Presented by Pauline M. Franko, PT, CEEAA FPTA Conference ... · Pauline M. Franko, PT, CEEAA FL...

Presented by

Pauline M. Franko, PT, CEEAA

FPTA Conference

Friday, September 12th 2014

Presenter:

Pauline M. Franko, PT, CEEAA FL License # 3174

Pauline is president and CEO of Encompass Consulting & Education, LLC created in

2014. She also authors the “Medicare Advisor” columns for the Advance for Physical

Therapists and Rehabilitation Medicine newsmagazine.

She graduated from Physiotherapy School in Coventry, England in 1966 and came to

the US in 1980. Her experience has always been in the area of geriatrics, including SNF,

Home Health, CORF and long term care rehabilitation administration. During her time

as a Regional Manager for a Long Term Care Company she became interested in the

area of Medicare Compliance. Pauline and another physical therapist, Danna D. Mullins

PT, MPT, established Encompass Education Inc. in 1999 to educate therapists on the

rules and regulations for Medicare Compliance. During this time she also became the

Director of Medicare Compliance and Education for a CORF In May 2004 that

Encompass Education was dissolved and Pauline established Encompass Consulting &

Education LLC.

In 2011 she was Certified as an Exercise Expert for the Aging Adult by the APTA. As

well as presenting seminars and webinars for Encompass, she has presented nationwide

including the annual conference of the APTA and State Associations as well as for other

therapy organizations.

Encompass Consulting & Education, LLC © 2014 1

Welcome to Surviving a Manual Medical Review

OBJECTIVES

1. Describe the four categories of non-

compliance that can lead to a denial

2. Distinguish between the different types of

Medical Review and who performs them

3. Define Medicare's Medical Necessity

Requirements for therapy services

4. Understand the top reasons for denials and

identify areas of their practice that need revision

THE WHAT IS:

Hands-on review of copies of the medical

record and other relevant documentation by a

qualified medical professional

Contractor sends an Additional Documentation

Request (ADR)

Identifies what documentation required and

what date due

Timeframe varies by contractor type

THE WHY IS:

“To determine if claims submitted for

payment were billed in compliance with

Medicare Regulations for that particular site

of service”

In Medicare’s other words - Was the claim

billed in “error”?

AN ERROR OCCURS WHEN THE

SERVICES PROVIDED:

Are excluded by Medicare

Do not meet the benefit category

Not billed in compliance with LCD or NCD

Are not reasonable and necessary

EXCLUDED BY MEDICARE

PT, OT and SLP are Medicare covered services in all sites of service:

• Acute: Hospitals

• Post-acute: SNF and Home Health

• Part B in hospital and other settings

Part B is a capitated service and can become an excluded benefit

NOT A BENEFIT CATEGORY

Each site of service has “Conditions of Coverage” criteria which must be met for payment.

Once beneficiary does not meet the requirements for coverage, it becomes a non-covered benefit category for that site


Conditions of Coverage

CONDITIONS OF COVERAGE -

TECHNICAL COMPONENTS

Must be met or the

claim will be denied

AND

is non-appealable

Medicare beneficiary with usable days

Qualifying 3 days hospital stay

Admitted to within 30 days from hospital D/C

Certification and Recertification by

Physician or NPP for the need of the stay

TECHNICAL COMPONENTS FOR PART

A SNF

Beneficiary must be confined to the home

Under the care of a physician

Receiving services under a POC

established and periodically reviewed by a

physician

TECHNICAL COMPONENTS FOR A

HOME HEALTH AGENCY

CONDITIONS OF COVERAGE -

CLINICAL COMPONENT

Each Part A provider setting

has different criteria

Always the same criteria for

Therapy whether A or B

1. CONDITION TREATED IN

HOSPITAL

Services are provided for a condition treated in hospital or occurred during SNF care for that condition

“In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiary’s admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.”

IOM Pub 100-02 Chapter 8 (Rev. 161, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)

2. DAILY SKILLED SERVICES

Needs and receives daily skilled nursing and

/ or rehab (at least 5 separate days of rehab

services)

“However, arbitrarily staggering the timing

of various therapy modalities though the

week, merely in order to have some type of

therapy session occur each day, would not

satisfy the SNF coverage requirement for

skilled care to be needed on a “daily basis.”


