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Medicare Documentation for the
Rehabilitation Patient:
Evidence of Progress
HARMONY UNIVERSITY
The Provider Unit of
Harmon...
Speaker Bio (Keri Hart)
30 Years Experience in Long-term Care
Corporate Director of Clinical
Reimbursement Services
MDS
Co...
Medicare Documentation for the Rehabilitation Patient:
Evidence of Progress
Disclosures: The planners and presenters of th...
Harmony Healthcare International, Inc.
Medicare Documentation for the Rehabilitation Patient:
Evidence of Progress
Disclos...
Harmony Healthcare International, Inc.
Medicare Documentation for the Rehabilitation Patient:
Evidence of Progress
Criteri...
Objectives:
The learner will be able to define skilled
coverage criteria.
The learner will be able to define key
elements ...
Increase in Medicare Documentation
Reviews
Significant increase in the number of medical review
requests from Medicare Adm...
Increase in Medicare Denials
Denials due to conflict between
Nursing Notes, MDS and Rehabilitation
documentation
Documenta...
OIG Report November 2012
In fiscal year (FY) 2012, Medicare paid $32.2 billion
for SNF services
Submission of inaccurate, ...
OIG Report November 2012
OIG recommendations (CMS concurred):
Increase and expand reviews of SNF claims
Use CMS fraud prev...
Physician Certification
Physician Certification Frequency
Admission
14th Day
Every 30 Days (from last certification)
Addre...
Physician Certifications
Therapy Certification
Plan of Treatment/Care
Frequency of Services
Plan
Goals
Physician Involveme...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
“Practical Matter” Criteria
“As a practical...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
“Practical Matter” Criteria
1. Outpatient s...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
“Practical Matter” Criteria
3. The availabi...
“Practical Matter” Criteria
Reasons for SNF stay:
Intensity of Therapy
Medical Complexity
Deficits
Less than 24-hour care ...
“Practical Matter” Criteria
Medical Complexity
Details of skilled assessment, observation
and interventions provided by Nu...
Clinical Eligibility Requirements
The need for skilled care must be
justified and documented in the
medical record
Conditi...
Relationship to Hospitalization
Acute Care hospitalization diagnosis
Pneumonia
Conditions identified at acute
Skin
History...
Relationship to Hospitalization
Although a deficit or problem exists, documentation
must reflect the relationship to hospi...
Therapy Documentation to Support
Related to hospitalization or problem
that arose during SNF stay:
Detail in reason for re...
What is Skilled Care?
Requires the skills of qualified technical or
professional health personnel such as RN, LPN, PT,
OT ...
Daily Basis
The patient requires these skilled
services on a daily basis (see §214.5)
Nursing 7 Days
Therapy combination P...
Basic Medicare Requirements
If not supported by the documentation
in the patient’s record, a stay in an SNF,
even though i...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
Skilled Care
Skilled Rehabilitation
Direct ...
Medical Necessity
The services provided requires the
skills of a therapist:
Modalities (Diathermy, Ultrasound)
Assessment
...
Skilled Rehabilitation
Evaluations; Reevaluations
Establishment of treatment goals to
address each problem identified in t...
Skilled Rehabilitation
Continued assessment at regular intervals
Instruction leading to establishment of
compensatory skil...
Treatment Modalities
Self care training
Therapeutic activities
Mobility training
Transfer training
Neuromuscular reeducati...
Treatment Modalities
Balance training
Therapeutic exercise
Electrical stimulation
Ultrasound
Modalities
Wound management
W...
Treatment Modalities
Home management training
Community reintegration
Safety education
Adaptive equipment training
Cogniti...
Therapy Documentation to Support
Evaluation
Decline from prior level of function
Relationship to hospitalization
Deficits
...
Therapy Documentation to Support
Documentation that the skills of a
therapist are required:
Why restorative nursing cannot...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
Direct Skilled Nursing
IV (parental) medica...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
Management and Evaluation of a
Care Plan
“C...
Management and Evaluation of a
Care Plan
Based on the Physician’s orders, these
services require the involvement of skille...
This area includes
The sum total of unskilled services
Potential for serious complications
High probability of relapse
Rec...
Management and Evaluation of a
Care Plan
Although any of the required services could be
performed by a properly instructed...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
Skilled Observation and
Assessment
Reasonab...
Skilled Observation and
Assessment
If a patient was admitted for skilled
observation but did not develop a further
acute e...
Skills of a Therapist or a Nurse
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
Skills of a Therapist or a Nurse
Must require, the expertise, knowledge,
clinical judgment, decision making and
abilities ...
Skills of a Therapist or a Nurse
Documentation must support:
Description of skilled treatment
Changes made to the plan of ...
Patient Education Services
Patient Education Services: Activities
which require skilled nursing or skilled
rehabilitation ...
Skilled Services Categories:
Patient Education Services
Colostomy care
Insulin
administration
Prosthesis
management
Cathet...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
Universal Documentation
Guidelines
Legible
...
