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Documentation: Our Best Defense for Scrutiny Why focus on Documentation Competency? • Communication of Resident Care – Among ISC clinicians, physicians, caregivers, other health care professionals • Development of clinician skill set – Promotes quality resident care through assessment, reassessment, planning and development – Objective feedback provides opportunity for growth and training • Justifies need for services – “Paints the picture” of the medical and functional deficits of the patient – Documentation of skilled treatment necessary to return the resident/patient to their prior level of function Why Focus on Documentation Competency? • Proactive Approach to Increased scrutiny – Increased ADRs across the Country – RACs, ZPICs, OIG, State Surveyors • Reduces Risk of: – Payment Denial – Legal dispute and clinical scrutiny • Remember the old saying “If it isn’t documented . . . it didn’t happen”! Objectives 1. Identify Top 5 areas of documentation focus 2. Provide training and support to improve 5 key areas of documentation 3. Implement documentation strategies to withstand scrutiny 4. Reduce rate of denial and ADR request volume 5. Improve survey / audit outcomes Objectives 1. Identify Top 5 areas of documentation focus 2. Provide training and support to improve 5 key areas of documentation 3. Implement documentation strategies to withstand scrutiny 4. Reduce rate of denial and ADR request volume 5. Improve survey / audit outcomes Objectives 1. Identify Top 5 areas of documentation focus 2. Provide training and support to improve 5 key areas of documentation 3. Implement documentation strategies to withstand scrutiny 4. Reduce rate of denial and ADR request volume 5. Improve survey / audit outcomes Objectives 1. Identify Top 5 areas of documentation focus 2. Provide training and support to improve 5 key areas of documentation 3. Implement documentation strategies to withstand scrutiny 4. Reduce rate of denial and ADR request volume 5. Improve survey / audit outcomes Objectives 1. Identify Top 5 areas of documentation focus 2. Provide training and support to improve 5 key areas of documentation 3. Implement documentation strategies to withstand scrutiny 4. Reduce rate of denial and ADR request volume 5. Improve survey / audit outcomes Who/What influences Documentation Standards/Requirements? • CMS – Center for Medicare and Medicaid Services – sets national guidelines • Medicare Administrative Contracts (MACs) – a CMS contracted third party that sets local guidelines for payment – (Example: Wisconsin Physician Services) • Regulatory Agencies – (Example: JCAHO, Rehab Agency, Home Health) • State Practice Guidelines – (Example: TX HCSS, practice acts) • Results of Probes, Reviews, and Audits performed by these agencies Who/What influences Documentation Standards/Requirements? • Primary template for documentation set by CMS and the MACs – Define payment for services – Other regulatory agencies also provide direction,i.e., CoPs for RA, HH, Hospice – Ongoing change of requirements and standards • ISC Model and Standards: – Our proactive model requires strict adherence to quality documentation to support and demonstrate medical necessity, functional deficits, skilled treatment Resources for Documentation Guidelines • National Coverage Determinants (published by CMS) • Local Coverage Determinants (published by Medicare Administrative Contractor-MAC) • State Practice Acts (State Licensing Board) • ISC chart audit forms (BSL net) • ISC Personnel – – – – – – – Coordinator Director of Therapy Services Director of Professional Services Regional Director of Operations Regional Director of Appeals Regional Director of Training Senior Director of Operations Essentials in Documentation • Technical Completion/Accuracy • Medical Necessity of Skilled Intervention Technical Accuracy: Required Documentation Components • All Documents (including orders) are . . . – Present • Utilize Medical Record Checklist for Outpatient and HCC • HCHB – Compliance with workflow – All supporting documents scanned into system – Timely and Dated • Ensure EACH document / note has a date and is completed on the date of service • Ensure EACH order is signed and dated by clinician or physician • Follow regulatory requirements for timelines Technical Accuracy: Required Documentation Components (continued) • Complete: NO spaces left blank • Indicate “not assessed” or strike through the item (paper documentation only) • Organized (See Chart Set-up in Documentation Manual) • Signature, Credentials and printed name • (e.g. John Smith, PT John