3. INPATIENT BASIS AS A

“PRACTICAL MATTER”

Only available in SNF if not available in the

area the resident resides or transportation

to the nearest facility would:

Be an excessive hardship

Less economical

Less efficient or effective than the SNF

PRACTICAL MATTER

As a Practical Matter can only be provided on inpatient basis

“This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.”

In need of skilled nursing care on an

intermittent basis

and / or PT

and / or SLP

or

Have a continuing need for OT

HOME HEALTH CLINICAL

COMPONENT

TECHNICAL COMPONENT OF

PART B THERAPY SERVICES

Physician

Certification of

Need

IOM Pub. 100-02, Benefit Manual:

§220.1.3

METHOD AND DISPOSITION

OF CERTIFICATIONS

Certification Requires:

A dated signature on the plan

Or

Some other document that indicates

approval of the plan

The date is required to determine if the

certification is timely!

TIMELY CERTIFICATIONS

The plan is reviewed and approved by the

Physician or Non Physician Practitioner

(NPP) within 30 days from the initial

treatment/evaluation

Physician Certification satisfies all

certification requirements for the

a) duration of the plan or

b) 90 calendar days from the initial treatment

whichever is less


Medical Necessity

DELAYED CERTIFICATION

IOM Pub. 100-02, Benefit Manual: §220.1.3D

Delayed Certification:

Delayed certification/recertification shall be

deemed satisfied where, at any later date,

a physician/NPP makes a certification

accompanied

by a reason for the delay.

NOT BILLED IN COMPLIANCE WITH

NCD & LCDS

CMS publishes NCDs of services they will not cover, e.g. Anodyne therapy

Medicare Administrative Contractors (MACs) publish their own LCDs

LCDs are contractor specific

Provider must follow guidelines or claim can be denied

NOT REASONABLE AND

NECESSARY

Guidelines apply to all sites of service

Must be clearly identified in documentation

If not, claim WILL BE denied


Medical Record Reviewers

“MEDICAL NECESSITY” DOES

NOT OCCUR WHEN

A pt suffers a transient and easily reversible

loss or reduction of function (e.g. temporary

weakness which may follow a brief period of

bed rest following abdominal surgery) which

could reasonably be expected to improve

spontaneously as pt gradually resumes

normal activities.

ZONE PROGRAM INTEGRITY

CONTRACTORS: ZPICS

Work with specific MACS

Responsible for monitoring all

Federal Programs

Became most aggressive

contractor

Performing reviews in States

with high level of fraud and

abuse

MEDICARE ADMINISTRATION

Department of Health & Human Service

Centers for Medicare & Medicaid

Contractors

• Medicare Administrative Contractors

• Safeguard contractors

A/B MAC RESPONSIBILITIES

Also Responsible

for

Provider enrollment

Level 1 appeals

Outreach &

Education

Reimbursement

Medical Review

LCD

Receive, Process & Pay Medicare A and B claims

SAFEGUARD CONTRACTORS

RESPONSIBILITIES:

Fraud Detection

and Prevention

Data Mining and

Analysis

Manual Medical Review

RECOVERY AUDITORS: RACS

Professional Collection Companies

4 Contractors cover 4 separate regions

Paid on % of monies recouped

Predominately focused on Hospital and Physician claims

Effective April 1st, became sole review source for Manual Medical Review above the $3700 threshold


