Download Physician`s Guide to Documenting Medical

Physician’s Guide to Documenting
Medical Necessity
Lisa Bazemore, MBA, MS, CCC-SLP
Re-examining Our Documentation
• We have increased scrutiny
 Transmittal 221, 347, 478, 938 – guide to the FI on 75%
rule compliance
 LCD (Local Coverage Determination) – FI guide on
medical necessity
 RAC (Recovery Audit Contractor) – Appointed by CMS to
ensure IRF payments are substantiated
Industry Trends
• From the beginning of the 75% rule modification in July
2004, over 118,281 fewer patients in the United States
were admitted to inpatient rehabilitation facilities.
• Assuming these patient were appropriate for inpatient
rehabilitation admission previously, it means that 118,281
patients who would have benefited from inpatient
rehabilitation did not receive it.
• Average conditional compliance percentage is 65.37% in
eRehabData for this calendar year. Why?
Industry Trend
• Appeals:
 986 denied claims in the eRehabData Appeals Tracking
System.
 Represents $18,771,439 in claims.
 Of the 178 closed appeals, only 33 have been denied
payment.
 $15,000,000 are still under dispute.
Exemption Criteria
Exemption Criteria
Physician 24/7
Documentation of medical and
rehab needs. Co-morbidities
need listing.
Rehab Nursing 24 hrs
Comprehensive Nursing Plan of
Care.
Relative Intensity
Documenting endurance in the
pre-admission screen and for
continued stay.
Multidisciplinary Team
Goal statements. Assessments
done before day four postadmission.
Exemption Criteria
Exemption Criteria
Comprehensive Plan
Justifies the admission.
Significant Progress Toward
Goals
Documentation matches
between chart and IRF – PAI.
75/25 rule
Each patient is assessed
individually.
Pre-admission screening
Add in CMG prediction for long
stay – heavy care patients.
Exemption Criteria
Exemption Criteria
Distinct space
Beds contiguous.
Team Conference
May change frequency.
3 to 10 day evaluation
Graduated therapy time frame.
Annual evaluation
IRF - PAI will be part of review.
Medical Necessity
• Basic Principles
 Service must be reasonable and necessary (in terms of
efficacy and, duration, frequency, and amount) for the
treatment of the patient’s condition
 It must be reasonable and necessary to furnish the
care on an inpatient hospital basis, rather than less
intensive facility such as a Skilled Nursing Facility, or
on an outpatient basis
Medical Necessity
• Most patients cannot be equally served in skilled
nursing facilities!
 IRF provides access to 24 hour rehabilitation
physician and nursing, 3 hours of therapy,
etc.
 Increased nursing time correlates with
enhanced education and improved
performance, as well as, reduction in medical
complications
 Research is being done to determine if
outcomes with hip and knee replacement
patients is equivocal
Key Areas
• Pre-admission screening
 Document needs to stand alone and justify admission
• Physician documentation
 Establishes the justification for admission through H&P
• Nursing documentation
 The rehab nursing plan of care ties the medical
condition established by the physician and the
rehabilitation goals set by therapy
• Therapy documentation
 Demonstrates significant progress toward established
functional goals
• Translate everything into, “What am I doing for this
patient?”
Pre-Admission Screening
• Document should paint the picture for the
reason for admission and convince the reviewer
of the appropriateness of the admission
• Medical Necessity Issues
 Standard practice
 Would patient benefit significantly from “intensive
inpatient” hospital program or “extensive” assessment?
 Is inpatient rehabilitation “reasonable and necessary”?
• 75/25 Issues
 Assists with determination
 Supports RIC, comorbidities
Pre-Admission Screening
Issue
Action
Is inpatient
rehab
“reasonable &
necessary”?
•Treatment is specific & effective for patient’s
condition
•Services are at level of complexity &
sophistication or condition of patient is such
that the services can be safely & effectively
performed only by a qualified therapist
•Must be the expectation that the condition will
improve significantly in reasonable period of
time
•Amount, frequency, and duration of services
must be reasonable for an acute rehab program
to deliver
Physician Documentation
Issues
Action
Establishing
Medical
Necessity
•Why does the patient need to: occupy an acute rehab
Could this care
have been
provided in a
SNF?
bed? receive intensive therapy? at your specific
program?