Smith, PT) • Legibility • Auditor should be able to clearly read documentation • Avoid overcrowding the forms Documentation Timeline Expectations Requirement Home Health Outpatient/HCC Orders Verbal orders required prior to initiation of eval and/or any changes in POC Signed & dated MD orders required prior to initiation of eval & tx. and/or any significant changes to POC Evaluation/Assessment Perform w/in 48 hours of referral Perform w/in 48 hours from receipt of order Completion of Initial Evaluation Certification Form On Date Services Provided On Date Services Provided (no later than 9:00 A.M. following day) OASIS Completion 4 calendar days from SOC N/A Physician Signed & Dated Evaluation Form Must have by End of Episode Within 30 days from SOC; or prior to billing of claim should f/u at 14-day assessment if not received to ensure compliance Daily Visit Notes Point of Service / By Daily Close Point of Service / By Daily Close Top 5 Focus Areas for Medical Necessity • • • • • Medical and Treatment Diagnosis supported Prior Level of Function Skilled Intervention Goals Progressed Patient’s Response / Progress Diagnosis Supported • Objective measures, tests, and assessments • Medical History • Medical Questionnaire • Physician’s Order includes diagnosis Diagnosis Supported Examples by discipline • PT Treatment Dx: Gait Abnormality – Objective tests: TUG, DGI, Tinetti, Berg – Medical History/Medical Questionnaire: prior CVA in 2003 • OT Treatment Dx: Lack of Coordination – Objective tests: PPT, 9-hole peg Test, etc. – General Medical Questionnaire: History of Athritis • ST Treatment Dx: Cognitive-Linguistic – Objective tests: SPMSQ, GDS, BCRS, etc. – Physician order: Dementia diagnosis • SN Dx: COPD – Objective tests: Borg RPE (Rate of Perceived exertion) – Medical History: COPD Where to document Diagnosis - HCHB Diagnoses - Tap diagnoses. To Add a Diagnosis - Tap “add.” Then tap “select…” next to code. The default value for the diagnosis code is Home Health (most frequently used diagnoses). If the diagnosis you are searching for does not appear within the search, tap on the down arrow next to “Home Health” and change to “all.” The second box is a dropdown box that allows a search by ICD code or description. The default value is ICD code. Tap on the down arrow to change from code to description. In the third field, type the code or description and tap “search.” (Remember to use the decimal if you are typing in a numeric code greater than 3 numbers). Where to Document Diagnosis – Outpatient and HCC • Evaluation Certification Form, Page 1, #’s 15-16 1. P atient’s Last Name 2 . Fir st Name Simpson Marge 5 . P r ovider Name Innovative Senior Care 6 . DO B 01-01-1931 MI Q 7 . A ge 81 8 . Sex M 9 . C ur r ent Living Environment F AL IL 1 1 . H ospitalization Related to this Episode of C are F RO M TO 1 3 . SO C Date 0 1 /0 3/2012 NA 15. Medical DX 1. IC D9 #_249.6 16. Treatment DX amb in room/apt 4 . P r ovider # 123-12-1234 000100 1 0 . P rior Living Environment (3 months prior) AL SNF O ther_________ 1 2 . P rior therapy (related to this condition/dx) N /A DA TE 12/1/11-12/28/11 HH PT/OT RE S U LTS Improved transfers and mobility in apt 1 4 . A re the ser vices of a car egiver/family member r equired? A ssistance prov ided for: 3 . H IC N amb outside of room/apt Description____Peripheral Neuropathy Yes (If y es check below ) transfers __________________ 2. IC D9 #_250.93___ Description____DM II uncontrolled 3. IC D9 #_250.72 __ Description____DM peripheral circulatory disorder ______________ O nset Date _12/20/11___ O nset Date _12/20/11__ 1. IC D9 #_781.2____ Description____abnormality of gait _______________________ 2. IC D9 #_781.3 ___ Description____Lack of coordination 3. IC D9 #_719.57___ Description____joint stiffness – bilateral ankles _________________ 1 8 . Reason for Referral (state change in function) _ No other ________________________________ 17. Rehab Potential O nset Date _12/20/11__ O nset Date _12/20/11___ _ good____ O nset Date _12/20/11___ O nset Date _12/20/11___ Multiple falls related to loss of protective sensation. Does not have any compensatory techniques ________ P atient’s G oal _Ambulate with her cane without pain or fear of falling_________________________________________________________________________________ She has a History of PVD with several grafts to both lower exremities, recent discovery of several small vasular infarcts in her brain with vision loss. She also has pain and stiffness in both shoulders and upper back area . _____________________________ History related to this treatment _ Fully Somewhat Not at all Yes (If Yes, how?