Therapy Documentation: What is Reasonable and Necessary?

Presented By:

Cindy Krafft MS PT, COS-C Director of Rehabilitation Consulting Services

President - Home Health Section APTA

June 15, 2010

243 King Street, Suite 246

Northampton, MA 01060

413-584-5300

fax: 413-584-0220

www.fazzi.com

Introduction of the Speaker Cindy Krafft MS PT, COS-C is the Director of Rehabilitation Consulting Services for Fazzi Associates. She has been in home health for 14 years in a variety of capacities from PRN clinician to the Director of Rehabilitation for a six agency home care system. She is currently working with agencies to develop their rehabilitation programs, helping them to achieve their highest potential both clinically and financially. She has been a well received speaker at both the state and national levels on the topics of documentation, program development, therapy utilization and recruitment. She is the newly elected President of the Home Health Section of the American Physical Therapy Association and the Chair of the NAHC Therapy Advisory Committee.

Instructions and Handouts for: Therapy Documentation

It is very important that you have these materials printed and ready to use prior to the

start of the training.

In order to participate in this training you will need to do the following:

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1. Each participant must complete an evaluation in order to receive contact hours.

Click on the following link in order to access the online evaluation form:

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*Please allow four weeks for processing.

Therapists Only: Directions to receive contact hours for the training.

The process for therapy CEUs varies state to state. In order to assist therapists with getting

a session approved, we have provided material that can be submitted to the state licensing

board. Please check with your individual state for more specific information as to the

process.

More information on APTA Guide to Practice can be found at the following websites:

www.cms.gov

www.medicare.com

http://oig.hhs.org

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Central Standard Time

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Mountain Standard Time

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Therapy Documentation:

What is Reasonable and Necessary?

June 15, 2010

©2010

Cindy Krafft MS PT, COS-C

Director of Rehabilitation Consulting Services

Fazzi Associates, Inc.

President - Home Health Section APTA

Objectives

• Establish clinical and documentation practices that ensure compliance with appropriate utilization.

• Assess the overall status of your therapy documentation

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documentation.

• Implement a structure to support “reasonable and necessary” when launching new therapy programs.

• Identify the difference between training and progress.

OASIS M2200

• “In the plan of care for the Medicare payment episode for which this assessment will define a case-mix group, what is the indicated need for therapy visits (total of reasonable and necessary

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visits (total of reasonable and necessary physical, occupational, and speech-pathology visits combined)?”

• The HHA would provide the total number of projected therapy visits, unless NA.

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Utilization Shifts

• Prior to 2008, more than 50% of “Hi” therapy cases ended with 10 – 13 visits.

• With the move to the tier model, this group has declined and growth has been seen in:

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– 6 – 9

– 14 – 19

– 20+

• Concerns about fraud and abuse in home care continue to be raised.

Recent Developments

• OASIS Analysis.

• Payment for 2010.

• MedPac Report.

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• April 2010 – Wall Street Journal Article.

• May 2010 – Senate Finance Committee.

• June 2010 - ???

OIG – What Is It?

• Office of Inspector General:

– Mandated by Public Law 95-452

– Protect the integrity of HHS

P t t b fi i i

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– Protect beneficiaries

– Network of audits, investigations and inspections

• Office of Audit Services:

– Reduce waste, abuse and mismanagement and promote economy and efficiency

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CMS ENHANCES PROGRAM INTEGRITY EFFORTS TO FIGHT FRAUD, WASTE AND ABUSE IN MEDICARE –

October 2008

• “As part of these enhanced efforts, CMS is consolidating its efforts with new program integrity contractors that will look at billing trends and patterns across Medicare. They will focus on companies and individuals whose billings for M di i hi h th th j it f

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Medicare services are higher than the majority of providers and suppliers in the community. CMS is also shifting its traditional approach to fighting fraud by working directly with beneficiaries by ensuring they received the durable medical equipment or home health services for which Medicare was billed and that the items or services were medically necessary.”

RAC Starting Point

• RAC program established in Medicare Modernization Act in 2003 with demo in three states.

• Tax Relief Act of 2006 (Section 302) makes

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RAC program permanent & nationwide no later than 2010.

• www.cms.hhs.gov/RAC.

RAC Regions

• Region A:

– Diversified Collection Services (DCS)

• Region B:

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– CGI Technologies and Solutions, Inc.

• Region C:

– Connolly Consulting, Inc.

• RegionD:

– HealthDataInsights, Inc.

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RAC Mission

• To detect and correct past improper payments and to

t f t

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prevent future payment issues:

– Underpayments

– Overpayments

Perspective

• The RACs will focus on multiple areas of health care and are not required to look into home health specifically.

• Complacency is a risk

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• Complacency is a risk.

• Knowledge and preparation are critical elements of dealing with RACs.