Handwriting Legibility
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
Handwriting Legibility
Documentation that is illegible or
indecipherable can result in denial of payment
Illegible handwri...
Electronic Medical Record (EMR)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
Electronic Medical Record (EMR)
Electronic signature must meet
requirements:
Sole usage (e.g., PIN required)
Name and desi...
Basics of Documentation
Clarity: Evidence of the need for further
skilled care
Content: Describe what you have done. There...
Documentation Using Skilled
Terminology
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
Acu...
Documentation Using Skilled
Terminology
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
Ana...
Non-Supportive Documentation
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
Generalized we...
Objective Evidence
Objective evidence consists of:
Standardized patient assessment instruments
Outcome measurements tools
...
Functional Outcome Measures
CMS Referenced Instruments:
National Outcomes Measurement System
(NOMS) by the American Speech...
Concept of Medical Necessity
Medical Complexity:
The service is so complex that the skills of
a therapist are required (mo...
Concept of Reasonable and Necessary
Services meet accepted standards of medical
practice
Specific and effective treatment ...
Concept of Reasonable and
Necessary
The following are not considered reasonable
and necessary:
Services provided for gener...
Functional Impact
Skilled rehabilitative therapy occurs when,
“The skills of a therapist are necessary to
safely and effec...
Importance of Evaluation
The initial evaluation sets the stage for
all subsequent therapy services
Poor evaluation documen...
Importance of Evaluation
Just because Medicare Part A does not allow time
spent on evaluation to be counted toward RUG
min...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
The Importance Prior Level of Function
Medi...
How to Document PLOF
Gather as much information regarding the patient’s
functional level prior to recent illnesses. Be Spe...
Prior Level of Function
Example
Admission after an acute CVA:
PT: Independent with all mobility without a device
for unres...
Nursing Documentation Prior
Level of Function
Document information obtained from resident and
family
Admission Assessment
...
What is Rehab Potential
The patient’s potential to achieve goals set
by the therapist
Not related to medical prognosis
Goa...
Nursing Documentation
Rehab Potential
Focus on the potential to achieve goals
Recent onset
Intact abilities
“Given the pat...
The Importance of Reason for Referral
Details the specifics of why skilled therapy
services are warranted
Clarifies the ev...
Reason for Referral Nursing and Therapy Examples
“Significant decline in function status post an acute
CVA on 9/1/13”
“Evi...
The Importance of Measuring
Functional Deficits
Supports Medical Necessity
Establishes the physical and cognitive
baseline...
Level of Assist
Devices and Adaptive Equipment Assessed
Diet Textures
Number of Caregivers to Assist
Functional Levels:
Ma...
Supervision
Supervision: Cueing
Reviewers may view this level of care as restorative
Ensure documentation of deficits are ...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
Supervision
Describe Causes of Cueing
Techn...
How to Measure Functional Deficits
Current level of function for each functional
deficit to be addressed in therapy
Define...
Reasons for Functional Limitations
Examples of reasons for functional limitation:
Lack of awareness of sensory cues
Impair...
Reasons for Functional Limitations
Safety Issues Related To:
Poor posture
Improper gait
Weak grip, arthritis
Dysphagia
Poo...
How to Measure Functional Deficits
Standardized Measurement Tools
Borg Scale= 5 (Severe Breathlessness)
Berg Functional Ba...
Complexity of Task
Environment
In room
In dining room
Distraction
Patient Condition
End of the day versus beginning
With p...
Nursing Documentation of Function
Focus on:
Functional tasks requiring assist
Partial task completion by caregivers
Comple...
The Importance of Summarizing
Findings
Supports Medical Necessity
Evidences the critical thinking process
Don’t leave it u...
How to Summarize Findings
Be descriptive
Chart your thinking
Guide the reviewer
State the obvious
It may only be obvious t...
The Importance of Functional
Rehabilitation Goal Writing
Guides the reviewer through progress
Reflects the logical plan of...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
What is a Measurable Rehabilitation Goal
Lo...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85
Performance Skills
Motor skills: moving and...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86
Performance Skills
Process Skills: managing...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
Performance Skills
Communication Skills: co...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
Duplication of Services
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
Duplication of Services
Rehab goals can app...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90
Duplication of Services
The goals must be w...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
Duplication of Services
PT Goal:
Pt. will d...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
Duplication of Services
OT Goal:
Pt. will d...
The Importance of Progress Reports
Required for Payment
Justifies outcome of skilled therapy
intervention
Supports the nee...
What is a Progress Report
The minimum Progress Report Period is at least once
on or before the 10th treatment day
No later...
Assistants and Progress Reports
The PT, OT or SLP clinician must write a
Progress Report during each Progress Report
Perio...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
How to Write a Progress Note
Each report sh...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
How to Write a Progress Note
Include:
Asses...
