Long Term Care Updates and Documentation
Strategies
Tina Young, MSOT, OTR/L
Older Adult MSG
May 2010

Objectives
• Introduction to the upcoming changes:
RAC, MDS 3.0 and RUGS IV
How they will affect OT practice?
• Documentation strategies with emphasis on the therapist rather than the client:
Medical necessity, skilled services, measurable progress/goals, coding and more

Goals
• Therapists will be able to state 2 upcoming changes in October 2010
• Therapists will be able to document better utilizing at least 5 strategies to prevent/minimize
Medicare denials and improve our clinical practices
• Therapists will understand the impact of our documentation on coverage and denials, protection of our skilled profession
• Therapists will realize documentation is about the therapists’ skills, not just the client’s progress

Long Term Care
Changes
• RAC
Recovery Audit Contractors
Contracted through CMS
Post payment review, identify improper overpayments after Oct 1, 2007
All providers are eligible to be audited, bills to
Medicare Part A and B
Collected over $1Billion in 3 years

Long Term Care
Changes
• RAC continued
Demand letters are sent to Medical Records, if you don’t respond, expect 100% denial of claim
They will apply the knowledge of Medicare rules and regulations to validate denials after reviewing the documentation
They will take $ back!!!!

Long Term Care
Changes
• RAC continued
Documentation can only use approved JCAHO abbreviations
2014 all documentation must be electronic nationwide
Claims could be for illegibility or incorrectly spelled words

Long Term Care
Changes
• RAC continued
Recommendations to consider:
Each goal should have own attainment date
Avoid “as per plan of care” and “patient tolerating tx well”
Emphasize OTR/OTA collaboration, OTA should not document changes in plan of care or emphasis on…. without “collaboration with OTR”

Long Term Care
Changes
• RAC continued
Transfer services from PRN therapists on evals
Errors procedure must include: single line through item, word “error”, initials and date on each entry

Long Term Care
Changes
• RAC continued
“OT evaluations can be denied if the following are not routinely noted on evals: Physiological status, cognitive baseline with a specific tool(s), communication status, specific testing of biom. measures. But due to the abbrev. ruling, such standard reporting as MMT cannot be reported in the abbrev., must be "manual muscle testing is
4/5 "(and then each assessment be interpreted),
"indicating good muscle strength in order to support use of bilat UE in push off from toilet, bed"
J. Winland’s AOTA CEU

Long Term Care
Changes
• MDS 3.0
CMS will adjust computations of ADLs,
Eliminate section T of MDS (projections),
OMRAs will be 1-3 days after therapy discharge (vs. 8-10 days)
Beginning after October 2010

Long Term Care
Changes
• RUGS IV
Beginning October 2010
66 RUGS (vs. 53)- new categories
Modify the hospital “look-back”
Update case-mix weights, nursing and therapy
Change in coding therapy minutes on the
MDS i.e. concurrent/group/individual

Long Term Care
Changes
• RUGS IV continued
Nursing will have more brief interview section for cognition (MMSE)
SLP will document signs/symptoms of swallowing deficits

Long Term Care
Changes
• Extension of Cap most likely beyond 12/31/10 deadline
• Section 6121 mandates dementia care and abuse training for all SNF employees by 3/2011
• Incentives for prevention and wellness
• Monitor readmissions to hospitals 1/2013
• CLASS Program developed rollout 2012

Long Term Care
Changes
• What do these 3 changes mean?

Medicare Denials/Audit
Process
• Appeal process:
Shortened time frame to appeal generally
Within 120 days of receiving the initial determination denial to pay the claim found on
MSN (Medicare Summary Notice), send a request for redetermination with all the documentation requested in the MSN and additional documentation that supports skilled therapy services such as: eval, treatment record, progress notes, discharge summary, orders nursing notes and physician signed POC

Medicare Denials/Audit
Process
Then you can appeal again with a reconsideration request, which is reviewed by a qualified independent contractor other than your
Medicare payer, send documents and letter
The third level of appeal is conducted by an administrative law judge, minimum of $110 in controversy
The fourth level of appeal is the Medicare appeals Council, only if there was an error in the law or the case is a question of policy or procedure, minimum of $1090 controversy

Medicare Denials/Audit
Process
• Recommendations:
Respond timely to denials
Respond to ALL Medicare denials
Prepare documentation/clinician to reduce denials as best defense (hone our documentation skills)
All clinicians should be educated and understand the proper coding and essential documentation policies

Medicare Denials/Audit
Process
• Do NOT assume that the medical reviewer understands the level of sophistication of our skilled services.
• Use materials to support the services that you are providing are within your profession, standards, guidelines, specialized knowledge and skills papers and evidences-based practice resources

Medicare Denials/Audit
Process
To Ensure Payment
• Paint a Picture of the Patient with content not fluff
• Be specific, clear and concise
• Don’t write defer/refer to…..
• Don’t leave blanks
• Ask a therapist “can I read the note and know what to do next?”

