafft PT, MS Director of Rehabilitation Consulting Services Fazzi Associates, Inc. MedPAC Report MedPAC wrote in the March 2010 report (MedPAC, 2010, p. 206) that payment incentives continue to influence treatment patterns, and that payment policy is such a significant factor in treatment patterns because the criteria for receipt of the HH benefit are ill-defined. Incentive? Example 1 Example 2 M02200 = 19 Actual = 14 M02200 = 19 Actual = 19 Revenue = $2337 ($663 lower) Revenue = $3000 Cost -$126 X 14 = $1764 Cost -$126 X 19 = $2394 Margin = $573 Margin = $606 1

4 Therapy in to % increase 14 to % decrease 20 or more 5% decrease 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. Diagnosis? A prescriptive definition of these sorts of conditions, such as a listing of specific disease states that provide subtext for these descriptions is impractical, as each patient s recovery from illness is based on unique characteristics. 2

5 Who Decides? We believe that rehabilitation professionals, by virtue of their education and experience, are typically able to determine when a functional impairment could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. We expect rehabilitation professionals to be able to recognize when their skills are appropriate to promote recovery. Back to the Beginning What is Medical Necessity? Necessity is defined as: An imperative requirement or need for something Indispensability 3

6 Therapy STARS Project Between 80% and 90% of the records could not support the number of therapy visits as medically necessary. Documenting Necessity SOC / ROC OASIS 485 / Plan of Care Therapy Assessments Therapy Reassessments Therapy Orders Therapy Visit Notes Therapy Assessments Create the foundation of the entire therapy plan of care. Begins to answer the question Why is therapy indispensible to this patient? 4

7 Gaining Skill Prior Level of Function Be specific to the task and the timeframe: PLOF = dependent Bathing PLOF = min A X 1 PLOF amb = dependent Patient non ambulatory X 5 years. Key piece to create baseline and set expectations. Skilled Assessment Measurements: ROM Strength Balance Vision Pain Sensation Communication Cognition Environment Equipment Functional Impact: Ambulation Transfers Bathing Dressing Toileting Incontinence Medication Management Swallowing Home Management 5

8 What Does a Therapist See? Gait Deficits : Patient 1 Visual and cognitive issues Patient 2 Leg length discrepancy and pain ADL Deficits : Patient 3 Anxiety and lack of transfer bench Patient 4 Balance and arm in a sling Swallowing Deficits : Patient 5 Posture and muscular weakness Patient 6 Attention and memory 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 Objective Data? AROM/PROM? Manual Muscle Testing? Components of a Transfer? Gait Cycle? Time Based Activities? Pain Assessments? Pressure Ulcer Risk? OASIS? 6

9 Setting Goals Considerations: Prior level of function Homebound status Patient goals Need to expand view beyond being functional in the home environment for those patients that want to re-enter the community Community Access Carry a 5 pound weight for >1000 feet? Carry packages averaging 6-7 pounds for short distances? Walk a minimum of 1000 feet per errand for 2 3 errands per trip? Change speeds and maintain balance? Negotiate safely around obstacles, slopes, or curbs while looking in a variety of directions? Multi-task while walking (walk and talk, walk and look from side to side or up and down)? Community Access Carry a package up and down the stairs? Safely engage in postural transitions such as changing directions, reaching, looking up or down or sideways, move backwards? Rise from a chair without the use of arms with minimal effort? Walk at 4 feet per second for at least 1 minute to cross a street? Walk at a minimum speed of 160 feet per minute or about 2.6 feet per second? 7

10 150 Feet Rule Any rules of thumb that would declare a claim not covered solely on the basis of elements, such as lack of restoration potential, ability to walk a certain number of feet, or degree of stability, is unacceptable without individual review of all pertinent facts to determine if coverage may be justified. Medical denial decisions must be based on a detailed and thorough analysis of the beneficiary s total condition and individual need for care. Measureable Goals CONSIDER: ROM MMT Distances Level of assistance Environment Testing Scores Specific Equipment Caregiver role Specific Instructions Any Complicating Factors AVOID: fair/good/poor WFL LRAD household community safe increase improve min/mod Modified Independent Meaningful Goals Connection to what is meaningful TO THE PATIENT Consider: to allow patient to so patient can to comply with 8