How to Write a Progress Note
Avoid:
Simply listing CPT code descriptors
Stating general treatment interventions
(Ther Ex, ...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99
How to Write a Progress Note
Include:
That ...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
How to Write a Progress Note
Summary:
1) S...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
Supportive Skilled Documentation
Patient a...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
Non-Supportive Skilled
Documentation
Plate...
Non-Supportive Skilled
Documentation
Quoted statements from patient refusing
therapy and asking to end the therapy
session...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
Progress Report Examples
On evaluation, pa...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 105
Progress Report Examples
The patient initi...
Progress Report Examples
The patient tolerated nectar thick liquids for
all meals with no evidence of aspiration. The
pati...
Nursing Documentation of Progress
Focus on:
New functional abilities
Partial task completion
Increased initiation attempts...
Monthly Progress Report
These are completed every 30 days and
include components of weekly progress
noted while also requi...
Monthly Progress Report
Any change in treatment plan would
require physician clarification orders
The completion of clarif...
Discharge Progress Report
The discharge note is a Progress Report
written by the clinician upon completion
of each program...
Discharge Progress Report
It is important to give a thorough
synopsis beginning with a comparison
between the initial leve...
112
Discharge Progress Report
List all techniques and methods trialed even
failed attempts
Discharge setting with cues for...
Nursing Discharge Documentation
Supplement with:
Functional Goals achieved
Medical diagnosis and conditions
that have reso...
Skilled Coverage Criteria
There is no such thing as a “Rehab” or
“Nursing Patient
One patient
One medical record
One claim...
References
Medicare Benefit Policy Manual
Chapter 8 - Coverage of Extended Care
(SNF) Services Under Hospital
Insurance (R...
Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
Khart@harmony-healthcare.com
www.harmony-healthcare....
Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
o...
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Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

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Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.

1. Learn to define skilled coverage criteria.

2. Learn to define key elements of documentation.

3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.

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Transcript of "Medicare Documentation for the Rehabilitation Patient: Evidence of Progress"

  1. 1. Medicare Documentation for the Rehabilitation Patient: Evidence of Progress HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QT Director of Rehabilitation & Reimbursement Education
  2. 2. Speaker Bio (Keri Hart) 30 Years Experience in Long-term Care Corporate Director of Clinical Reimbursement Services MDS Corporate Rehab Director Rehab Director SLP Cognition (Dementia and Head Injury) Head and Neck (Dysphagia and Voice) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Medicare Documentation for the Rehabilitation Patient: Evidence of Progress Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenter: Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QT Director of Rehabilitation & Reimbursement Education Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Harmony Healthcare International, Inc. Medicare Documentation for the Rehabilitation Patient: Evidence of Progress Disclosure Speaker: Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QT Director of Rehabilitation & Reimbursement Education The speaker has no relevant financial relationships to disclose The speaker has no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 4
  5. 5. Harmony Healthcare International, Inc. Medicare Documentation for the Rehabilitation Patient: Evidence of Progress Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form. Copyright © 2013 All Rights Reserved 5
  6. 6. Objectives: The learner will be able to define skilled coverage criteria. The learner will be able to define key elements of Documentation. The learner will be able to provide examples of Rehabilitation Documentation to support Medicare coverage criteria. The learner will be able to provide examples of Nursing Documentation to support Medicare coverage criteria. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. Increase in Medicare Documentation Reviews Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) Lower 14 Billing inconsistencies ICD-9 Coding triggers Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's Number of "Help Letters“ was astoundingly high Investigations into potential fraudulent billing practices increased Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. Increase in Medicare Denials Denials due to conflict between Nursing Notes, MDS and Rehabilitation documentation Documentation by Nursing of Medical Complexity supports need to receive rehabilitation at a SNF level of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. OIG Report November 2012 In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF services Submission of inaccurate, medically unnecessary, and fraudulent claims Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments Increase and expand reviews of SNF claims Use CMS fraud prevention system to identify SNFs billing higher paying RUGs Monitor compliance with therapy assessments (COT) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. OIG Report November 2012 OIG recommendations (CMS concurred): Increase and expand reviews of SNF claims Use CMS fraud prevention system to identify SNFs billing higher paying RUGs Monitor compliance with therapy assessments (COT) Change the current method for determining how much therapy is needed to ensure appropriate payments Improve the accuracy of MDS items Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. Physician Certification Physician Certification Frequency Admission 14th Day Every 30 Days (from last certification) Addresses all skilled qualifiers Rehab Nursing Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Physician Certifications Therapy Certification Plan of Treatment/Care Frequency of Services Plan Goals Physician Involvement Therapy Physician Orders Evaluation Treatment clarification Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13 “Practical Matter” Criteria “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility”