Types of Medical Review

COMPREHENSIVE ERROR RATE

TESTING CONTRACTORS: CERT

Perform random post-pay reviews

Monitors: All providers, suppliers and practitioners

MACs

CMS

Report directly back to MACs on common review denials in their region

Publish an Annual Report

SUPPLEMENTAL REVIEW

CONTRACTOR – THE NEW KID

Strategic Health Solutions: works for CMS

assisting MLN produce easy to understand

information

Now also performing MMR as instructed by

CMS

Reviewing OPT claims between 7/12 & 3/13

Focus: therapy stopped or delayed prior to

reaching the $3700 cap

TYPES OF MEDICAL REVIEW

Pre-pay or Post-pay Review

Simple

Automatic

Complex/MMR

Probe

GlobalProvider Specific

Random

SIMPLE REVIEWS

Claims Review

Looking for inappropriate charges

• Billing more than 1 unit for non-time sensitive codes

• Billing multiple re-evaluation codes

Review may lead to a complex review

PROBE REVIEWS

Developed on analysis of patterns of claims

Normal Practice Patterns

Yours Statewide National

Notification letter not required

Notification letter required

GLOBAL PROBE VS PROVIDER

PROBE

General probe of

several providers

Limited to 100

claims per review

Initially 20 to 40

claims reviewed

Individual provider

issue

Global Probe Provider Probe

Error rate and prior history will determine

next level of review


PROBE REVIEWS

Any aberrances from the norm

Potential areas of over-utilization

Use of high paying CPT or RUG codes

Length of Stay

Patterns of non-covered care

Use of ICD-9 codes –especially V-codes

Use of KX modifier

PRE-PAY MEDICAL REVIEW

Ending the pay & chase

Using sophisticated

“Data Mining” tools

Becoming preferred method of review in

some states

THRESHOLD REVIEWS

CMS assigned the RACs to perform these reviews

Current RAC contracts are up for review

February 28th last day for ADRs

Claims from March 1st on hold

August 4th CMS awarded restricted contracts to current RACs to start limited MMRs

Therapy Services included

PART B CAP-SPECIFIC MMR

HIGH FRAUD RATE

FL

CA

MI

TX

NY

LO

IL

SHORT STAYS

PA

OH

NC

MO

SEQUENCE

Claim received by MAC

MAC issues ADR

Records sent to

RAC

RAC reviews in 10

business days or less

RAC sends findings to MAC, letter to provider

MAC Adjudicate response

PROGRESSIVE CORRECTIVE

ACTION - PCA

Data Collection

and Analysis

Medical Review

of Claims

Provider Education on

Requirements for Payment


OVERALL REVIEW PROCESS

ADR sent

Provider sends documentation

Documentation checked for completeness

Reviewed for accuracy of items billed

Reviewed for medical necessity

Provider Notified of negative findings

IMMEDIATE DENIALS

Documentation does not arrive timely

• Timeframe identified on ADR

Insufficient documentation

Documentation is illegible

• Reviewer cannot read it

• Reviewer cannot understand it

Signatures are illegible

ACCEPTABLE SIGNATURES

Hand written signatures

Electronic signatures

Signature Log

BUT NEVER a stamped signature

LEGIBLE SIGNATURES ARE

Legible full signature

Legible first initial and full last name

Initials placed above a typed or printed name

Illegible signature placed above a typed or

printed name

Illegible signature where other information on

the page identifies signor

Illegible signature accompanied by a signature

log

REVIEW CONSIDERATIONS - SNF

Do Diagnosis(es) support use of therapy

Do: Dates billed support skilled days used

Does: Documentation support RUG(s) billed

Does: Documentation support Medical Necessity for Site of Service

REVIEW CONSIDERATIONS –

PART B

Does: Diagnoses support therapy intervention

Do: Dates of treatment match claim

Are: CPT codes supported by documentation

Do: Units billed match time documented

Are: Modifiers used appropriate

Does: Documentation support Medical Necessity


Progressive Corrective Action

WHAT HAS BEEN LEARNED

FROM MMR

The regulations

are standard

The reviewers

interpretations

are NOT

CERT CONTRACTOR

Insufficient Documentation

Did not arrive in time

Was illegible

No documentation for date of service

Too many abbreviation for reviewer to understand

Services Coded Incorrectly

Units billed not substantiated by documentation

Documentation does not support skilled treatment

(interventions not clearly identified to support codes billed)


Reasons for Denials

CERT CONTRACTOR

Medically Unnecessary Services

Treatment provided not supported by Plan

No documentation of physician approval of Plan

Treatment provided after last day approved by physician

Documentation appears repetitious with no change in

treatment

No documentation of progress in a reasonable period of time

Duplication of services

CAP THRESHOLD DENIALS

Not submitting therapy records

No POC or evidence of physician approval

(certification)

Goals not measurable

Services maintenance in nature

Already having lots of time in therapy

CAP THRESHOLD DENIALS

Inadequate prior level of function

Documentation missing elements to substantiate

medical necessity for additional services

Unable to determine functional deficit

NOTIFICATIONS FROM A RAC

“Review of Medical Record does not show

sufficient documentation supporting services

provided and medical necessity for therapy

amount, frequency & duration of physical

therapy services delivered on XX for code

97140”

“

NOTIFICATIONS FROM A RAC

“Documentation … insufficient in identifying

rationale for use of manual therapy

intervention….does not indicate…patient

response to treatment or benefits obtained

to support the use of this procedure”

NOTIFICATIONS FROM RACS

“Documentation supports….provision of

repetitive exercises and functional activities

with no clear complexity of service that

indicate a need for ongoing skilled clinician care

or input, no verbal tactile cueing was noted”


Documenting Skilled Therapy


“Documentation indicates the same exercises

and/or functional activities are being

performed daily with no clear complexity of

services that indicate the need for ongoing

skilled clinician input, i.e. no ongoing

progressive instruction or verbal/tactile

cueing was noted.


