Documenting Rehab Services
for a Medicare Reviewer
PACAH 2015
Colleen Williams, MS, CCC-SLP, Clinical Specialist
Michelle Seeley, COTA, Director of Rehab
Jaclyn Warshauer, PT, Sr. Clinical Claims Review Specialist
OBJECTIVES
• Gain a better understanding of the medical
review process
• Recognize key pieces of documentation a
Medicare reviewer uses to make Rehab
coverage decisions
• Learn pros and cons of electronic
documentation
CMS
Medicare Claims Review Entities
-
Medicare Administrative Contractor (MAC)
-
Recovery Audit Program (RAs-formerly the RAC)
-
Supplemental Medical Review Contractor (SMRC)
-
Comprehensive Error Rate Testing Contractors (CERT)
-
Zone Program Integrity Contractor (ZPIC)
Coming in the future:
•
Unified Program Integrity Contractor
4
Medicare – From ADR to ALJ
Additional Development Request (ADR) Phase*
**An ADR Request is NOT a “Denial”
•
•
•
•
You May or May Not receive a Probe Notification Letter
You will receive an ADR Request for Medical Records
You typically have 30 days to submit
You will receive your Initial Determination Decision within
60 days if ADR is from MAC or RA; Indefinite time period
for CERT, ZPIC, or OIG.
5
Medicare – From ADR to ALJ
Level
Summary of
Review Process
Who
performs
the
Review?
When must
you request
an appeal?
When should
you get a
decision?
AIC
1st Level Redetermina
tion
Document review
of initial claim
determination
MAC
Up to 120
days after
receipt of
initial
determination
60 days
No
• Info for slides 6 – 10 taken from “Medicare Parts A and B Appeals Process”
CMS publication.
• AIC = Amount in Controversy Threshold
6
Medicare – From ADR to ALJ
Level
Summary of
Review
Process
Who
performs
the
Review?
2nd Level Reconsideration
Document
QIC
review of
redetermination
(you should
submit any
evidence not
previously
presented at
this level)
When must
you request
an appeal?
When should
you get a
decision?
AIC
Up to 180
days after
you receive
MRN/RA
60 days
No
7
Medicare – From ADR to ALJ
Level
Summary of
Review Process
Who
performs
the
Review?
When must
you request
an appeal?
When should
you get a
decision?
AIC
3rd Level –
ALJ Hearing
May be an on-therecord review or
an interactive
hearing between
parties
ALJ
Up to 60 days May be
after you
delayed due to
receive notice volume
of QIC
decision or
after
expiration of
the applicable
QIC
reconsiderati
on timeframe
if you do not
receive a
decision
Yes
8
Medicare – From ADR to ALJ
Level
Summary of
Review Process
Who
performs
the
Review?
When must
you request
an appeal?
When should
you get a
decision?
AIC
4th Level –
Medicare
Appeals
Council
Review
Document review
of ALJ’s decision
or dismissal (but
you may request
oral arguments)
Appeals
Council
Up to 60 days
after you
receive notice
of ALJ
decision or
after
expiration of
the applicable
ALJ hearing
timeframe if
you do not
receive a
decision
90 days if
appealing ALJ
decision or 180
days if ALJ
review time
expired w/o a
decision
No
9
Medicare – From ADR to ALJ
Level
Summary of
Review Process
Who
performs
the
Review?
When must
you request
an appeal?
When
should you
get a
decision?
AIC
5th Level –
Judicial
Review
Judicial review
U.S.