Reason for admission (medical necessity)
Primary rehab diagnosis
Site the etiologic diagnosis and the rehab impairment classification (RIC)
Review of systems
Active co-morbid conditions – conditions that will be addressed by the
physician
List all medical problems with particular note to those that will affect the
rehab outcome
Identify functional limitations
Determine rehabilitation potential: for functional gain & for return to
independence
Identify pre-morbid function
Other therapy receive and outcome
Identify pre-morbid living situation
Establish general outcome goals: yours and the patient’s
Orders for therapy and nursing – including rehab nursing
Estimate the length of stay as it applies to goals
Note the expected discharge destination
Initiate discharge planning
Physician Documentation
Issues
Action
Close
•See patient every 2 – 3 days
medical
 Do each of these visits serve to demonstrate
supervision
active intervention by the physicians on the
medical and rehabilitation needs of the patient?
 Are there changes in orders for the
rehabilitation intervention by other members of
the team?
Document progress with rehabilitation
programs
Document changes in plan of care
Document barriers to attaining goals
Document collaborative efforts of team and
other consulting physicians
Components of the H&P
• Accurate and comprehensive
diagnosis
• Include all active comorbidities
• Review of body systems –
include risks and what
conditions require
continuous management and
may interfere with
participation
• Discuss any prior
rehabilitation efforts
• Identify functional abilities
and deficits
• Give reasons why patient
needs intense rehab not just
state patient will receive PT,
OT and nursing care
• Discuss rehab potential and
why potential is good or
excellent
• Estimate the LOS and
potential discharge location
Creating a Problem List
• The problem list is an essential component of physician
documentation
• It should be fully supported by the previous components of the
H&P
• It is the basis for the preliminary plan of care
• It is the foundation for team meeting
*Creating a Problem List slides from Dr. Pam Smith, Extreme
Makeover for Medical Rehabilitation
Creating a Problem List
• List should include:
 Rehabilitation diagnosis (primary functional limitation,
primary impairment and cause)
 Secondary impairments and complications
 Coexisting conditions
 Symptoms that will require treatment
 Chronic and ever-present medical conditions
 Potential conditions that require preventive measures,
restrictions and/or precautions
Creating a Problem List
• List should include:
 Functional deficits to be treated by the program, specify:
•
•
•
•
•
•
Self-care
Mobility (transfers)
Locomotion (gait abnormality)
Bladder and bowel function
Communication
Social cognition
• The problem list should be the basis for daily progress notes
• It is a working list that tracks the status of conditions treated during the
program – ongoing treatment or resolved
• Number the problems and refer to them in specifically in daily progress
notes, add to the list as needed
Creating a Problem List
• The problem list provides evidence of medical
necessity by detailing:
 medical conditions that require daily physician
oversight
 functional deficits that require intensive, coordinated
therapy
 complexity of conditions that require nursing
assessment and carry over 24 hours a day
Creating a Problem List
• The problem list is the basis for proper coding
• Actively treated conditions are evident
• Newly recognized conditions are apparent
• Resolved conditions are obvious
Problem List Examples
PROBLEM LIST – Patient #1
10) Neurogenic bowel
1) TBI secondary to fall on
xx/xx/xx
11) Posttraumatic Headache
2) Bilateral hemiparesis
3) Severe cognitive deficits
12) Hypophosphatemia
13) LUL Lung nodule
4) Communication deficits
14) Anxiety Disorder
5) Gait Abnormality
15) Paroxysmal Supraventricular
Tachycardia
6) Hyponatremia- cerebral salt
wasting
16) Hyperlipidemia
7) Hypothyroidism
8) Impaired Self Care Skills
9) Neurogenic bladder
17) H/O remote Stroke
18) Osteoporosis
IMPAIRMENT GROUP CODE
Brain Dysfunction: 02.22
Traumatic, Closed Injury
Problem List Examples
PROBLEM LIST - Patient #2
1) Medulary CVA with bilateral
extremity strength compromise,
poor balance, cognitive
impairment.
7) Cardiomegaly on CXR - CHF?, he is requiring
supplemental O2, will check BNP (likely
inaccurate due to the history of CRI) but if
this is not elevated then confusion is more
likely UTI
8) UTI - initiate Levaquin but conversion to
Vancomycin may be necessary
2) Insulin dependent diabetes
mellitus - monitor and adjust
9) Agitation - URI? , Dementia?, hypoxia? (on
supplemental O2). eval further
3) Peripheral vascular disease - long
standing left foot ischemic wound
10) CEA
4) Hypertension
5) Dementia - will initiate schedule
valproic acid and PRN Seroquel,
due to his renal impairment, these
doses may need to be reduced.