“The professional skills of a therapist are not

required to improve or restore full function

that could reasonably be expected to

improve as the patient gradually resumes

normal activities. There are no additional

medical complexities noted that would inhibit

the patient from progressing on her own.”


“Medical record does not show sufficient

documentation supporting the services provided for

XXX for CPT codes 97110, GO283 and 97140. The

patient has been seen for 3 months after shoulder

surgery. At the time of review the patient continues to

have ongoing functional difficulties including

reaching items in cupboard, donning seatbelt etc.

The patient has made little progress especially in the

last month. There is no change in the POC or focus

on the specific activities she is having difficulty

with. The exercise and treatment plan are repetitive

with no change especially when progress seems to

have slowed or plateaued.”


“Additional documentation is needing regarding why a clinician was required to provide the care or reasoning behind the decline that would warrant skilled care.

Documentation for an exception should indicate how the patient’s medical complexity directly and significantly affects the treatment for a therapy condition and the medical necessity of ongoing care. Services that exceed those typically billed should be carefully documented.

In summary the medical record does not show sufficient documentation to support the services provided and medically necessary for the physical therapy services on XXX for 97110, GO283 and 97140.”

SURVIVAL TACTICS:

Documenting Skilled Therapy

Work on Quality of

Documentation

MANDATORY

DOCUMENTATION

Part A:

Very few guidelines

Identified in Code of Federal Regulations

Standardized by industry practice

Part B:

Extremely specific guidelines

Identified in CMS IOM Pub.100-02, Chapter 15

Completely updated in 2005 with updates in 2007, 2009 and 2013


MANDATORY DOCUMENTATION

Evaluation and Plan of Care / Treatment

(Can be 1 document or 2 separate

documents)

Evidence a physician / NPP has reviewed and

approved the plan (certification)

Daily documentation to support time billed and

skilled services provided

Progress Reports and Discharge Note

USE OF TEMPLATES IN PROGRESS

NOTES

March 2013: CMS updated IOM 100-08 -

Program Integrity Manual - to clarify what

reviewers will consider during Manual

Medical Review

Chapter 3: §3.3.2.1 - Documents on Which to

Base a Determination addresses use of

templates in progress notes.

CHANGE REQUEST 8033

CMS does not prohibit use of templates to

facilitate record-keeping

CMS does not endorse or approve any particular

templates

Some templates provide limited options and/or

space for collection of information such as using

“check boxes,” predefined answers, limited

space to enter information, etc.

CMS discourages the use of such templates

CHANGE REQUEST 8033

Claim review experience shows that limited

space templates often fail to capture sufficient

detailed clinical information to demonstrate

that all coverage and coding requirements are

met:

Templates designed to gather selected

information focused primarily for

reimbursement purposes are often insufficient

to demonstrate that all coverage and coding

requirements are met

CHANGE REQUEST 8033

This is often because these documents generally

do not provide sufficient information to

adequately show that the medical necessity

criteria for the item/service are met

When choosing to use a template during patient

visit, CMS encourages selection of one that

allows for a full and complete collection of

information to demonstrate that applicable

coverage and coding criteria are met

SKILL DIFFERENCES BETWEEN PART

A AND PART B

Remember! Only difference between A and B is the Conditions of Coverage

Documentation focuses on

SNF A: Medical necessity of services supporting need for treatment 5 or more day a week

Part B: Medical necessity of services supporting a need for treatment

For Both: Identification of skilled services that cannot be provided by family or caregiver


Connecting the Dots - Evaluation

COLOR LEGEND

Level of Function / LTG / DC plans

Impairment

Diagnoses / Complexity

Tests and Measures

Treatment Interventions / Skilled therapy

Information

THE REVIEWER NEEDS TO SEE

Prior

Function

Change

Impairments

Tests &

Measures

Skilled

Therapy

Return

ANSWERS THE QUESTION

Is there a problem?