District
Court
Up to 60 days No statutory
after you
time limit
receive notice
of Appeals
Council
decision or
after expiration
of the
applicable
Appeals
Council review
timeframe if
you do not
receive a
decision
Yes
10
2015 Part B Therapy Cap and Therapy Threshold
• $1940 - Medicare Part B therapy cap for OT
• $1940 - The combined cap for PT and SLP
• Exceptions to the therapy cap are allowed for
reasonable and necessary therapy services by
appending the KX modifier
• Per beneficiary, services above the $3,700
threshold for PT and SLP services combined
and/or $3,700 threshold for OT services are
subject to manual medical review
11
Best Practices
- System for tracking when you are approaching $3700,
based on “burn rate” and projected therapy
- Anticipate which claims will be ADR’d
- Pro-active assignment of tasks
- Communication that ADR received and results
received
- Responsibility for assembling ADR packet
- Tracking of ADR / Appeals
12
Responding to the Part B Therapy ADR
Requests
• Have a system to assign accountability for
assembling the ADR packet:
•
•
•
•
Who will print the signed orders (as applicable)
Who will make a copy of the signed physician certification
Who will print the therapy medical records
Who will review the physician and nursing notes to
determine which notes to include
• Who will organize, assemble, tab the ADR packet
• Who will review the packet for legibility and completeness
• Who will send the ADR packet to the FI/MAC
• Be sure to make a copy first
13
Tracking Part B Therapy ADRs
• Assign accountability for Tracking the ADRs and Appeals
• Record specific claims ADR’d, services under review
• Date sent to FI/MAC
• Verify delivery via certified mail, Fed-Ex signatures
and/or fax receipts
• Date claim adjudicated / response received
• Results of medical review
• Follow same format for tracking through each level of
appeal, as applicable
14
SNF Part A Coverage – Four Required Conditions
1. Requires skilled nursing or rehabilitation services
• Ordered by a physician
• Condition for which the patient received
inpatient services or for a condition that arose
while receiving care in a SNF for a condition in
which the patient received inpatient hospital
services
• “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.”
15
Daily Skilled Services
2. Requires Skilled Services Daily
DAILY Defined: “A patient whose inpatient stay is
based solely on the need for skilled rehabilitation
services would meet the “daily basis” requirement
when they need and receive those services on at
least 5 days a week.”
16
Daily Skilled Services
• “The daily basis requirement can be met by furnishing a single
type of skilled service every day, or by furnishing various
types of skilled services on different days of the week that
collectively add up to “daily” skilled services.”
• “Arbitrarily staggering the timing of various therapy modalities
through 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.”
17
“Daily” Requirement
• “It is not sufficient for the scheduling of therapy sessions to be
arranged so that some therapy is furnished each day, unless
the patient's medical needs indicate that daily therapy is
required. For example, if physical therapy is furnished on 3
days each week and occupational therapy is furnished on 2
other days each week, the “daily basis” requirement would be
satisfied only if there is a valid medical reason why both
cannot be furnished on the same day.”
• “The basic issue here is not whether the services are needed,
but when they are needed. Unless there is a legitimate medical
need for scheduling a therapy session each day, the “daily
basis” requirement for SNF coverage would not be met.”
18
Four Required Conditions
3.
Can only be provided in a SNF on an inpatient basis
•
“The services must be ones that, as a practical matter, can
only be provided in a SNF on an inpatient basis”
•
This applies not only at the time of admission, but
also through the SNF stay
19
Four Required Conditions
4.
The services must be reasonable and necessary for the
treatment of a patient’s illness or injury
•
•
•
be consistent with the nature and severity of the
individual’s illness of injury
the particular medical needs
and accepted standard’s of medical practice
The services must also be reasonable in terms of duration and quantity.