__education provided on benefits/ risks of therapy _____________________________) To w hat extent is pt/guardian aw are of therapy dx/prognosis? C oncerns addressed? Expectation for P ositive P rognosis A w are of diagnosis S timulable M otiv ated F amily S upport P rev ious Interv entions w ere P ositiv e No N/A O ther ___________________________________ 3 step commands Is a cognitiv e therapy referral needed? Yes N o Referral to: ST O T _______________________________ P ain: Location__feet__________________________ Rating__7____/10 Location__Right leg______________________ Rating_ 7_/10 N A – N o pain reported A ble to follow : 1 2 P t is unsafe in the follow ing activ ities: A mbulation ( Lev el S urfaces, U nlev el S urfaces) Transfers W/C M obility S tairs O ther ___________________ Prior Level of Function • Describes the patient’s highest functional abilities prior to the onset of their complaint, incident or decline in functional capacity – Usually within 3 months of the onset • Must be discipline and treatment specific – i.e. ST describes prior communication abilities, while OT describes prior ADL planning abilities since that is their focus of treatment • Include PLOF for each functional focus or deficit that is being treated Prior Level of Function Examples • PT – “Pt. amb. Independently 1000’ with std. cane on in/outdoor surfaces without loss of balance” • OT – “Pt. donned/doffed clothing independently without shortness of breath, fatigue or loss of balance in less than 5 minutes” • ST – “Pt. tolerated unrestricted diet consistency without signs/symptoms of aspiration” • SN – “Pt. managed medications independently” Where to document PLOF HCHB PATIENT NOT DEEMED HOMEBOUND OTHER/NARRATIVE FORM: Q: INDICATE REASONS CLIENT IS HOMEBOUND:... - A: OTHER - SPECIFY INDICATE OTHER HOMEBOUND STATUS REASON: TYPE: TEXT - MULTISELECT: N N/A [INSURANCE] HEALTH HISTORY - 3 (ADD-ON: OT/PT/ST) NEW *Effective From 12/08/2010 To 01/01/2100 INDICATE PATIENT PRIOR LEVEL OF FUNCTION - PRIOR TO THIS EPISODE OF ILLNESS (MARK ALL THAT APPLY): TYPE: LIST - MULTISELECT: Y INDEPENDENT IN COMMUNITY INDEPENDENT AT HOME INDEPENDENT WITH USE OF ASSISTIVE DEVICES OTHER/NARRATIVE FORM: Q: INDICATE PATIENT PRIOR LEVEL OF FUNCT... - A: OTHER (SPECIFY) INDICATE OTHER PRIOR LEVEL OF FUNCTION: TYPE: TEXT - MULTISELECT: N ENVIRONMENTAL - 9 (ADD-ON: OT), (D/C FROM DISCIPLINE: OT), AND (VISITS: OT) *Effective From 12/08/2010 To 01/01/2100 ARCHITECTURAL ASSESSMENT/HOME EVALUATION ASSESSED? TYPE: LIST - MULTISELECT: N NO FORM: ENVIRONMENTAL - A: 0 - NO INDICATE REASON ARCHITECTURAL ASSESSMENT/HOME EVALUATION NOT ASSESSED: TYPE: LIST - MULTISELECT: N NOT APPROPRIATE AT TIME OF EVALUATION NOT APPLICABLE YES FORM: ENVIRONMENTAL - A: 1 - YES Where to Document PLOF – Outpatient and HCC • Outpatient/HCC Evaluation Certification Form: Page 2, Space #20 Skilled Intervention • MUST be documented in each visit note • All services documented must show a level of skill and complexity that only a skilled therapist, therapy assistant or nurse can provide • Should include specific goal-directed actions the therapist or nurse provided during the visit to achieve functional outcomes Skilled Intervention Examples • “PT instructed patient in safe, sit-to-stand transfer sequence, pt. return demonstrated with 50% accuracy” • “ST facilitated production of multi-syllabic words in isolation with focus on accuracy” • “OT designed compensatory tools to aid in appropriate sequencing of dressing tasks” • “SN instructed use of Medication reminder tool to aid in independence with medication management” Skilled Intervention Action Words Where to document Skill Outpatient and HCC Where to document Skill HC HB • Login to PointCare – Tap on the PointCare application on the device – review agent ID, password, version and server – Interventions for today’s visit. What you taught, what you did. Interventions are disease-specific and were selected at the SOC visit – All interventions appear at all therapy/nursing subsequent visits unless an exception code is used to discontinue them – Therapy Goals/Status – Therapy/Nursing specific items are tracked from status/goals perspective Short-Term Goals Progressed Short Term Goals • Smaller objective, functional goals that will be progressed and revised throughout the POC to achieve the LTG Short-term Goals Progressed (cont.) • Listed with anticipated time for completion • Written as “patient will . . . ” describing expected outcomes • Objective/measurable (e.g. time, level of assistance, number of errors, etc.) • Functional (Must answer “For what functional purpose does this