Evaluation:

EVALUATION ESTABLISHES

Current Level of Function < Prior Level of

Function

Patient History including: Current Medical and Psychosocial History as well as Relevant Medications

Impairments quantified by Tests and Measures leading to an Impairment based Treatment Diagnosis and Onset Date

Discharge Plan


CLOF AT START OF CARE

Current Level of

Function

answer the

question

“Why are you

here?”

PLOF AT START OF CARE

Prior Level of Function

answers the

questions

What were you able to do that you

can’t do now ?”

How long ago since you did it?

(onset date)

WARNING!

Reviewers are looking at prior level of function more intensely to determine the medical necessity of treatment

The more complete the better!

PSYCHOSOCIAL HISTORY

Where does the patient live?

What barriers are within the home?

Who do they live with?

What responsibilities do they have?

Do they have any one to help them?

MEDICAL HISTORY

CHF / COPD

Obesity

Osteoporosis

Diabetes

Alzheimer's Disease

Renal Failure

Hearing loss

Chronic Wounds

Malnutrition

Vestibular disorders

Depression

Rheumatoid Arthritis

Glaucoma and Low Vision

Cancer

Co-morbidities / Complexities that impact

on and are pertinent to the Plan of Care

MEDICAL HISTORY

What treatment has been done by physician?

Actual treatments (surgery, various medication

changes)

X-rays, CAT scans or MRIs

Lab work results


Impairments & Measurements

RELEVANT MEDICATIONS

What medication is the patient taking?

Prescribed

(Additional For Part B)

Over the counter

Herbal medication or

supplements

Non-prescribed!!!!!!!!

MEDICAL HISTORY

What Rx has been done by therapy for same or

other conditions

Hospital

SNF

HHA

Other Part B therapies

Your therapy department

What’s causing the

problem?

Impairments and

Measurements:


Impairments

Quantify impairments

Identify impairments

Treat impairments

Restore or Improve Function

OBJECTIVE TESTS AND

MEASURES

Must quantify identified impairment(s) to be

treated as well as co-morbidities/complexities

affecting POT

Use accepted standardized tests and measures and /

or

Use functional assessment scores with

subjective patient self report

Use patient questionnaires

SURVIVAL TACTICS:

All relevant impairments must have an

objective test, measure or assessment to

quantify them

Treatment strategies must relate to

impairments identified as a result of the

diagnosis and/or condition and/or

complexity


Connecting the Dots – Plan of Care

What am I going to do

about it?

Plan of Care:


DOCUMENTATION REQUIREMENTS

CFR §424.24, 410.61

Plan shall contain at a minimum:

• Diagnosis;

• Long term treatment goals; and

• Type, amount, duration and frequency of

therapy services

INTERVENTIONS, PROCEDURES,

TECHNIQUES

Identify skilled services therapist will provide

They are NOT CPT codes or code descriptors

When clearly defined in the plan, do not have to be repeated each time in the daily note

e.g. parameters of a modality – e-stim to paraspinals L1 thru L5 for 15 minutes at X intensity to increase circulation & decrease pain

INTERVENTIONS, PROCEDURES,

TECHNIQUES

Are specific treatment strategies

Along with the specific areas / body part to be treated (joints; muscle groups etc.)

Must: Correlate with the impairments identified in the evaluation

e.g. stretchings & soft tissue mobilization techniques to L knee joint to reduce muscle spasms and pain and increase mobility

TYPES OF GOALS

Long Term Functional Goals:

Final outcome level

Short Term Goals:

Stepping stones to LTG

Impairment Goals:

Therapist’s treatment objectives

Diagnoses! Different meanings

for different circumstances

Coding / Billing

(ICD-9 codes)

Medical

Review

Criteria

(IOM Manuals

and LCD)

Medicare

Documentation

(condition being

treated)


DIAGNOSIS FOR DOCUMENTATION

Is: The condition for which you are rendering

skilled therapy services

Can be: Description of the specific problem be

evaluated / treated (impairment based

treatment diagnosis)

May: Include medical diagnosis provided by

the physician

Is not: An ICD-9 code

DIAGNOSIS FOR CODING / BILLING

First listed diagnosis on the claim form:

Is: The ICD- 9 code that is chiefly responsible

for the services provided.