Levels of Review

• Automated Review.

• Complex Review – HHRG Validation.

C

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• Complex Review – Medical Necessity.

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HHRG Validation

• Slated for FY 2010.

• Will require the submission of additional

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documentation.

• Do the records support the HHRG/ case mix?

OIG – 2009 Work Plan

• Accuracy of Coding and Claims for Medicare Home Health Resource Groups:– We will review Medicare claims submitted by HHAs to

determine the extent to which the home health resource group (HHRG) billing codes that are used in determining payments to HHAs are accurate and supported by

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documentation in the medical record. The Social Security Act, § 1895, governs the payment basis and reimbursement for claims submitted by HHAs including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of coding by HHAs.

OASIS Implications

• Are the responses consistent and supportive throughout the document and the plan of care?

• Are the diagnoses selected supported and

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e t e d ag oses se ected suppo ted a dused according to coding rules?

• Therapy utilization and medical necessity?

• OASIS C transition risks?

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Medical Necessity

• Slated for FY 2010.

• Will require the submission of

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sub ss o oadditional documentation.

• What is “medical necessity?”

Necessary

• Speaks to the need for a skilled clinician to be involved with the care.

• Changes in the patient status does notautomatically support necessity:

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automatically support necessity:

– Is it occurring because of unique and specific interventions or by “accident?”

– Could it have occurred without the clinician being involved?

“Independent”

• Use of this term can be a “red flag” that therapy is not needed or has reached set

l d f th i it

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goals and further visits are not warranted:

– Think like OASIS

– Consistency between disciplines

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Showing Skilled Need

Comprehensive Assessment

Patient

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Plan of Care

Care Coordination

Patient

Documentation Tools

• Tools need to facilitate good documentation.

• Paper versus

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ape e suselectronic???

• The responsibility will always remain with the therapy professional.

Reading Documentation

• OASIS.

• Comprehensive Assessment.

• Plan of Care.

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• Orders.

• Visit Notes.

• Do you see medical necessity?

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What to Look For

• Overriding issue: Can you determine “why” the patient requires skilled therapy to be involved in the case?

• Key Areas:– Comprehensive Initial Assessment:

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Comprehensive Initial Assessment:

• Previous Functional Status is critical

– Goals that are functional AND measureable:

• Define “why” it is important to the patient

– Clear “necessity” of each therapy visit:

• Could it have been done by someone else?

Components of Review Tool

• Clinicians involved.

• Orders.

• Number of visits completed.

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• Initial assessment.

• Goals.

• Medical Necessity.

• Quantify risk.

Fazzi Audit Findings

• Over 75% of records have visits removed.

• Average financial risk is about $1,000 per record.

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• Main issues:– Incomplete Assessments

– Interventions not relating to assessment

– Goals not functional

– “Goals Met” not supported

– Unclear need for all visits provided

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Assessments?

• Patient amb household distances with walker and SBA.

• Patient amb 35 feet with SBA and required 50% verbal cues to maintain equal step l th bil t ll

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length bilaterally.

• Patient completes ADLs with modified independence.

• Patient completes bathing using a transfer bench with supervision throughout the task due to min unsteadiness noted with fatigue.

Goals?

• Patient will amb 385 feet on appropriate surfaces with least assistive device.

• Patient will amb 300 feet independently over driveway surface with walker to allow access

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to mailbox and vehicle.

• Patient will complete ADLs safely.

• Patient will complete ADLs with a focus on self management.

• Patient will shower with no AD independently as was previous functional level.

Need for the Visit?

• Amb 50 feet X 3.

• Patient advanced ambulation to 35’ with walker.

• Patient amb 45 feet with walker, CGA and 50% b l t i t l th

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50% verbal cues to increase step length on the right.

• Patient completed shower activity.

• Standing ex X 10 reps each

• Ther ex per flow sheet X 10 reps with VC needed 80% of the time for correct technique.

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Documentation and Clinical Practice

• From the first visit to the last, determine “why” the patient is being

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seen.

• If that question does not have a clear answer, the plan of care should be reassessed.

Implications for Program Development

• Practice patterns that are different that peer agencies can be a trigger for a documentation audit.

• Different does not mean “bad ”

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Different does not mean bad.

• Awareness of risk and a plan to be proactive is key to audit readiness BUT is not audit prevention.

Components of Documentation

• Initial Examination/Evaluation:– Examination:

• History

• Systems Review

• Tests and Measures

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– Evaluation:

• Problem list/statement of assessment

– Diagnosis:

• ICD-9 implications

– Prognosis

– Plan of Care/GoalsAPTA Defensible Documentation for Patient/Client Management

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Components of Well Written Goals

• Identification of person who is receiving therapy and will carry out the program.

• Description of the

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• Description of the movement or activity that the patient will perform.

• A connection of the movement/activity to a specific function.