6) Chronic renal insufficiency Valproic and seroquel may need to
have their doses reduced, monitor
for sedation
11) CABG
12) Diabetic peripheral neuropathy - pursue
tight control
13) Deafness - unlikely to accept an aid but will
evaluate
14) Obesity
15) Gait abnormality
16) Ischemic foot wound - continue local care
Creating a Problem List
• The problem list should portray the depth and
breadth of the conditions being treated by an
interdisciplinary group of clinicians requiring
an inpatient stay
• It will become a “key witness” to your defense
against denials
Composing the Plan
• The preliminary plan supports medical necessity by describing
the “treatment for the condition”
• Demonstrates the thoughtful process behind the admission
decision
• Provides evidence of the complexity of the program to be
provided by the team
• Describes the plan to provide care in the IRF setting
• Lists the interventions (at least in general terms) to be provided
by each team member
• Implies the skill level required to provide such services
*Composing a Plan slides from Dr. Pam Smith, Extreme Makeover for
Medical Rehabilitation
Composing the Plan
• The preliminary plan supports medical
necessity by highlighting the multidisciplinary
nature of the treatment and the uniqueness of
the care of individual patients:
• Medical management
• Therapy strategies
• Nursing intervention
Composing a Plan
The preliminary plan is not…
…..a set of goals
...a canned statement that is the same for every patient
…”admit to rehab”
...OT/PT
...”this patient will benefit from a comprehensive inpatient
rehabilitation program”
Inadequate Example of a Plan
• Example of the “canned plan”
 Patient to receive comprehensive
rehabilitation services that include nursing,
PT, OT, NP, and TR for: mobility training, self
care training, bowel and bladder training,
adjustment counseling, community
reintegration, and adapted devices
Inadequate Example of a Plan
PLAN OF CARE –
6) hypotension - resolved
1) left hemiparesis - restart
7) neurogenic bowel
therapy
2) MM - check with Dr X on the
timing of his stem cell
infusion
3) recurrent aspiration -
monitor and initiate speech
4) history of esophageal
hemorrhage - monitor
5) dysphagia - per speech
8) neurogenic bladder
9) hypertension - monitor
10) cardioembolic CVA engage Dr. X in follow-up
11) gait abnormality therapy initiated
12) debility - therapy
Composing a Plan
PLAN OF CARE - Patient #1
1) TBI secondary to fall on 12/27/05- with diffuse SAH and IVH- repeat
Cranial CT scan during rehab stay
2) Bilateral hemiparesis- PT, OT, and rehab nursing to facilitate use of
limbs in functional activities, focus on strengthening, and conditioning
3) Severe cognitive deficits- Using neurostim- Amantadine 100 mg TIDNeuropsych and SLP working with rehab nursing will eval and treat
safety issues; develop compensatory strategies for deficits; focus on
facilitating expression of basic needs and wants
4) Communication deficits- SLP will eval pt- Apraxia may be
compounding communication deficits- but may have aphasia secondary
to left hemisphere involvement
5) Gait Abnormality- PT will address balance issues, strengthening for
pregait activities, analyze gait deviations and develop progress gait
training program using assistive devices as progress permits; patient
may benefit from aquatic program if continence will permit.
Composing a Plan
6) Hyponatremia- cerebral salt wasting- will continue fluid restrictions
to 1000 ml daily; monitor strict I/O's; give salt tabs 4 grams q 6 hours
and check Sodium q 12 hours- consider endocrinology consult
7) Hypothyroidism- Continue Synthroid- check TSH and free T4
8) Impaired Self Care Skills- OT evaluation and treatment for ADL
training working with rehab nursing to provide training opportunities
9) Neurogenic bladder- continue foley for now to facilitate monitoring of
I/O's- after sodium's stable, will remove foley and begin timed void trials
with rehab nursing while monitoring post void residuals; check
baseline UA/ Urine culture
10) Neurogenic bowel- Miralax daily; will add Mylicon and daily
dulcolax suppository
11) Posttraumatic Headache- consider Elavil at HS if persists; Tylenol
for now
Composing a Plan
12) Hypophosphatemia- monitor renal panels
13) LUL Lung nodule- patient to F/U with Dr. X in ~ 4
weeks
14) Anxiety Disorder- avoid Thiothixene; Neuropsych to
address via counseling; provide safe/ structured
environment via third floor rehab nursing
15) Paroxysmal Supraventricular Tachycardia- Continue
medication management; monitor HR via Rehab Nursing
and during therapies; Continue Dig- check level
16) Hyperlipidemia- Monitor Lipid panel
17) H/O remote Stroke- Plavix and ASA
18) Osteoporosis- Fosamax and exercise program
Composing a Plan
PLAN: For stroke prophylaxis, she will continue Plavix and
aspirin. For her cardiovascular disease she will continue
atenolol, Norvasc, and lisinopril. For her hyperlipidemia, she
is on a fairly high dose of Lipitor. Her swallowing with be
monitored by speech and language pathology; currently
mechanical soft diet, aspiration precautions. She will need
speech therapy as well for cognitive, neglect issues. She
needs nursing care for bowel and bladder management, such
as a regular daily bowel program and timed voiding to
improve continence. She will be checked for urinary
retention with a few post-void residuals. She will be seen by
physical therapy and occupational therapy. Preliminary
mobility goals will be supervised at the wheelchair level and
home, minimal to contact assist transfers and ambulation
short distances within the home. Preliminary occupational
therapy goals will be supervised and set up for light/upper
body daily living skills; minimal assist for lower body
dressing, toileting, toilet transfers, tub transfers and bathing.