Can: Be symptom, sign or ill-defined condition

Can: Be a V-code

Other diagnoses on the claim

Are: Treatment diagnoses / conditions /

complexities that impact on the POT

DIAGNOSIS FOR MEDICAL REVIEW

ICD-9 code: Is not excluded through

Local Coverage Determinations (LCD)

Claim will be returned

ICD-9 code: On claim accurately

reflects documented diagnosis(es)

supporting Medical Necessity

Medical Diagnosis: (R) humeral

fracture with ORIF onset

06/01/2012

Conditions Being Treated: Painful

(R) shoulder with decreased ROM

and muscle strength, muscle

spasms resulting in reduced ability

to perform ADLs

DIAGNOSIS: WHICH ONE TO USE?

AMOUNT, FREQUENCY AND

DURATION

Must: Reasonable based on data collected

during assessment / evaluation

Clinician must: Determine appropriate levels

based on evaluation

Should: Change throughout episode based on

patient response

For POT is: Number of times per day treatment

provided, if not stated assumed to be once

Can: Be BID when appropriate (dementia

patients / severe medical conditions)

Is also: Total daily treatment provided

Should: Change throughout the episode of care

based on patient response

AMOUNT OF TREATMENT


Connecting the Dots – Daily Notes

For POT is: The number of times type of

treatment is to be provided

Part B: Can be tapered: To improve outcomes

and limit treatment time

Tapered treatments may: Result in better

outcomes, or earlier D/C than routine treatment

3 X week for 4 weeks

No requirement for: Exact number of

treatments

FREQUENCY OF TREATMENT

Require: Planned beginning and ending

frequency

e.g. “3 times a week tapered to once a

week over 6 weeks”

Changes: Should be made based on the

clinician’s assessment of daily progress

TAPERED FREQUENCY: PART B

Can: be number of days / weeks /

treatments for this specific POT or

If care anticipated to exceed 90 days

clinician can estimate entire duration in this

setting

Should never be a range

DURATION OF TREATMENT

What skilled services did

I provide and how long

did it take?

Daily Treatment Notes:

ANSWER THE QUESTION

Must: Be written for every day patient is seen

AND identify every therapy service provided

Must: Record the time of services to justify

billing codes (both RUG and CPT codes)on

claim

Format: Shall not be dictated by Contractor

AND may vary depending on responsible

clinician or clinical setting

DAILY TREATMENT NOTES

IDENTIFICATION

Patient Name

Date of treatment

Legible signature of qualified professional

with professional identification

Recommendation:

Include patient MR number or other identifier

Do not include Medicare number or other confidential information


SKILLED TREATMENT

Reviewers want to see what YOU are doing, not

just patient’s exercise log or equipment print

out

Document your actions

Your thought process

Changes you determine are necessary to

progress patient through your plan

SOME SKILLED WORDS

Analyze

Assess

Adjust

Modify

Adapt

Instruct

Upgrade

Progress

Incorporate

Redirect

Reassess

Compensatory training (specify)

Fabrication

Inhibit

Instruct in (specify)

Model

Normalized

Facilitated

Reduced

Anticipate

Training in task segmentation

SKILLED PHRASES

Transfer training:

Facilitate forward weight shift

Teach concentric/eccentric control during sit to stand

Bed Mobility

Trained pt in rolling onto unaffected side by facilitating trunk rotation

Instructed pt in log rolling technique to reduce exacerbation of muscle spasm during bed rolling & supine to sit activites

SKILLED PHRASES

Pt trained in concentric/eccentric control

during sit to stand

Pt educated in techniques to promote

forward weight shift during sit to stand

transfers

Instructed and trained pt in stepping

strategies to self-correct balance

Facilitated co-contraction during stance

phase

NON-SKILLED PHRASES

Ambulated xxx ft

Patient performed ROM exs

Patient practiced fine motor activities

Decreased physical assistance

Modalities as appropriate

Stair climbing

DOCUMENTATION FLOW FOR

PART B

Allocation of Units

What you did that was skilled

Total and Direct Treatment Time

Identification of CPT Codes


Connecting the Dots – Progress Reports

Is the treatment working and

the patient improving?