Medicare Denials/Audit
Process
To Ensure Payment
• Don’t write NT- you didn’t test for a reason, why
• Use percentages, number of episodes
• Document severity and impact of loss on whole person
• Support reason for intensity (minutes of service)

Medicare Denials/Audit
Process
• Statements to avoid:
Tolerated treatment well (assumption unless stated otherwise)
Continue per plan of care
As above
Good/well
Cognition interferes with therapy

Medicare Denials/Audit
Process
• Cognitive Aspects:
Document skills of a therapist with education given, visual cues, establish compensatory strategies for safe return to…, able to recall…..spaced retrieval cues, use adaptations/compensatory strategies, strategies to reduce behaviors, address deficits that lead to functional loss, caregiver feedback, address the patient’s need for the goal

Medicare Denials/Audit
Process
• Addressing group therapy documentation
Reason why for group, write clinical benefits, group addressed…… to improve…….

Medicare Denials/Audit
Process
• My recent experience with ADRs:
Dementia diagnoses are most common
Lack of cognitive scores
UI treatment
Lack of sufficient prior level status on evals
Continuing goals met, lack of progress for a reviewer (in the
FIMS section of notes)
Group code, GO283 code, abbreviations, lack of supportive documentation from physician and nursing, where did referral come from

Relevant Transmittals that affect Documentation and denials
Transmittal #63-documentation needs to be measurable and asks for functional assessment scores
Recommend standardized test scores on evaluations and progress notes
Show baseline and improvement correlated with function (what does the score mean?)

Relevant Transmittals that affect Documentation and denials
• Transmittal #262
3 requirements for Medicare Coverage eligibility, MUST be met:
Ordered service by a physician
A skilled service is provided on a daily basis
Service is reasonable and necessary

Relevant Transmittals that affect Documentation and denials
• Transmittal #262 continued
Dementia clients can make progress
Allowed us to treat clients to their highest level

Relevant Transmittals that affect Documentation and denials
• Transmittal #262 continued
Stress remaining abilities that can be capitalized versus barriers d/t cognition
Cognitive recall is not necessary to participate in this plan of care nor necessary for skilled intervention

Documentation: Focus is
YOU
• Standardized tests
• Medical necessity and correlation to function
• Skilled services
• Referral from who, supportive documentation
• Physician order and certification
• Expectation of
Improvement
• Goals-reasonable, predictable period of time
• Medical complexities
• Prior level
• Supervision/cosignatures
• Measurable
• Coding: ICD-9 and
CPT

Documentation: Focus is
YOU
Need to answer in your documentation:
Why should YOU be involved?
What did YOU do?
Did YOU analyze and adjust POC?
Did YOU say that?
Why are you needed (skills) vs. CNA”?

Documentation: Focus is
YOU
• Initial Evaluation:
Document functional performance prior level and current level, standardized tests and relation to function (interpretation or analysis), all applicable medical diagnoses, ICD-9 codes, precautions, contraindications, specific problem areas being evaluated- body part,

Documentation: Focus is
YOU
• Initial Evaluation:
Qualifications of a therapist needed to provide intervention, pertinent medical or therapy history to determine degree of functional loss, reason for referral-why evaluating

Documentation: Focus is
YOU
• Reasons for referral:
Identify DME needed, identify number of medications, how mental/cognitive disorders impact the rate of recovery, cause of condition, symptoms, other health services concurrently being provided (dietitian, social services, nursing, hospital or physician consultations

Documentation: Focus is
YOU
• If you don’t document the reason for the referral, it can be denied as not medically necessary, we should discuss referral sources’ comments in our documentation to support our claim

Documentation: Focus is
YOU
• Evaluations are extremely important since 2/3 of denials are based on medical and skilled necessity
• Document how to link medical diagnoses to functional changes, why have therapy?, medical dx alone doesn’t say what we are doing for the patient
• Age, severity, time of onset
• Expectation of improvement