goal help the patient achieve”) • Related to the care setting (IP/OP/HH) and expected D/C location Short – Term Goals Progressed Examples Outpatient: “In 2 weeks, pt. will amb. 150’ with 4w/w supervised with minimal shortness of breath to increase functional ambulation tolerance” – How would you change or progress this goal? • • • • • Distance Device Level of supervision Amount of perceived shortness of breath (Borg scale) Ambulation destination (bathroom, dining room, grocery store, etc.) Home Health: “In 3 visits, pt. will verbalize 2/5 safety precautions for safe O2 use in the home” – How would you change or progress this goal? • Number of items verbalized correctly • Demonstration versus verbalization Home Health vs. Outpatient Goals Home Health • Safety in home with ADL function • Pain management • Stabilize medical condition • Perform ADLs safely with use of adaptive devices/assist • Judgment related to safety Outpatient • Ability to maximally function in/out of home environment • Increased strength/ endurance for outside activity • Maximize independence with ADL function • Higher level executive function Where to Document ShortTerm Goals in HCHB • The NDPs (Nursing Diagnoses/Problem Statements) establish each discipline’s 485 orders and 485 goals as well as set up the care plan for all future visits in the episode • NDPs are established by the evaluating RN or therapist in the field, however, office users can also edit NDPs from two different screens: (1) While Reviewing Evaluation Documentation visits; or (2) Via Clinical Input by right clicking on the visit from the applicable Visit Note. If the second is used, the patient’s care plan is updated the day after the Interventions and Goals were regenerated in HCHB • Interventions and Goals will be generated (or regenerated if the NDP is edited) for all visits of that discipline that have not yet been started Where to Document Short-Term Goals in Outpatient/HCC • Evaluation Certification Form: Page 2, #24 Patient’s Response / Progress Documented • Response and Improvement is evidenced by – Successive objective measurements – Subjective measures (evidence-based) • Visual Analog Scale (VAS) • Documented in progress notes and summaries Patient’s Response / Progress Examples • PT: “Pt. demonstrated increased tolerance of UE exercises using 1lb. with increased repetitions to 15 • OT: “Pt. requires 50% less verbal cues /prompting for safety and sequencing of dressing tasks. • ST: “Pt. improved short-term recall to from 5/10 to 9/10 items” • SN: “Pt. now demonstrates 5/5 safety precautions in use of O2 in the home.” Where to Document Patient Response/Progress - HCHB • Login to PointCare (Tap on the PointCare application on the device – review agent ID, password, version and server) • Therapy Goals/Status - Therapy-specific items are tracked from status/goals perspective. Only select those items necessary for the patient. – If the goal and the status are the same, a red exclamation mark will appear in the carryover status. Carryover if you want to continue to monitor that item. – Can enter remarks. Tap set remark, enter remark, tap set remark. – Goals can be updated by a therapist only – not by an assistant – This becomes the “O” of the soap note – objective • Therapy Assess/Plan – Free text boxes. Becomes the “A” and “P” part of the SOAP note – assessment / plan. Give a short assessment of the visit and the plan for next visit Where to Document Patient Response/Progress – Outpatient and HCC • Daily Visit Notes – Pt. Comments – Weekly Summary of Progress – Exercise Record • 14-day Progress Summary • Discharge Summary Patient’s Response / Progress Example – Exercise Record EXERCISE RECORD PT OT ST Patient's Name _____Susan Smith_________ Patient’s Tx Wk (ex: Tues – Mon or Fri to Thurs) Friday ____________________ to to ________________________ Thursday Record reps, w eights, time, etc. to document progress and increased levels of difficulty. Date 10/20/06 Date 10/23/06 Date 10/24/06 Date 10/25/06 Date 10/26/07 Exercise Lingual lateralization Lingual Resistance x5 reps 2 seconds x10 reps 2-3 seconds x15 reps 5 seconds x20 reps 5 seconds x20 reps 10 seconds • Note progress in repetitions, seconds, etc. Final Thoughts Good Documentation tells the patient’s story. In any care setting. . . we can demonstrate the value and necessity of our service by describing the patient’s functional decline AND how the skilled services we provide helps to meet their needs, achieve meaningful independence, and quality of life. Remember: Documentation is our Best Defense!! Innovative Senior Care Rehabilitation…Fitness…Education