Physician

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Physicians Guide to Documenting Medical Necessity

• Lisa Bazemore, MBA, MS, CCC-SLP

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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

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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?

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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.

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Exemption Criteria
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 post-admission.
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Exemption Criteria
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.
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Exemption Criteria
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.
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Medical Necessity

• Basic Principles
• Service must be reasonable and necessary (in
  terms of efficacy and, duration, frequency, and
  amount) for the treatment of the patients
  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

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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

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Key Areas

• Pre-admission screening
• Document needs to stand alone and justify
  admission
• Physician documentation
• Establishes the justification for admission
  through HP
• 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?

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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

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Pre-Admission Screening
Issue Action
Is inpatient rehab reasonable necessary? Treatment is specific effective for patients 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
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Physician Documentation
Issues Action
Establishing Medical Necessity Could this care have been provided in a SNF? Why does the patient need to occupy an acute rehab 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 patients 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
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Physician Documentation
Issues Action
Close medical supervision See patient every 2 3 days Do each of these visits serve to demonstrate 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
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Components of the HP

• Accurate and comprehensive diagnosis
• Include all active co-morbidities
• 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

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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 HP
• 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

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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

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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

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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

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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

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Problem List Examples

• PROBLEM LIST Patient 1
• 1) TBI secondary to fall on xx/xx/xx 2)
  Bilateral hemiparesis 3) Severe cognitive
  deficits 4) Communication deficits 5) Gait
  Abnormality 6) Hyponatremia- cerebral salt
  wasting
• 7) Hypothyroidism 8) Impaired Self Care Skills
  9) Neurogenic bladder

• 10) Neurogenic bowel 11) Posttraumatic
  Headache 12) Hypophosphatemia 13) LUL Lung
  nodule
• 14) Anxiety Disorder 15) Paroxysmal
  Supraventricular Tachycardia 16) Hyperlipidemia
  17) H/O remote Stroke 18) Osteoporosis
• IMPAIRMENT GROUP CODE
• Brain Dysfunction 02.22 Traumatic, Closed Injury
  

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Problem List Examples

• PROBLEM LIST - Patient 2
• 1) Medulary CVA with bilateral extremity strength
  compromise, poor balance, cognitive impairment.
• 2) Insulin dependent diabetes mellitus - monitor
  and adjust
• 3) Peripheral vascular disease - long standing
  left foot ischemic wound
• 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

• 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
• 9) Agitation - URI? , Dementia?, hypoxia? (on
  supplemental O2). eval further
• 10) CEA
• 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

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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

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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

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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

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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

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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

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Inadequate Example of a Plan

• PLAN OF CARE
• left hemiparesis - restart therapy
• MM - check with Dr X on the timing of his stem
  cell infusion
• recurrent aspiration - monitor and initiate
  speech
• history of esophageal hemorrhage - monitor
• dysphagia - per speech

• 6) hypotension - resolved
• 7) neurogenic bowel
• 8) neurogenic bladder
• 9) hypertension - monitor
• 10) cardioembolic CVA - engage Dr. X in follow-up
  
• 11) gait abnormality - therapy initiated
• 12) debility - therapy

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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 TID-
  Neuropsych 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.

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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

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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

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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.

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Composing a Plan

• The Plan is the most important piece of the HP
  because it sets the interdisciplinary care plan
• It defines the medical, nursing, and therapy
  needs of the patient.

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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

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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 patients functional gains as discussed
  with patient

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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 Discharge
• Eating
• Grooming
• Bathing
• UE Dressing
• LE Dressing
• Toileting
•  

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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

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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

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Justification of Medical Necessity

• When used appropriately, these words help justify
  medical necessity.
• Managing Increase in function
• Critical Required the skills of a therapist
• Risk of infection Reasonable and necessary
• Prior level of function Safe and effective
  delivery
• Gains Medical complications
• Appropriate Reasonable probability
• Progress Potential for complications
• Improvement High risk factor
• Motivated Safety issues
• Continued Significant
• Responsive The patient has the potential
• for a sudden change in status

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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.

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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 unitexternal
  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.

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Questions?

• Contact me at
• Lbazemore_at_erehabdata.com
• 202-588-1766