  14. 14. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14 “Practical Matter” Criteria 1. Outpatient services are not available in the area where the individual lives 2. Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility
  15. 15. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15 “Practical Matter” Criteria 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/resident to reside there safely 4. If the use of alternative services would adversely affect the patient/resident’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis
  16. 16. “Practical Matter” Criteria Reasons for SNF stay: Intensity of Therapy Medical Complexity Deficits Less than 24-hour care would impose safety risks Less than 24-hour care would result in adverse impact on medical condition Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. “Practical Matter” Criteria Medical Complexity Details of skilled assessment, observation and interventions provided by Nursing and Rehabilitation Services Deficits ADL Documentation accurately reflects assist provided to support deficits Rehabilitation documentation reflects deficits with tasks of increasing complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. Clinical Eligibility Requirements The need for skilled care must be justified and documented in the medical record Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF Harmony Healthcare International, Inc. 18Copyright © 2013 All Rights Reserved
  19. 19. Relationship to Hospitalization Acute Care hospitalization diagnosis Pneumonia Conditions identified at acute Skin History of conditions and diagnosis now requiring skilled assessment, observation and intervention Diabetes CHF COPD Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Relationship to Hospitalization Although a deficit or problem exists, documentation must reflect the relationship to hospitalization or problem that arose in the SNF Documentation should be clarified to ensure the reviewer can see the connection “New onset of difficulty swallowing upon return from hospitalization” No longer able to…. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. Therapy Documentation to Support Related to hospitalization or problem that arose during SNF stay: Detail in reason for referral Address in narrative summary Prior level of function reflects a change compared to prior to hospitalization Chronic conditions: How has the condition changed? What is the functional impact? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result “General supervision” requires initial direction and periodic inspection of activity Ordered by a physician Services are needed and provided on a daily basis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Daily Basis The patient requires these skilled services on a daily basis (see §214.5) Nursing 7 Days Therapy combination PT, OT and/or SLP 5 days of 7 Supporting Documentation: Daily Therapy Note Daily Nursing Notes Treatment Sheets Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Basic Medicare Requirements If not supported by the documentation in the patient’s record, a stay in an SNF, even though it might include the delivery of daily skilled services, is not covered For Example: Payment for a SNF level of care may not be made if documentation supports a patient’s need as intermittent rather than daily skilled service Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25 Skilled Care Skilled Rehabilitation Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training
  26. 26. Medical Necessity The services provided requires the skills of a therapist: Modalities (Diathermy, Ultrasound) Assessment Management and progression of the plan of care The patient is medically complex and requires the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Skilled Rehabilitation Evaluations; Reevaluations Establishment of treatment goals to address each problem identified in the evaluation Design of a plan of care , including establishing procedures to obtain goals, determine frequency and duration of treatment Harmony Healthcare International, Inc. 27Copyright © 2013 All Rights Reserved
  28. 28. Skilled Rehabilitation Continued assessment at regular intervals Instruction leading to establishment of compensatory skills Selection of devices to replace or augment a function Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family is ongoing through treatment and instructions may be modified intermittently if the patient’s status changes. 28Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  29. 29. Treatment Modalities Self care training Therapeutic activities Mobility training Transfer training Neuromuscular reeducation Gait training Orthotic/prosthetic training UE splinting Manual therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29Copyright © 2013 All Rights Reserved
  30. 30. Treatment Modalities Balance training Therapeutic exercise Electrical stimulation Ultrasound Modalities Wound management Wheelchair management Patient/caregiver education and training Compensatory techniques Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30Copyright © 2013 All Rights Reserved
  31. 31. Treatment Modalities Home management training Community reintegration Safety education Adaptive equipment training Cognitive retraining Visual motor/ perception training Dysphagia management Cognitive-linguistic treatment for newly impaired 31Harmony Healthcare International, Inc.Copyright © 2013 All Rights ReservedCopyright © 2013 All Rights Reserved
  32. 32. Therapy Documentation to Support Evaluation Decline from prior level of function Relationship to hospitalization Deficits Risks without therapy Medical Complexity Daily Treatment Notes to Support daily provision MD involvement: Signed Plan of Treatment Physician orders Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
