9/5/2016. Documenting Compliantly and Efficiently: Best Practices and Techniques. Course Objectives. Legal Disclaimer

Transcription

1 Documenting Compliantly and Efficiently: Best Practices and Techniques Veda Collmer, Esq., OTR/L Course Objectives Participants will be able to identify basic information required for documenting in the medical record. Participants will be able to identify compliance pitfalls and other documentation errors that may trigger an audit. Participants will be able to understand how charges support documentation. Legal Disclaimer This presentation has been written for general informational purposes only. The information presented is not legal advice and is not to be acted on as such. 1

2 Healthcare in the US: The Past, the Present, and the Future Healthcare of the Past Passage of Medicare and Medicaid led to increased access to care We are living longer More chronic illnesses and conditions, such as heart disease, stroke, diabetes, that are costly and preventable Fragmented, fee for service health care reimbursement model did not adequately improve health and was not sustainable Healthcare Now More access to health care with insurance mandates and Medicaid expansion More focus on population health Innovative new ways to pay for healthcare 2

3 Healthcare in the Future Coordinated care Alternative Payment Methods (APMs) and Merit Based Incentive Payment Systems (MIPS) Evidenced based practice and data driven medicine Patient Satisfaction More resources for fraud, waste, and abuse investigations Afforable Care Act Initative: Reduce Fraud, Waste and Abuse of Healthcare Spending $1.9 Billion Recovered by the Department of Justice in 2016 Federal and State Efforts to Reduce Healthcare Fraud Self-Reporting Whistleblowers Data Mining CMS Recovery Audit Program 3

4 Insufficient documentation: One of the Most Common Audit Findings Medical documentation was inadequate to support services billed (e.g., reviewer could not determine whether services were provided at the level billed or were medically necessary). Strategies for Better Documentation Purposes for Medical Documentation Legal Document Compliance Reimbursement Care coordination 4

5 Include relevant patient information and the referral source. Patient demographics, referral source, onset date, medical history, history of therapy services provided, precautions and contraindications that can impact plan of care. Explain how complexities affect treatment (e.g., type, frequency, intensity, and/or duration): Complicated medical history (e.g., spinal cord injury, diabetic neuropathy) Poor compliance with rehabilitation education Poor pain management Identify cognitive deficits/impairments that could impact plan of care or progress. Dementia Altered mental status Difficulty following multi step directions Difficulty initiating tasks Limited carryover of instruction Requires visual and physical cues to engage in activity due to poor attention to task Impaired safety awareness 5

6 Thoroughly document prior level of function. Consider support systems, level of independence, community living skills, durable medical equipment, and adaptive equipment. Example: Client demonstrates poor activity tolerance and muscle weakness after a recent hospital stay. Client has had a diagnosis of paraplegia for 20 years. PLOF- Client lived alone in a 1 level home. Home modified with walk in shower, shower chair and grab bars, ramp at front entry, and counter tops to accommodate wheelchair use. Client was independent with ADLs and IADLs, including yard work, housecleaning, laundry, driving, and grocery shopping. Client was very active in her community, visiting friends and engaging in community activities. Analyze objective information and tie to functional performance. Use standardized assessments, as appropriate, to establish a baseline of function. Standardized assessments provide an objective measurement to show progress towards goals. Standardized assessments include: Berg Balance Scale Mini Mental Exam Clinical observations Goniometry measurements Manual muscle testing 6

7 Example: Clinical observation of poor activity tolerance impacting participation in self-care activities. Standardized assessments that can support clinical observations includes pulse oximetry measurements before and after activity or MMT. Intervention must demonstrate the services are medically necessary and require the skilled services of an occupational therapist. Clinical impressions summarize how deficits impact function and how occupational therapy will treat deficits. Client's rehabilitation potential is stated. American Medical Association Definition of Medical Necessity Medically necessary is defined as health care services needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of practice. 7

8 Medical Necessity is: In accordance with generally accepted standard of practice Clinically appropriate in terms of type, frequency, extent, site, and duration Not intended for the economic benefit of the health plan or purchaser or for the convenience of the patient or provider Medicare's Definition of Medical Necessity No payment may be made under Part A or Part B for expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicare Policy Manual, Chapter 15 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. 8

