Physician’s Guide to Documenting Medical Necessity

1. Physician’s Guide to Documenting Medical Necessity Lisa Bazemore, MBA, MS, CCC-SLP

2. 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

3. 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?

4. 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.

5. Exemption Criteria

6. Exemption Criteria

7. Exemption Criteria

8. Medical Necessity • Basic Principles • Service must be reasonable and necessary (in terms of efficacy and, duration, frequency, and amount) for the treatment of the patient’s 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

9. 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

10. 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?”

11. 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

12. Pre-Admission Screening

13. Physician Documentation

14. Physician Documentation

15. 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

16. 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 H&P • 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

17. 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

18. 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

19. 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

20. 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

21. 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 Problem List Examples

22. 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 Problem List Examples

23. 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

24. 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

25. 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

26. 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”

27. 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

28. 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 Inadequate Example of a Plan

29. 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.

30. 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

31. 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

32. 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.

33. Composing a Plan • 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.

34. 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

35. 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

36. 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

37. 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

38. 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”

39. 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

40. 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.

41. 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 unit…external 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.

42. Questions? Contact me at: Lbazemore@erehabdata.com 202-588-1766