11 Therapy Reassessments Audit results showing some issues with completion in the correct time frames Larger issues with content NOT meeting the standard to support continuing therapy Qualified Therapist We believe that when a unique condition of an individual patient requires more therapy than a typical Medicare HH rehabilitation patient, such a patient should be more closely monitored by a qualified therapist to ensure high-quality, effective services are being provided and/or acceptable progress towards goals is being achieved. Evaluation vs. Reassessment Evaluation of the patient for the purposes of forming a diagnosis and plan of treatment. Reassessment focuses on the plan of care using relevant patient information. 9

12 Reassessment Documentation Clinically supported statement of expectation that the patient can continue to progress or resume progress after plateau or regression. Speak to the effectiveness of therapy in relation to the goals. Plans to continue or discontinue: Refer to clinical findings (objective assessments) and treatment plan revisions Proposed PPS 2013 Overall Impact on Therapy Proposed policies are better than expected Larger cuts in payment as a result of case-mix creep averted No proposals regarding alternatives to therapy payment and payment differentials/reductions for use of PTAs Major issues regarding therapy functional reassessments addressed 10

13 When Coverage Resumes Currently AFTER the Reassessment is completed 11, 12, 13, 14, 15(RA done), 16, 17(DC) Total covered visits = 15 Proposed 2013 ON the Reassessment visit 11, 12, 13, 14, 15(RA done), 16, 17(DC) Total covered visits = 16 Multiple Therapies Currently Missed Reassessment impacts ALL therapy visits Proposed PPS 2013 Only the therapy the missed the Reassessment is impacted Implications for counting?? Multiple Therapies Currently Close to 13 and 19 with no specified ranges Proposed PPS 2013 Ranges of 11 to 13 and 17 to 19 in place Implications for scheduling?? 11

14 Patient Driven Exceptions Missed Visits? Single Therapy Multiple Therapy Interruptions in Care? Hospitalization SNF Who caused the missed reassessment?? Therapy Visit Notes Following the Plan of Care Independent Direction of the assistant Repetitive Interventions Skilled Interventions Intervention = interference Disruption of the current process Driven by the assessment findings 12

15 Selecting Interventions Current Model: Gait training Transfer Training Ther Ex/HEP Balance Training ADL Retraining Visual Training Oral Motor Training Cognitive Training Fall Prevention Training Moving Forward: Use the assessment to drive the interventions: Why is a certain level of assistance needed? Examples: Visual compensation techniques for macular degeneration that impacts safe dressing and med management Focus of Care Restorative Therapy Intent is to improvethe patient s ability to function. Qualified therapist establishes the plan of care and completes required reassessments. Therapy assistants CAN provide care. Maintenance Therapy Intent is to preventfurther loss of function. Qualified therapist establishes the plan of care and completes the required reassessments. Therapy assistants CANNOT provide care. Therapy G Codes Maintenance G0159 G0160 G0161 Physical Therapist in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes. Occupational Therapist in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. Speech-Language Pathologist in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes. 13

16 Maintenance = Skilled require the specialized skills, knowledge, and judgmentof the qualified therapist to design or establisha safe and effective maintenance program the unique clinical conditions of a patient may require the specialized skills of a qualified therapist to performa safe and effective maintenance program Examples Why Therapy Patient considered at risk for pressure ulcers due to current level of immobility. Transfer and gait training will focus on necessary position changes to decrease risk. Patient s daughter requires training in lower extremity positioning techniques and PROM to ensure correct follow through. Examples Why Therapy Transfer training to decrease workload on caregiver Upper extremity stretching techniques taught to caregiver to prevent contracture and continue participation in grooming Education regarding correct use of thickener to decrease risk of aspiration 14

17 Delivering Care Biggest risk is repetitive documentation without showing skill. Defend why a therapist must be involved with each visit. Specifically address the plan to transition care to someone else. Skilled Care WHY does it need to be a clinician with that specific skill set in the home during these activities? WHY YOU? WHY NOW? AVOID: fair/good/poor WFL min/mod Modified Independent performed / completed household community safe increased improved How Many Visits? There are no specific minimum or maximum number of visits. Defining issue is the level of skill required. Caregiver Ed. Must maintain clarity regarding the true needs of the patient. 15

18 Reasonable and Necessary? If an individual s expected restorative potential would be insignificant in relation to the extent and duration of therapy services required to achieve such potential, therapy would not be considered reasonable and necessary, and thus would not be covered. Medical Necessity is Indispensible Disruption Contact Information Website ckrafft@fazzi.com Twitter Account FazziRehab 16