Documentation: Focus is
YOU
• Add social, psychological and medical stability, motivation, acuity of condition, prognosis, complexity of condition, explain why progress may be slower secondary to medical conditions and co morbidities, patient self report

Documentation: Focus is
YOU
• Medicare recommends we use tests and measures published in research: KELS,
Dynamometer, Functional Reach Test,
MMT, RPE (rating of perceived exertion), goniometric ROM, TUG, BERG, ACL,
CPT

Documentation: Focus is
YOU
• Explain results of tests: i.e. MMT below 3/5, patient is unable to utilize
UE for feeding successfully without assistance or would be unable to assist with bathroom transfers

Documentation: Focus is
YOU
• If no standardized tests used,
Medicare recommends functional progress towards goals which is the standard independence scale that we use most often.

Documentation: Focus is
YOU
• Last option if not using standardized tests per Medicare:
“Ask the client- at the present time, would you say that your health is excellent, very good, fair or poor?” Document the response at eval and discharge.

Documentation: Focus is
YOU
• ICD-9
Choose a code that is close as possible to a 5 digit number = highest level of specificity
Main function of codes is to set up screens or filters for medical review, a diagnosis may be used as an item in a medical review
They are updated October 1 st each year
Rehab diagnosis is the impairment based diagnosis relevant to the problem to be treated.

Documentation: Focus is
YOU
• ICD-9
• Try to use exception codes and complicating Co morbidities (CC) codes, they will qualify a client for caps and exceptions
• Be sure to include all of the applicable codes
• Some instances the medical diagnosis has an inherent correlation to rehab services i.e. MS
• Some diagnosis is associated with the medical diagnosis i.e. CVA

Documentation: Focus is
YOU
• ICD-9
• V codes are allowed such as
V43.64 THR
V43.65 TKR
V49.75 BKA
V 49.66 AEA

Documentation: Focus is
YOU
• POC (Plan of Care)
Document necessity of therapy with: client self reporting, goals, treatment intensity/frequency/duration, certified POC with physician signature in 30 treatment days, identifies procedures and modalities used, outcomes/goals must be measurable/realistic/time limited, potential to return to premorbid status, include discharge criteria and follow up care

Documentation: Focus is
YOU
• POC (Plan of Care) continued
Document intervention requires complex skill level by a clinician
Outcome measures and intervention need to change if there is limited change in function
Changing of LTG and dates need to have justification documented

Documentation: Focus is
YOU
• Goals Criteria for being measurable:
1 Performance- client focused, objective, observable behavior
(Who/What)
2 Criteria- degree to measure outcome (quality of action)
3 Conditions- when, where, with whom and under what circumstances
4 Time Frame- date, when

Documentation: Focus is
YOU
• POC (Plan of Care) continued
Outcome measures need to have a baseline of function to measure change
Standardized test scores alone are not functional performance related to occupation
Outcomes need to be measurable and client centered (not written like: therapist will do….)

Documentation: Focus is
YOU
• Terminology to Avoid
Slow progress, little progress noted, patient agitated or confused, unable to learn, disoriented to time and place, poor attention span, no problems noted, little hope for progress

Documentation: Focus is
YOU
• Suggested terminology
Redirected patient behavior, individualized training program to maximize performance, customized treatment approach to match condition of patient, techniques to teach new skill added to program, condition continues to require skilled services, deficits continue to compromise safety, positive results with safety issues addressed

Documentation: Focus is
YOU
• Treatment Encounter Notes
Identify the daily skilled treatment activities and daily modalities provided, identify the professional daily providing the service, use
CPT codes that match the treatment providedtimed and untimed codes, the note is the justification for the billing doe on the claim,
Medicare assumes the client tolerated the treatment unless there is documentation stating otherwise, client’s response to intervention is a good idea

Documentation: Focus is
YOU
• Treatment Encounter Notes continued
Document consistent units and timed treatment minutes on the claim
Document change in frequency and intensity of treatment from the POC
Document change in skilled treatment activities or modalities (added/deleted) between progress notes

Documentation: Focus is
YOU
• CPT Coding
Selection of code is based on -skills required
Skills required= technical skills physical effort intent of service desired outcome mental effort and judgment risks involved if it could go wrong

Documentation: Focus is
YOU
• CPT Coding
Consider which service is more intricate, intense and/or highly skilled

Documentation: Focus is
YOU
• CPT Coding
Descriptions given for each code but it is up to the interpretation of the clinician
Recommend consistency in methods and practices in addition to how to define or explain intent