20
Skilled Rehabilitation – All Must be Met
• Directly and specifically related to an active written treatment
plan...approved by the physician
• A level of complexity and sophistication, or the condition of
the patient must be of a nature that requires the judgment,
knowledge, and skills of a therapist
• Will improve materially in a reasonable and generally
predictable period of time; or must be necessary for the
establishment of a safe and effective maintenance program; or
the services must require the skills of a therapist for
performance of a safe and effective maintenance program
21
Skilled Rehabilitation
• Be reasonable and necessary for the treatment of the patient’s
condition
• Amount, frequency, and duration of the services must be
reasonable
• Therapy services are not reasonable and necessary and
would not be covered if the expected results are
insignificant in relation to the extent and duration of
physical therapy services that would be required to achieve
those results
• Accepted standards of practice to be specific and effective
treatment for the patient’s condition
22
Skilled Rehabilitation
• When rehabilitation services are the primary services, the key
issue is whether the skills of a therapist are needed
• The deciding factor is not the patient’s potential for recovery,
but whether the services needed require the skills of a therapist
or whether they can be provided by non-skilled personnel
23
Medical Review
• When a Medical Reviewer looks at Records…they are
concerned about:
• The Bill Type – tells the reviewer if this is an outpatient hospital
clinic, a home health agency, a SNF Part A claim or a SNF part B
claim, an outpatient rehab facility claim, and there are more bill
types…the bill type is important because it tells the reviewer what
coverage guidelines need to be applied in the review
• The Edit Number - might tell them if this is a provider specific probe
for outpatient PT services, or maybe it’s a widespread probe for say,
lower SNF RUGS. The edit number tells the reviewer which service
are to be audited
• Dates of Service
• The patient as described in the record in front of them
24
Medical Review
• When a Medical Reviewer looks at Records…they are
NOT concerned about:
• The Facility Name – It doesn’t matter WHO they are
reviewing….they are reviewing a service.
• The other thing to keep in mind is that in the Part B therapy world it
doesn’t matter to a reviewer what type of facility you are
• Medicare calls Part B therapy “outpatient therapy” even if the patient is
not an “outpatient”
• The outpatient therapy coverage and general billing guidelines are the
same whether the patient is receiving services in an outpatient hospital,
a PT/OT/SLP private practice, as a resident in a NF or ALF, or as Home
Health part B services. The guidelines are all the same.
25
Productivity
• Reviewers have productivity expectations too!
• How you can help
• Document payable services
• Quality, not Quantity
• Clear, concise, objective, measurable, functional and
legible
• Paint the complexity of the patient’s condition
• Describe the complex nature of the treatment provided
• Assessment of the activity and the treatment adjustments
made
26
Reviewers love to PAY claims!
Simple
Two
Step
Process
27
“I never got a denial so I must be doing everything
right!”
28
Documentation…
Convincing the Reviewer
29
Coverage Determinations
• Medicare coverage determinations are made based on the
documentation, and the documentation alone
• The reviewer knows nothing else about the patient or the quality
of your facility
• The documentation is used to determine if the patient’s condition and
level of function required the special knowledge and skills of a
therapist/nurse
• “Make it easy for me to pay this.”
• Avoid making the reviewer search to determine if the services are
medically necessary
• Risks some important piece of information being missed
• Risks findings of inconsistencies in the documentation = denials
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a bit more detail….
31
It’s all about the Initial Evaluation/Intake!
• The initial evaluation sets the stage for all
subsequent clinical services
• Reviewers will begin to anticipate how much
therapy/skilled nursing might be needed for the
condition described
• Poor or scant evaluation/intake documentation
risks that ALL subsequent services will be
denied
32
• Descriptive Initial Evaluation – Tell the patient’s STORY
• Must have some sentences/phrases
• Makes it a “real” patient for the reviewer
• Limit the amount of check boxes/drop down boxes for
describing the Reason for Referral, Recent History,
and any Assessment Summaries
• Connect the dots for the reviewer
33
• Complex
• Describe the complex nature of the patient’s condition
• Where not obvious describe the impact the
complexities will have on the plan of treatment
 Complexity =  Amount of therapy/treatment
34
• Logical
• Must make the reviewer think, “Oh, I can see why
this patient requires skilled services now.”
• Logical flow from the reason for referral, to the
assessment findings/scores, to the selected treatment
interventions, and the subsequent goals
35
Initial Evaluation “Must Haves”
1. Reason for Referral in paragraph form
This happened and then this happened and now the
patient can’t do this and requires therapy in order to
do this.
2. PLOF and CLOF for every area that you will be
addressing in therapy
3. Comprehensive Underlying Impairment
assessment
If you don’t measure it – and re-measure it – you can’t
treat it!
