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Documentation for
Older Adults:
What does yours say?
Tina Young, MSOT, OTR/L
Older Adult MSG
March 26, 2011
[email protected]
Goals
• 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
Long Term Care
Changes
• What do these changes mean?
Increase in Audits
And Denials
Medicare Denials/Audit
Process
Recommendations:
Respond to ALL Medicare denials
Prepare documentation/clinicians to reduce
denials as best defense (hone our
documentation skills)
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
• 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…….
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
Stress remaining abilities that can be capitalized
versus barriers due to cognition
Cognitive recall is not necessary to participate in
this plan of care nor necessary for skilled
intervention
Documentation becomes fact,
Louder than what we do.
Joyce Smith
Documentation: Focus is
YOU
• Standardized tests
• Medical necessity
• Skilled services
• Referral from who,
supportive
documentation
• Physician order
and certification
• Expectation of
Improvement
•
•
•
•
•
•
and correlation to
function
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?
Why are YOUR needed (skills) vs. CNA?
HCR CEU
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
• 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
• POC (Plan of Care)
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
• POC
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
• 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
• 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
• CPT Coding
Selection of code is based on -skills required
intent of service
desired outcome
Skills required= technical skills
physical effort
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
• Progress Notes/Reports
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
• 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
Consider every note having:
 Statement of some progress
 Types of modalities provided and why and to
where
 Potential for future progress
 Plan for following week
 Use quotes from protocols and regulations
 Use standardized tests
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
Resources
• OOTA CEUs, Board meetings and Older Adult MSG
Roundtable discussions
• OOTA State Pre-Conference 2010 Older Adult Focus
• 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