Documentation: Focus is
YOU
• Progress Notes/Reports
Summarized the intervention and provides justification for medical necessity, current functional performance from previous performance, progress towards outcomes for each goal objectively/measurable/describe changes in treatment care, identify additions/deletions/changes to the expected outcome and client’s response to changes, revisions to POC

Documentation: Focus is
YOU
• Progress Notes/Reports continued
Document specialized skills used by the clinician to validate medical necessity
Document current status in relation to functional goals
Document need for intensity of therapy for functional outcome
Document changes of skilled services if different than the original POC (additions/deletions) and explain the clinician’s reasoning

Documentation: Focus is
YOU
• Progress Notes/Reports continued
Identify the body part when documenting therapeutic exercises or identify activity when billing for therapeutic activities
Describe type of group activity in the progress note if billing group therapy for
Medicare Part B

Documentation: Focus is
YOU
• Discharge summaries:
Document changes from the entire care to justify medical necessity, including if services were extended beyond the customary length of time, summarize progress in client’s ability to engage in functional occupational activities, recommendations for future needs, follow up plans and referral information

Documentation: Focus is
YOU
• Discharge summaries:
Document progress toward goals in the summary
Document appropriate carry over training to client or caregiver
Document medical necessity for the interventions used
Document clear skilled progress from last note to discharge i.e. 1/31 to 2/5

Documentation: Focus is
YOU
• Cognition Aspects:
Document deficits lead to functional loss such as disorientation and memory loss
Caregiver feedback, education given
Interventions: visual cues, distractions, strategies to reduce behaviors, able to recall __ spaced retrieval cues, use compensatory strategies for safe return to__ or use calendar for __

Documentation: Focus is
YOU
• Cognition Aspects:
Document how you are addressing impaired cognition that is affecting __
Skills of a therapist or needs OT for __
Determine if the patient has a need for the goal

Documentation: Focus is
YOU
• Cognition Aspects:
Example: if __cue is not used, the client’s success rate drops to __.
__cues enhance ADL task, allowing percentage of function/independence .

Documentation: Focus is
YOU
• Group Therapy
Document why chose group therapy
Write clinical benefits
“Group addressed…… to improve……”

Documentation: Focus is
YOU
• General things to consider when treating and then documenting:
Use percentages
Describe level of functioning
Speed of response/response latency
Appropriateness of response
Describe successive approximations
HCR CEU 2010

Documentation: Focus is
YOU
• General things to consider when treating and then documenting:
Number of episodes/occurrences
Physiological variations in the activity
What happened when you did what you did with the patient?
Why is that change significant from a functional point of view?
HCR CEU 2010

Documentation: Focus is
YOU
• General things to consider when treating and then documenting:
Knowing that change occurred, what will you do now?
What would you do more of?
What would you do less of?
What would you do differently?
HCR CEU 2010

Documentation: Focus is
YOU
Consider every note having:
 Statement of some progress
 Types of modalities provided and why
 Potential for future progress
 Plan for following week
 Use quotes from protocols and regulations
 Use standardized tests

Documentation: Focus is
YOU
Consider every note having:
 Strengths
 Barriers to discharge or complicating factors
 Goals not met- why
 Teaching provided

Documentation: Focus is
YOU
• Tips:
Document with client present
Consider carryover effect
Break mindset that treatment is more important “I could be treating other patients”
Our jobs depend on our documentation
Our clients depend on our documentation

Documentation: Focus is
YOU
• Example
Mr. Smith demonstrates left sided neglect and left sided visual deficits secondary to recent CVA.
Mr. Smith continues to have decreased oral intake secondary to left sided neglect and left sided visual deficits. Weight loss will result since foods and liquids to the left are not consumed.

Documentation: Focus is
YOU
• Example
Mrs. Smith demonstrates poor posture while seated out of bed in her wheelchair.
Mrs. Smith demonstrates skin tears and poor positioning of flaccid arm found behind her, sitting on it and entangled with the wheelchair itself. Mrs. Smith will demonstrate ability to maintain neutral position for __increments with
__adaptations for __sessions.

Resources
• OOTA CEUs, Board meetings and Older Adult
MSG Roundtable discussions
• Monica Robinson’s many CEUs
• OT Practice 12(2) February 2007
• OT Practice August 14, 2006
• HCR’s many CEUs and related trainings
• Ohio Health employee education
• Jan Winland’s AOTA CEU update 2010