Composing a Plan
• The Plan is the most important piece of the H&P
because it sets the interdisciplinary care plan
• It defines the medical, nursing, and therapy
needs of the patient.
Components of the Daily Note
SUBJECTIVE:
OBJECTIVE:
Vitals: BP , T , P , R , Pulse ox
LUNGS: clear to auscultation bilaterally __, rhonchi __, rales __, wheezes __, crackles __
CV: regular rate and rhythm __ murmurs __, rubs __, gallops __
Abd: soft __, non-tender __, normal active bowel sounds __, obese __
Ext: cyanosis __, clubbing __, edema __, calf tenderness __ (Right __ Left __)
Neuro:
Labs:
PLAN:
1. Justification for continued stay 2. Medical issues being followed closely 3. Issues that 24 hours rehabilitation nursing is following 4. Rehab progress since last note –
5. Continue current care and rehab
Components of the Daily Note
• Medication changes – document why changed
• Lab results – document decisions made based on lab results
• Ordering additional tests/labs – document reason why ordered,
discuss risks, advantages, hasten rehab participation and
discharge
• Document interaction with other professionals
• Document patient’s functional gains as discussed with patient
Components of the Discharge Summary
Medical Issues that required an acute level of care:
Patient is a 63 year old male with a history of… While on the unit we managed these complicated issues…
Brief History of Rehab Stay:
Functional Independent Measures Scores
Ambulation - The patient was () on admission with gait at () feet with/without assistive
device. The patient was () at discharge with gait at () feet with/without assistive device.
Admission
Eating
Grooming
Bathing
UE Dressing
LE Dressing
Toileting
Discharge
Components of the Discharge Summary
continued
Discharge Diagnosis:
Discharge Co-morbidities:
Discharge Follow-up:
Discharge Diet: regular __, ADA __, AHA __, low salt __
Discharge Condition: stable __, fair __, guarded __
DISCHARGE MEDICATIONS:
DISCHARGE LABS:
DISCHARGE RADIOLOGY REPORTS:
PLAN:
1. Discharge medications written
2. Discharge follow-up with
3. Discharge therapy with outpatient/home health care/no therapy needed
Justifying Medical Necessity
These words when used may not support medical
necessity:
Normal
Maintained
Monitoring
Combative
Regression in function
Insignificant
Poor rehab potential
Custodial
Inability to follow directions Minimal
Refused to participate
Plateau
Chronic/long term condition Inappropriate
Demented/Confused
Old onset
Uncooperative
Stable
“Nothing to do. Continue current
care and rehab”
Justification of Medical Necessity
When used appropriately, these words help justify medical
necessity.
Managing
Critical
Risk of infection
Prior level of function
Gains
Appropriate
Progress
Improvement
Motivated
Continued
Responsive
Increase in function
Required the skills of a therapist
Reasonable and necessary
Safe and effective delivery
Medical complications
Reasonable probability
Potential for complications
High risk factor
Safety issues
Significant
The patient has the potential
for a sudden change in status
Why do we do this?
• This is about access to care!
• We have not identified or not admitted too
many patients that with appropriate treatment
to help them recover and regain their prior level
of function would have benefited from an IRF
stay.
• Think back to the old days. Who benefited from
rehab and what types of patients were you
trained to treat in an IRF? Admit those patients,
document appropriately, and be prepared to
fight every denial and everybody wins.
What else can we do?
• Medical Directors should meet with leadership
team to work on performance improvement.
• Review admission times and the admission
process. Make it as easy as possible to admit to
the IRF. See if this paradox exists on your
unit…external admissions are approved more
readily than internal admissions.
• Improve communication with coders. Ensure
that you are capturing all conditions that are
being treated. This is vital to obtaining the most
appropriate reimbursement.
Questions?
Contact me at:
[email protected]
202-588-1766