Progress Reports:

ANSWER THE

QUESTION

PROGRESS REPORTS

What the reviewer needs to see:

Evidence that skilled services have been

provide

Progress towards goals is significant in

relation to pt’s condition and co-morbidities

Changes in objective measures are

occurring in response to treatment

Has been written by the clinician and

clinician has provided at least 1 billable

treatment during the progress report period

PART A PROGRESS REPORTS

Federal statutes and CMS provide no guidelines for timing

Generally dictated by Facility Policy

Can be written by therapist or therapist assistant if State Practice Act or State statutes allows

Justify Medical Necessity of both prior and continued treatment

Legible signature with professional designation and date written (date does not have to be within the reporting period)

PART B PROGRESS REPORTS

Must: Be written by the therapist at least once

every 10th treatment day

Justify Medical Necessity of both prior and

continued treatment

Require a beginning and end date of reporting

period

Legible signature with professional

designation and date written (date does not

have to be within the reporting period)

PROGRESS REPORTS

Documentation must clearly identify:

Clinical assessment of overall progress (or

lack) towards each long term goal

Changes in objective tests / measures

(comparison with last progress report)

STGs achieved and updates established

Plans for focus of continued treatment and / or

changes made or to be made to treatment plan

PROGRESS REPORTS

Documentation must clearly identify:

Update to functional reporting and severity

codes:

If goal met and code discharged, new

functional reporting code can be established

along with severity modifier and be reported

in the next treatment note along with method

of selection


BASIS OF SKILLED PHRASES

Pt continues to demonstrate noticeable

improvement in (Function) with increase in

(objective measure) from (last measure/score) to

(current measure/score) from last report

Pt has received training / education/ instruction

in (skilled technique) but still requires (skilled

technique) due to (impairment)

BASIS OF SKILLED PHRASES

Pt has achieved STG 2c (describe goal) and

new goal STG2d (describe goal) has been

established

Skilled treatment will continue to focus on

(task performance / impairment) with

emphasis on (skilled technique / objective

measure)

LACK OF PROGRESS

Identify problems causing lack of

progress.

Modify Treatment

Assess Response

Re-evaluate if lack of progress

continues

SURVIVAL TACTICS:

Create a Compliance Program

and

Institute an Audit System to

include claims review

SURVIVAL TACTICS:

Initial Emphasis on

Legibility

Certification

Completeness of documentation

Billing Compliance

Knowing and following Medicare coverage and

billing guidelines.

Knowing and following local coverage determinations

(LCDs)

Remain aware of new / changed policies

Ensure that correct bills are

submitted

Submitting all necessary paperwork requested in

timely manner

Survival Tactics:


Physical Therapy – Skilled Documentation Examples:

Assessed energy expenditure during activities thru observation & monitoring of vital signs

and use of Borg RPE measure

Pt educated in techniques to promote adequate forward weight shift during sit to stand

transfers

Pt trained in safe manipulation of lower extremities during car transfer

Pt trained in selective movement control to reduce/eliminate LE flexion synergistic patterns

Facilitation to initiate & sustain co-contraction of quads/hamstrings

Pt assessed for and trained in functional stride length during gait

Pt trained in appropriate gait sequencing utilizing PNF patterning

Trained pt in safe maneuvering & walker placement in ambulating around obstacles

Trained pt in rolling onto unaffected side by facilitating trunk rotation

Pt trained in diaphragmatic breathing emphasizing relaxed expiration to minimize SOB during

activities

Educated and trained pt in low velocity weight shifts to develop awareness of limits of stability

Instructed and trained pt in stepping strategies to self-correct balance

Facilitated forward weight shift

Educated pt in concentric/eccentric control during sit to stand

Facilitate co-contraction during stance phase

Strengthening exercises to quads and hamstrings to facilitate transfers

Instruction in strengthening exs to bilateral quads, emphasis on achieving terminal extension

of knee and facilitation of vastus medialis thru stroking & tapping

Slow stretching (L) hamstring utilizing contract relax technique

Transfer training with emphasis on maintaining center of gravity over base during hip

extension phase

PNF patterning to bilateral LEs with emphasis on achieving knee extension with hip flexion

Observed and assessed HR, RR and RPE during training in home exercise program

Instruction in scooting forward in chair utilizing alternating hip hiking and contralateral weight

shift

Manual resisted exercises to (R) quads, utilizing quick stretch techniques

Presented by Pauline M. Franko, PT, CEEAA FPTA Conference ... · Pauline M. Franko, PT, CEEAA FL...

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Transcript of Presented by Pauline M. Franko, PT, CEEAA FPTA Conference ... · Pauline M. Franko, PT, CEEAA FL...