Section 3: Embracing Medical Necessity

Setting the Stage Why do we document care?  To insure payment for the services rendered  To insure continuity of care Principles of documentation:  Document to your audience  Focus on deficits  Attainable goals  Progress towards goals  Consider barriers to discharge  Consider return to both home and community

Setting the Stage What is Medical Necessity?  A course of treatment that is seen as most helpful for the specific health symptoms that the patient is experiencing. This course of treatment is determined by the patient and their healthcare team.

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 a decrease in UTI’s and other complications  Research is being done to determine if outcomes with hip and knee replacement patients is equivocal

Setting the Stage 7 Criteria of Medical Necessity 1.Medical Supervision 2.24 Hour Rehab Nursing 3.Relatively Intense Level of Services 4.Multidisciplinary Approach 5.Coordinated Care Plan 6.Significant Practical Improvement 7.Realistic Goals

Components of Medical Necessity Close Medical Supervision  24 hour availability of a physician  Entries in the chart every 2 -3 days minimum  Greater involvement that in other settings

Components of Medical Necessity 24 Hour Rehabilitation Nursing  Need availability of an RN with rehab experience around the clock  Have clear, functional rehabilitation goals  Nursing is involved in the overall plan of care, not just medical issues and bowel and bladder management  Nursing documentation supports FIM scores  Nursing documentation clearly identifies how they facilitate the carryover of learning from therapy sessions  Nursing documentation supports the medical management of the patient

Components of Medical Necessity Relatively Intense Level of Rehabilitation Services  The 3 Hour Rule  Minimum of 3 hours of therapy, 5 days per week  Therapy is at a skilled level  Must be necessary for meeting the basic needs of the patient’s health  Must be consistent in type, frequency, and duration  Consistent with the patient’s diagnosis

Components of Medical Necessity Interdisciplinary Approach  Members work collaboratively to develop goals and the treatment plan  Team members engage and learn from each other  Collaborative ownership of the patient treatment plan

Components of Medical Necessity Coordinated Plan of Care  Records need to show a treatment plan that is: Derived from team assessment and patient expectations Identifies STG’s and LTG’s Defines how disciplines share responsibility Supports need for intensive rehab services Weekly team conference

Components of Medical Necessity Significant Practical Improvement  We do not expect 100% independence for all rehab patients  We do expect reasonable, practical improvement  Improvement must be the result of skilled services provided  Important that it is documented clearly

Components of Medical Necessity Realistic Goals  Aim of treatment needs to be achieving the maximum level of function possible

How Do We Document Medical Necessity? Team has an ongoing opportunity to document medical necessity. This is achieved by documenting:  That services needed are of a complex nature that they require a licensed clinician  Services need to be in an inpatient setting  Services are consistent with diagnosis, need, and medical condition  Services are consistent with the treatment plan  Services are reasonable and necessary  Patient is making progress towards reasonable goals

Where Do We Document Medical Necessity? Pre-admission Screening Physician Documentation Team Admission Assessments Nursing Admission Assessments Patient Care Plan  Long term goals  Short term goals  Identification of involved disciplines  Weekly progress notes  Discharge summaries Team Conference Summaries

Key Areas Pre-admission screening  Document needs to stand alone and justify admission Physician documentation  Establishes the justification for admission through H&P 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?”

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

Pre-Admission Screening IssueAction Is inpatient rehab “reasonable & necessary”? Treatment is specific & effective for patient’s 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

Preadmission Screening Diagnoses Comorbidities Age Current interventions Functional Assessment Vitals Safety History Medications Pre-morbid status/function Recommendation of need for 2 or more disciplines Rehab potential Areas where improvement is expected

Physician Documentation IssuesAction 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 patient’s  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

Physician Documentation IssuesAction 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

Components of the H&P 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

Components of the H&P The Plan is the most important piece of the H&P because it sets the interdisciplinary care plan It defines the medical, nursing, and therapy needs of the patient. Suggested goals:  Will consult physical therapy for  Will order occupational therapy for  Will order speech/swallowing therapy for  Rehabilitation nursing is required for the following specific duties -  Will consult Dr. () with internal medicine.  Will consult Dr. () with rehab psychology to work on maximizing interactions with therapy, to decrease stress, to work on pain management issues and adjustment issues as necessary.  Medical issues being managed closely and require the 24 hour availability of a physician specializing in physical medicine and rehabilitation are as follows -  Goals - The patient is currently () with ADL's, ambulation, and transfers. We would like the patient to be modified independent with ADL's, ambulation, and transfers by discharge.