  33. 33. Therapy Documentation to Support Documentation that the skills of a therapist are required: Why restorative nursing cannot address identified issues? Assessment and changes to the treatment regime Medical Complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34 Direct Skilled Nursing IV (parental) medications N/G, gastrostomy tubes, jejunostomy tubes Application of dressing with prescription medications and aseptic technique Treatment of pressure ulcer grade III or worse Initial phases of a regimen involving medical gases such as bronchodilators and oxygen therapy New Colostomy Care Bowel and Bladder Training
  35. 35. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35 Management and Evaluation of a Care Plan “Constitute skilled services when, because of the patient’s physical or mental condition, those activities require the involvement of technical or professional personnel in order to meet the patient’s needs, promote recovery and ensure medical safety.” (Final Rule 7/31/99)
  36. 36. Management and Evaluation of a Care Plan Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s Medical needs Promote recovery Ensure medical safety Harmony Healthcare International, Inc. 36Copyright © 2013 All Rights Reserved
  37. 37. This area includes The sum total of unskilled services Potential for serious complications High probability of relapse Recovery and safety Meet medical needs Includes resident’s overall condition Harmony Healthcare International, Inc. 37 Management and Evaluation of a Care Plan Copyright © 2013 All Rights Reserved
  38. 38. Management and Evaluation of a Care Plan Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel. Harmony Healthcare International, Inc. 38Copyright © 2013 All Rights Reserved
  39. 39. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39 Skilled Observation and Assessment Reasonable probability for complications or potential for further acute episodes of the patient’s changing condition needed to identify and evaluate the patient’s need for modification of treatment or additional medical procedures until his or her condition is stabilized
  40. 40. Skilled Observation and Assessment If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services are still covered so long as there was reasonable probability for such a complication or further acute episode “Reasonable probability” means that a potential complication or further acute episode is a likely possibility Harmony Healthcare International, Inc. 40Copyright © 2013 All Rights Reserved
  41. 41. Skills of a Therapist or a Nurse Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Skills of a Therapist or a Nurse Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. Skills of a Therapist or a Nurse Documentation must support: Description of skilled treatment Changes made to the plan of care due to assessment of the patient’s needs Medical complexity Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. Patient Education Services Patient Education Services: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen Skilled if the use of technical or professional personnel is necessary to teach a patient self-maintenance Harmony Healthcare International, Inc. 44Copyright © 2013 All Rights Reserved
  45. 45. Skilled Services Categories: Patient Education Services Colostomy care Insulin administration Prosthesis management Catheter care G-tube feedings IV access sites Braces, splints and orthotics Wound dressings and skin treatments Medication Management Orthopedic Precautions Harmony Healthcare International, Inc. 45Copyright © 2013 All Rights Reserved
  46. 46. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46 Universal Documentation Guidelines Legible Dated Standard abbreviations Joint Commission is commonly used as a standard Facility policy Understood by all readers Detail-oriented Clear
  47. 47. Handwriting Legibility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Handwriting Legibility Documentation that is illegible or indecipherable can result in denial of payment Illegible handwriting is defined as the inability of two out of three individuals not being able to read an unfamiliar chart entry Someone can read what you wrote on the first attempt Legible does not mean several people standing around the nursing station can figure out what it was supposed to say Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Electronic Medical Record (EMR) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. Electronic Medical Record (EMR) Electronic signature must meet requirements: Sole usage (e.g., PIN required) Name and designation EMR still requires the user to understand the requirements for Medicare Canned documentation may not support the services provided Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. Basics of Documentation Clarity: Evidence of the need for further skilled care Content: Describe what you have done. There is a beginning, middle and end of every good note. Communication: Document any changes in the patient Document what needs to be changed regarding the plan of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Documentation Using Skilled Terminology Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52 Acute Beginning to respond Description of a balance deficit Evaluated Measured amount Reddened area Continues to progress Difficulty with Incapable of Self help devices New skills added Techniques or strategies Functional outcomes Evaluate Increased carryover Increased generalization Individualized Condition is complicated by High risk for Goal achieved
  53. 53. Documentation Using Skilled Terminology Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53 Analyzing Establishing Modifying Implementing Hierarchy of tasks Skilled teaching or feedback Optimum performance Compensatory skills Skilled activities Active skilled program Significant practical improvement Change in living environment Safe and effective Complexity of performance Adaptive procedures Customized Increased consistency
  54. 54. Non-Supportive Documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54 Generalized weakness Chronic Stabilized Good, fair, poor, or other general term Monitored Scant, little, much, great Slight improvement Slightly red Slow progress No problem Routine Practice General Conditioning Exercises Maintenance Repetitious Refuses to Making slow progress Unable to learn Reinforced previously taught..