36
Ongoing Therapy Services
• Must continue to support Medical Necessity and
Skilled Services
• Medical Necessity (the patient’s condition)
• Progress Reports – minimum every 10 treatment
visits for Medicare
• Consistently include objective measures of every:
• Functional Deficit addressed or going to be addressed
• Underlying Impairment treated or going to be treated
If you don’t measure it – and re-measure it – you can’t treat it!
• Documentation needs to include descriptions of any treatment
adaptations, changes, adjustments and progressions. This
information can be in either daily notes or in progress reports.
37
• The services must be so inherently complex that they
can only be safely and effectively performed by a
therapist/assistant
• Services that can be performed by or taught to nonskilled persons or can be completed as an
independent program are NOT skilled therapy
• Non-skilled: the patient, personal trainer, CNA,
spouse, caregiver, aide, tech, etc
38
The Quick Hit Denial
Repetitive
Services
39
• Reviewers expect to see documentation of adjustments,
progressions and/or modifications to the treatment
techniques, activities and interventions
40
Supportive Documentation
• Need to have supportive nursing documentation to
support the need for therapy.
• Also need documentation to support progress made
in therapy.
• Nursing documentation should be functional in
nature and reflect the resident’s performance as it
relates to their Rehab program.
41
A few samples of supportive documentation
• PT - Ambulation: Address the resident’s ability to
ambulate on the unit. Include distance and any
assistance required. This could include staff or a device
used, such as a walker. (example: Ambulates in hall with
the assistance of a CNA. Resident ambulates 25 feet to
and from the bathroom with a walker and contact guard
of one.)
• ST - Swallowing/Chewing: Notes should include mention
of the resident’s ability to swallow including drooling,
difficulty chewing, pocketing, coughing, choking, gagging.
(example: Resident drools when give PO water.
Resident coughs occasionally when given PO fluids.)
42
• OT - Bathing: Please note the resident’s ability to bathe
or participate in the bathing/showering process. This
should include the ability and degree of participation
exhibited by the resident as well as any assistance
required. (example: Resident needs assistance with tub
and shower. Is able to wash face and upper body with
set up and minimal cueing.)
43
Achieving Convincing Documentation
•
•
•
•
Do documentation audits
Increase documentation audits in high-risk facilities
Increase documentation audits for “outliers”
Provide FEEDBACK during audits
• Feedback is effective in changing behavior
• Validate
• Provide feedback for auditors as well to assure
they are providing a quality review with feedback
44
Avoid being an “outlier”
• Do not to fall into treatment/documentation patterns of:
•
•
•
•
•
ICD-9 Codes
CPT Codes
RUG levels
Frequency
Duration
• UNIQUE PATIENT 
UNIQUE/INDIVIDUALIZED PLAN OF CARE
45
• Recognize when you might be an outlier
• There are valid reasons to be an outlier
• Be diligent in your documentation and your
documentation audits
• If identified as an outlier and/or on probe review:
• BE EXTRA diligent in documentation
• All payment decisions are made based on the
documentation, and the documentation alone
46
Electronic Documentation
47
Electronic Documentation Cons
• The documentation is still only as good as the therapist making
the entries
• Even with controls for “required” fields and electronic
mapping, need to do internal documentation audits
• Difficult for the reviewer to obtain a unique picture of the patient
(Significant con!)
• Feels like there’s just a bunch of dots on the page and
nothing is connected
• Some documentation programs carry over entries from the
previous days
• Denial risk
48
Electronic Documentation Pros
• LEGIBLE!
• You can control the fields that are required
• Allows for starter phrases or controlled entries using
language suggestive of medical necessity or skilled
services
• Make use of the narrative entry areas! Show the individuality
of the patient’s condition and their plan of care
• Reports and alerts for missing or incomplete
documentation
• Can be accessed from a distance
49
Questions???
Contact Information:
Colleen Williams, SLP, Clinical Specialist
colleen.williams@aegistherapies.com
Michelle Seeley, COTA, Director of Rehab
michelle.seeley@aegistherapies.com
50
Thank you!