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

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 patient’s functional gains as discussed with patient

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. AdmissionDischarge Eating Grooming Bathing UE Dressing LE Dressing Toileting

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

Team Admission Assessment Prior level of function Required assistance Living situation Anticipated discharge plans Patients rehab expectation Individual FIM’s with emphasis on findings ROM and Strength limits Sensation, tone, etc. Community reintegration Pain assessments Summaries of findings

Documenting on the Patient Care Plan The Patient Care Plan should include:  Prioritized patient goals  Impairments, Activity, Participation  Planned Discharge Site  Interdisciplinary Long Term Goals  What disciplines will be involved in the care of the patient  Interventions

IAP Example AdmissionDischarge Impairments Osteoarthritis in knees, hips, back, R shoulder Activities Impaired mobility, LB dressing, bathing & toileting Improved to mod I in mobility, bathing & dressing w/adaptive equip. Participation Can’t shop for groceries, Afraid to cook, can’t perform job duties, can’t play golf Able to shop for basic food items, can prepare simple meal, will return to work 2 weeks post d/c, return to golf 6 mo post d/c

Documenting Progress At least weekly, a summary of the patient’s progress should be documented.  Document progress toward goals  Detail barriers to achievement of goals  Describe changes to the plan of care as appropriate  Describe patient’s response to treatment  State the justification for continued stay on the rehab unit

Daily Documentation of Medical Necessity Daily documentation should show skilled need in:  Weekly short term goals  Total units of therapy  Treatment/training  Daily comments

What Constitutes a Skilled Service Knowledge and training of a professional is necessary Need should be indicated in initial evaluation Evidence that skilled services were performed should be reflected in notes

What Constitutes a Skilled Service Services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can only be safely and effectively performed by qualified nurses and therapists. Skilled services can be:  Diagnostic and assessment  Designing treatment  Establishment of compensatory skills  Providing patient instruction  Reevaluations

Skilled versus Non-Skilled NonskilledSkilled Observed patient trying to get out of bed. Pt unable to come to sitting without help. Training provided to facilitate independence in bed mobility. Tactile and verbal cuing provided to produce knee flexion and arm extension and push. Pt expression - 2 with nurses. Pt. taught to use call light and respond “bathroom”. Pt able to perform sequence of pushing call light and responding to nurse 4/5. Pt – UB Dressing 4 Pt. taught strategies for compensation of left visual neglect to facilitate independence in dressing. Min assist required for buttoning shirt.

Terms Terms To AvoidTerms That Connote Skilled Services AmbulateGait training MonitorAssess ObserveEvaluate Tires easilyRequired rest periods due to….. EncourageInstruct/educate DiscussTeach DrillsTasks Little changeContinues to require Pt performedContinues to progress SupervisedAnalyze Design

Justifying Medical Necessity These words when used may not support medical necessity: NormalMaintained MonitoringCombative Regression in function Insignificant Poor rehab potentialCustodial Inability to follow directionsMinimal Refused to participatePlateau Chronic/long term conditionInappropriate Demented/ConfusedOld onset UncooperativeStable “Nothing to do. Continue current care and rehab”

Justification of Medical Necessity When used appropriately, these words help justify medical necessity. ManagingIncrease in function CriticalRequired the skills of a therapist Risk of infectionReasonable and necessary Prior level of functionSafe and effective delivery GainsMedical complications AppropriateReasonable probability ProgressPotential for complications ImprovementHigh risk factor MotivatedSafety issues ContinuedSignificant ResponsiveThe patient has the potential for a sudden change in status

Denials Why do payers tell us they deny claims?  Patient does not meet eligibility criteria  Services are not skilled  Services are not necessary for patient’s diagnosis, medical condition, or no assessed need

Denials How can we avoid denials?  Document interventions clearly and precisely  Use active, descriptive verbs

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.

What else can we do? Medical Directors should meet with leadership team to work on case finding 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 unit…external admissions are approved more readily than internal admissions. Improve communication with case management, the patient, and referring physician when patients are denied transfer or the transfer is delayed

Questions? Lisa Bazemore, MBA, MS, CCC-SLP (202)