  55. 55. Objective Evidence Objective evidence consists of: Standardized patient assessment instruments Outcome measurements tools Measurable assessments of functional outcome Not required, but their use will enhance the justification for needed therapy Use of objective measures at: The beginning of treatment During and/or after treatment Quantify progress and support justifications for continued treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Functional Outcome Measures CMS Referenced Instruments: National Outcomes Measurement System (NOMS) by the American Speech- Language Hearing Association Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO) Activity Measure – Post Acute Care (AM- PAC) OPTIMAL by Cedaron through the American Physical Therapy Association Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Concept of Medical Necessity Medical Complexity: The service is so complex that the skills of a therapist are required (modalities) The patient is so complex that the services require the skills of a therapist Both require documentation to support Describe why and/or how complicating factors (complexities) affect treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Concept of Reasonable and Necessary Services meet accepted standards of medical practice Specific and effective treatment for the condition A level of complexity/sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist (or supervised PTA/OTA) Patient’s clinical condition requires the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Concept of Reasonable and Necessary The following are not considered reasonable and necessary: Services provided for general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes Services that are not provided under a therapy plan of care, or are provided by staff who are not qualified or appropriately supervised, are not covered or payable therapy services Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
  60. 60. Functional Impact Skilled rehabilitative therapy occurs when, “The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation” Documentation should focus on functional abilities and deficits Evaluation Goals Progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. Importance of Evaluation The initial evaluation sets the stage for all subsequent therapy services Poor evaluation documentation risks that ALL subsequent therapy services will be denied Poor evaluation limits potential goals as therapy progresses Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Importance of Evaluation Just because Medicare Part A does not allow time spent on evaluation to be counted toward RUG minutes doesn’t mean we shouldn’t fully assess: Get them on the mat Full ADLs Full meal assessment Document reason for functional deficits in descriptive terms Additional data can be obtained through diagnostic treatment Registered therapist treats during initial visits Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63 The Importance Prior Level of Function Medicare supports skilled intervention to assist the patient to attain their highest/prior level of function PLOF is vital to supporting medical necessity for skilled rehabilitation and support the intensity of services rendered Evidence of a Change in Condition Evidence of the potential to achieve a higher level of function
  64. 64. How to Document PLOF Gather as much information regarding the patient’s functional level prior to recent illnesses. Be Specific. Onset of illness on re-admission Address all Goals areas: Setting Distance Device Diet Paint a picture to portray the patients lifestyle prior to onset of illness Focus on function Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. Prior Level of Function Example Admission after an acute CVA: PT: Independent with all mobility without a device for unrestricted distances. Independently climbs a flight of stairs to enter home. OT: Independent with all ADL and IADLs without an assistive device or adaptive equipment. Lives alone in own home Speech: Lives independently in own home alone managing all medical and financial affairs. Communicates in high level conversation with no reported difficulty Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. Nursing Documentation Prior Level of Function Document information obtained from resident and family Admission Assessment Weekends Document patient reported goals Document specific abilities prior to onset of illness …”no longer able to wash face and comb hair” Daughter reports the patient is lived completely independently and did not use a device to ambulate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. What is Rehab Potential The patient’s potential to achieve goals set by the therapist Not related to medical prognosis Goals should be achievable with good to excellent potential to achieve Rehab potential set to Fair, guarded or Poor would indicate to Medicare that the therapist does not believe in their plan Include “Due to” or “Given the patient’s…” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Nursing Documentation Rehab Potential Focus on the potential to achieve goals Recent onset Intact abilities “Given the patient’s level of intact cognition…” “Given the recent onset of decline, the patient evidences good rehab potential” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. The Importance of Reason for Referral Details the specifics of why skilled therapy services are warranted Clarifies the events that led to a therapy referral Establishes the relationship to recent hospitalization Details the event that prompted evaluation Clarifies the specifics of the decline in function from prior level of function Points the reviewer to specific areas of the medical record Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Reason for Referral Nursing and Therapy Examples “Significant decline in function status post an acute CVA on 9/1/13” “Evidences decreased ability to safely ambulate after a 3 week hospitalization for an MI on 9/1/13” “..recurrent Pneumonia despite medical intervention indicating potential Dysphagia” “new onset of cognitive deficits impacting ability to progress in medically necessary PT and OT ” “change in cognitive status after resolution of …… “New onset of slurred speech impacting ability to communicate” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. The Importance of Measuring Functional Deficits Supports Medical Necessity Establishes the physical and cognitive baseline data necessary for assessing expected rehabilitation potential, setting realistic goals, and measuring progress Baseline from which to measure progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Level of Assist Devices and Adaptive Equipment Assessed Diet Textures Number of Caregivers to Assist Functional Levels: Maximum Assistance: The need for 75 percent assistance by one person to physically perform any part of a functional activity Moderate Assistance: The need for 50 percent assistance by one person to physically perform any part of a functional activity Minimal Assistance: The need for 25 percent assistance by one person to physically perform any part of a functional activity Contact Guard: Contact Assist to provide cues or guided maneuvering Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72