Physical Therapy Reimbursement News, Volume 13, Number 3

Components of Well Written GoalsContinued…

• Specific conditions in which the activity will be performed.

• Factors for measuring performance.

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• Time Frame for achieving goal.

Physical Therapy Reimbursement News, Volume 13, Number 3

Components of Documentation

• Follow Up Visit:

– Patient or caregiver report

– Interventions provided including (as i t )

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appropriate):

• Frequency

• Intensity

• Time

APTA Defensible Documentation for Patient/Client Management

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Components of DocumentationContinued…

• Follow Up Visit (Continued):

– Patient response to treatment/interventions

– Communication/collaboration with other providers/family/patient as applicable/indicated

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p y p pp

– Factors that modify frequency or intensity of intervention and progression within the plan of care

– Plan for next visit including interventions with objectives, progression parameters and precautions if indicated within the plan of care

APTA Defensible Documentation for Patient/Client Management

Documentation References

• Functional Outcomes Documentation for Rehabilitation:

– By Lori Quinn and

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James Gordon

– Published by Saunders

• APTA - Defensible Documentation for Patient/Client Management.

Read Your Documentation!

• Every clinician needs to periodically read his or her documentation to determine if it reads as it was intended.

• Documentation represents both the skills

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ocu e tat o ep ese ts bot t e s sof the individual as well as those of the profession as a whole.

• Particular risk when changing tools.

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RAC Contact Info• Region A: Diversified Collection Services

– www.dcsrac.com

– 1-866-201-0580

• Region B: CGI– http://racb.cgi.com

– 1-877-316-7222

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– 1-877-316-7222

• Region C: Connolly Consulting– www.connollyhealthcare.com/RAC

– 1-866-360-2507

• Region D: HealthDataInsights– http://racinfo.healthdatainsights.com

– Part A: 1-866-590-5598

Helpful Resources

• American Physical Therapy Association:– www.apta.org

• Home Health Section

• State Level Associations

• American Occupational Therapy Association:

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p py

– www.aota.org

• American Speech and Hearing Association:

– ww.asha.org

• National Association of Home Care.

• State Home Care Associations.

ckrafft@fazzi.com

fazzi.comfazzi.com

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800 ●379 ●0361

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you will gain access to highly engaging interactive online sessions held monthly. Each session will open with a

preliminary discussion by a small panel of experts on an important home care issue and then is opened up for

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$300 Discount Coupon | Therapy Audit As a webinar participant, you are eligible to receive $300 off your

next therapy audit. Promotion Code FazziSave300. But don't

wait, this offer expires August 7, 2010.

*One discount per agency. Discount extended to all live and recording therapy

webinar purchases. Audit need not be completed before coupon expiration

With the proposed cuts facing our industry, you

cannot afford to lose money with documentation

that does not support medical necessity.

To learn more about Fazzi's therapy auditing services or

schedule your next audit, contact Cindy Krafft, MS, PT,

COS-C at ckrafft@fazzi.com. Don't forget to mention the

promotion code on the coupon to receive your discount!

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The process for therapy CEUs varies state to state. In order to assist therapists with getting a session approved, we have provided material that can be submitted to the state licensing board. Please check with your individual state for more specific information as to the process.

EDUCATIONAL ACTIVITY CONTENT OUTLINE

Title of activity: Therapy Documentation: What is Reasonable and Necessary? Date: June 15, 2010 Purpose/Goal: To provide best practice strategies for accurate documentation of the therapy plan of care and interventions.

OBJECTIVES CONTENT (Topics) TIME FRAME PRESENTER TEACHING METHODS

Review why there is such a focus on therapy services in home care.

Examine the relationship between therapy visits and reimbursement.

Discuss concerns about therapy utilization in home health.

25 mins Cindy Krafft MS PT, COS-C Lecture, power point

Discuss the components of appropriate therapy utilization as they relate to “reasonable and necessary” for both assessments and ongoing visits.

Define reasonable. Define necessary.

Explore medical necessity. 20 mins Cindy Krafft MS PT, COS-C Lecture, power point

Examine examples of documentation samples and audit tools.

Discuss the qualities of documentation that support medical necessity by assessing

actual documentation samples. 15 mins Cindy Krafft MS PT, COS-C

Lecture, power point

Establish clinical and documentation practices that ensure compliance with appropriate therapy utilization.

Discuss the elements that need to be in place to support medically necessary

therapy services. 10 mins Cindy Krafft MS PT, COS-C

Question and Answer

Implement the structure to support “reasonable and necessary” when launching new therapy programs.

Explore how to create documentation tools that work when developing new therapy

programs. 10 mins Cindy Krafft MS PT, COS-C

Question and Answer

Questions and answers. 10 mins Cindy Krafft MS PT, COS-C Question and Answer