9 Skilled Services include: Evaluations and re evaluations Establishing treatment goals Designing a plan of care Ongoing assessment Instruction leading to development of compensatory skills Selection of devices to improve function Client and caregiver training Connect baselines with outcomes goals in the plan of care. Objective measurements must support ICD-10 treatment codes Example objective measurements: Client reported falling several times at home in the past year. Client fell in her driveway, suffering a right hip fracture, s/p THR. During evaluation, client with loss of balance backwards while transferring on and off the toilet, requiring mod A to regain balance. Supporting ICD-10 Codes: R29.6 Repeated falls (falling, tendency to fall), Z91.81 at risk for falling, Z91.18 history of falling 9

10 9/5/2016 The Daily Note The Daily Note Changes to the frequency or duration of treatment must be supported with a reason for the change. The Daily Note The documentation must identify the goal(s) addressed and the client s response to the treatment. Example: Client performed functional standing activity of hanging clothes in her closet to maximize independence with self-care skills. Client required CGA to maintain dynamic standing balance. Client with shortness of breath after 5 minutes on room air, requiring a seated rest break. Pulse oximetry indicated oxygen desaturation of 87% on room air after standing activity. Client instructed in deep breathing activity and client performed deep breathing exercises for approximately 5 minutes while seated. Pulse oximetry after deep breathing and rest break indicated oxygen saturation of 95% on room air. 10

11 The Daily Note The codes billed, the treatment time, and the intervention dates must match the documentation. Therapeutic Procedure codes- use for intervention where clinical skills or services will attempt to improve function; requires direct (one-to-one contact) Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Manual Therapy Technique, 1 or more regions, each 15 minutes self-care/home management Therapeutic activities- direct one to one patient contact, activities to improve functional performance The Daily Note Example: CPT code: neuromuscular re-education Documentation: Client performed reaching tasks in all planes while standing with CGA. Client reached for objects with loss of balance one time with self-correction. The Daily Note Bill for only actual treatment time. Rest breaks are not billable; however, educating the client about compensatory strategies can be a billable activity. Education must be reflected in the documentation. 11

12 The Daily Note Documentation reflects client s progress towards goals (or if no progress, the reason why the client is not progressing). Documentation reflects supervision of assistants in compliance with state licensure requirements. Document group or concurrent therapy The Progress Note The Progress Note Document changes in the client s status and progress towards goals. Only use common abbreviations. Illustrate how intervention activities support functional outcomes. Avoid duplicating services. Document interventions and modalities used to achieve outcomes. 12

13 The Progress Note Indicate changes in plan of care and client s status. Changes to frequency, duration, goals must be supported by a reason for the change. The Progress Note Document skilled services. Use the following verbs to indicate skilled services- evaluate, fabricate, analyze, educate, adapt, modify The Discharge Summary 13

14 The Discharge Summary Document client and caregiver training and their responses to training Document progress towards all goals The Discharge Summary Include discharge recommendations. follow up care adaptive equipment compensatory strategies supervision community support durable medical equipment My EHR made me commit fraud! Watch out for the following compliance pitfalls in your EHR/EMR: Copy forward, cloning or copy and paste can lead to inaccurate notes in the client s medical record and inappropriate charges billed for services. Single click template notes or auto populate can lead to excessive documentation that is irrelevant or false. Make me an author or other features allow the alteration or creation of documentation under another provider s name. 14

15 Safeguards against fraudulent electronic documentation and charges: Review your documentation before finalization to ensure you have provided an accurate story of the services provided and the client s response to intervention. Remember: An electronic signature is the same as a wet signature. Never finalize or alter documentation of another provider. Only document the services provided to the client. If you use the build features, make sure they accurately reflect the intervention and client response. Point of Service Documentation Tips that Improve Accuracy Without Alienating Your Client Get familiar with your EHR so you know the fields to complete during your time with the client. Involve the client in the process to improve trust and engagement. Explain to your clients that Point of Service documentation can improve the accuracy and detail of documentation. Better documentation leads to reimbursement, which means the client will receive the services they need to rehabilitate. Master documentation best practices so you can easily document the right information during your Point of Service documentation. Use the right technology for the setting (e.g., laptops, tablets, smart phones). Contact Information Veda Collmer, Esq., OTR/L vedacollmer@gmail.com Heather Boysel, Esq., Gammage and Burnham hboysel@gblaw.com 15