  73. 73. Supervision Supervision: Cueing Reviewers may view this level of care as restorative Ensure documentation of deficits are clearly stated Analyze task to determine if the patient is not receiving hands on assist for a portion of the task Describe Cueing Constant (max) Frequent (mod) Occasional (mod) Rare (min) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73
  74. 74. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74 Supervision Describe Causes of Cueing Technique Sequencing Pacing Initiation Describe Type of Cueing Verbal Tactile Visual
  75. 75. How to Measure Functional Deficits Current level of function for each functional deficit to be addressed in therapy Define/describe the behavior without using min/mod/max assist if needed Objective measures of function Be descriptive Amount and type Describe underlying impairments Reason for functional impairment/limitation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75
  76. 76. Reasons for Functional Limitations Examples of reasons for functional limitation: Lack of awareness of sensory cues Impaired attention span Impaired strength and or coordination Abnormal muscle tone Range of motion limitations Impaired body scheme Perceptual deficits Impaired balance/head control Environmental barriers Delayed initiation of swallow Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Reasons for Functional Limitations Safety Issues Related To: Poor posture Improper gait Weak grip, arthritis Dysphagia Poor communication skills Paralysis/paresis Perceptual deficits Vestibular disorder Cognitive disorder COPD, emphysema Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. How to Measure Functional Deficits Standardized Measurement Tools Borg Scale= 5 (Severe Breathlessness) Berg Functional Balance Scale 39/56 (Medium Fall Risk) Western Aphasia Battery(WAB) 29.9/100 (Moderate to Severe Broca’s Aphasia) Functional Outcome Measures Composite Scale Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Complexity of Task Environment In room In dining room Distraction Patient Condition End of the day versus beginning With pain (how often does this occur?) With shortness of breath (how often does this occur?) Sequence Dressing after rising from bed and toileting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Nursing Documentation of Function Focus on: Functional tasks requiring assist Partial task completion by caregivers Complex tasks that pose a challenge Functional impact of pain, dyspnea, anxiety etc. Risk assessment outcomes “Patient ambulated to the dining room with Limited Assist for the first time since returning from the hospital” Patient with limited ability to prticipate in ADLs due to increased pain with movement” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. The Importance of Summarizing Findings Supports Medical Necessity Evidences the critical thinking process Don’t leave it up to the reviewer to determine Tell a story Evidences individualization of the plan of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81
  82. 82. How to Summarize Findings Be descriptive Chart your thinking Guide the reviewer State the obvious It may only be obvious to you! Focus on the relevant Individualize Avoid canned phrases Avoid negative statements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. The Importance of Functional Rehabilitation Goal Writing Guides the reviewer through progress Reflects the logical plan of care based on the evaluation findings Supports medical necessity “The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84 What is a Measurable Rehabilitation Goal Long-Term Goals Level you expect patient to be at discharge Short-Term Goals (2 to 4 weeks) Incremental steps toward the long term goals. Think beyond diet texture, transfers, ambulation, and ADLs Based on deficits identified on assessment and in nursing documentation
  85. 85. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85 Performance Skills Motor skills: moving and interacting with task, objects, and environment Posture Mobility Coordination Strength Effort Energy
  86. 86. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86 Performance Skills Process Skills: managing and modifying action when completing tasks Energy Knowledge Temporal organization Organizing space and objects Adaptation
  87. 87. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87 Performance Skills Communication Skills: conveying intention and need and coordinating social behaviors Physicality Information exchange Relations
  88. 88. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88 Duplication of Services
  89. 89. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89 Duplication of Services Rehab goals can appear to be demonstrating a duplication of services. High risk of denial. Commonly seen goal areas: Bed mobility (PT/OT) Functional transfers (PT/OT) Functional mobility/Ambulation (PT/OT) Cognition (OT/ST) Safety (PT/OT/ST) Standing balance (PT/OT)
  90. 90. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90 Duplication of Services The goals must be written to differentiate the skilled area to be addressed by each discipline High Risk of Denial Most reviewers are NOT therapists
  91. 91. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91 Duplication of Services PT Goal: Pt. will demonstrate Good Functional Balance Better Stated As: Pt. will be able to I ambulate around obstacles in their room without loss of balance
  92. 92. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92 Duplication of Services OT Goal: Pt. will demonstrate Good Functional Balance for ADLs Better Stated As: Pt. will I complete Grooming task standing at sink without loss of balance
  93. 93. The Importance of Progress Reports Required for Payment Justifies outcome of skilled therapy intervention Supports the need to continue skilled therapy intervention Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
  94. 94. What is a Progress Report The minimum Progress Report Period is at least once on or before the 10th treatment day No later than 30 days Recommended weekly The beginning of the first reporting period is the first day of the episode of treatment Service provided on the first day of treatment is the evaluation, re-evaluation or treatment. The Progress Report Period requirements are met when both the Progress Report and the Therapist’s active participation in treatment have been documented Copyright © 2013 All Rights Reserved 94Harmony Healthcare International, Inc.
  95. 95. Assistants and Progress Reports The PT, OT or SLP clinician must write a Progress Report during each Progress Report Period regardless of whether the assistant writes other reports. Must provide treatment. Reports written by assistants are not complete Progress Reports Physical Therapist Assistants or Occupational Therapy Assistants may write elements of the Progress Report dated between clinician reports Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96 How to Write a Progress Note Each report should compare and contrast the prior level of function and describe specific areas which reflect improvement Within each level of function include specific performance tasks that the patient can demonstrate as a result of skilled intervention
  97. 97. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97 How to Write a Progress Note Include: Assessment of improvement and extent of progress (or lack thereof) toward each goal Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions Changes to long or short-term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment
  98. 98. How to Write a Progress Note Avoid: Simply listing CPT code descriptors Stating general treatment interventions (Ther Ex, strengthening, balance activities) Reflecting repetitive exercises that an unskilled care giver or restorative could provided Endurance training Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  99. 99. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99 How to Write a Progress Note Include: That the patient’s condition has the potential to improve or is improving in response to therapy That maximum improvement is yet to be attained That there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time
  100. 100. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100 How to Write a Progress Note Summary: 1) Skilled services provided since previous report to progress towards goals 2) Current Status 3) Specific progress towards each short term goal 4) Ongoing impairments to be addressed to progress towards long-term goals
  101. 101. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101 Supportive Skilled Documentation Patient at high risk for Skilled assessment of Reasonable probability Potential for recurrence Monitoring for consistency The medical regimen is not essentially stabilized Patient continues to require daily skilled rehab for Patient requires daily skilled evaluation of the plan of care
  102. 102. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102 Non-Supportive Skilled Documentation Plateau in progress Still requires Patient is unable to follow directions Patient has poor rehab potential Patient refuses to participate in therapy (without documentation of root of refusal) Within normal limits “Slow, steady gains” described in progress notes but comparison of function is without change from one week to the next
  103. 103. Non-Supportive Skilled Documentation Quoted statements from patient refusing therapy and asking to end the therapy sessions/program, yet services continued without documented improvement Monitor or observed at meals versus assessed Focus on behaviors versus what skills of a therapist were required to manage Copyright © 2013 All Rights Reserved 103Harmony Healthcare International, Inc.
  104. 104. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104 Progress Report Examples On evaluation, patient required max verbal and tactile cueing for initiation of upper body bathing while seated at the sink. At this time the patient only requires min verbal cueing and no tactile cueing to initiate upper body bathing. Progression of hip/glut strengthening exercises to now include weighted resistance
  105. 105. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 105 Progress Report Examples The patient initiated use of their prior level device of a cane for mobility this week. The patient required minimal assist to ambulate 45 to 50 feet at the beginning of the reporting period. The patient has improved to ambulate 45 – 50 feet with CGA with the cane at the end of the reporting period.
  106. 106. Progress Report Examples The patient tolerated nectar thick liquids for all meals with no evidence of aspiration. The patient was assessed with thin liquids with overt signs and symptoms of aspiration on 10% of trials. Aspiration was eliminated with patient utilization of a chin tuck with continual minimal tactile cues during the meal. Patient and care giver education was provided on use of the chin tuck compensatory swallow strategy. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106
  107. 107. Nursing Documentation of Progress Focus on: New functional abilities Partial task completion Increased initiation attempts Lesser levels of care Decreased Number of assist or symptoms “Initiated participation in care as evidenced by….” No signs or symptoms of aspiration with diet upgrade to thin liquids on 10/1/13 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107
  108. 108. Monthly Progress Report These are completed every 30 days and include components of weekly progress noted while also requiring: Updated goals and treatment plan with identification of significant improvement in functional skills “Significant” means a generally measurable and substantial increase in the patient’s present level of functional independence, and competence compared to the level of function at the time treatment was initiated. HIM 12, 544. Copyright © 2013 All Rights Reserved 108Harmony Healthcare International, Inc.
  109. 109. Monthly Progress Report Any change in treatment plan would require physician clarification orders The completion of clarification orders to communicate the expected treatment plan with the physician and receive verbal approval for the treatment to continue Copyright © 2013 All Rights Reserved 109Harmony Healthcare International, Inc.
  110. 110. Discharge Progress Report The discharge note is a Progress Report written by the clinician upon completion of each program Supports outcome of therapy intervention for all payors Copyright © 2013 All Rights Reserved 110Harmony Healthcare International, Inc.
  111. 111. Discharge Progress Report It is important to give a thorough synopsis beginning with a comparison between the initial level of function and discharge status The clinician should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode for review purposes Copyright © 2013 All Rights Reserved 111Harmony Healthcare International, Inc.
  112. 112. 112 Discharge Progress Report List all techniques and methods trialed even failed attempts Discharge setting with cues for re-referral for skilled therapy Unanticipated discharge: Data related to discharge not noted in the previous Progress Report will require the clinician writing the final note to rely on treatment notes and verbal reports of the assistant or qualified personnel Summary of progress is still needed to support services provided Copyright © 2013 All Rights Reserved 112Harmony Healthcare International, Inc.
  113. 113. Nursing Discharge Documentation Supplement with: Functional Goals achieved Medical diagnosis and conditions that have resolved Patient Education Reoccurrence of UTI Fall Risk Home Safety and Home Exercise Program developed by therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 113
  114. 114. Skilled Coverage Criteria There is no such thing as a “Rehab” or “Nursing Patient One patient One medical record One claim billed One set of Medicare coverage criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 114
  115. 115. References Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 161, 10-26-12) CMS MDS 3.0 RAI Manual v1.11 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 115
  116. 116. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 Khart@harmony-healthcare.com www.harmony-healthcare.com Harmony Healthcare International, Inc. 116116Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  117. 117. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved 117Harmony Healthcare International, Inc.
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