Physician Documentation Tips

Physician Documentation Tips Lisa Werner Bazemore, MBA, MS, CCC-SLP Director of Consulting Services

Documentation • Why is documentation so important to medical necessity? • This is a time of “defensive documentation” • Just like universal precautions – assume any and all charts will be audited. • A reviewer of your medical record will only see the ink and paper you send. • In some cases they are incentivised to deny your claims!

Documentation • What is your perception of these statements from actual medical records? • The patient has no previous history of suicides. • The patient refused autopsy. • Discharge status: alive but without my permission. • She stated that she had been constipated most of her life until 1989 when she got a divorce. • Rectal examination revealed a normal-size thyroid. • On the second day the knee was better, and on the third day it had completely disappeared. • The patient has been depressed since she began seeing me in 1993. • Healthy appearing decrepit 69 year old male, mentally alert but forgetful.

Documentation • When auditors review our charts, all they see is what we have documented. They don’t know the patient and don’t know our protocols for patient care.

Physician Documentation • Purpose: • Establish medical necessity • Clearly state why the patient needed to occupy an inpatient rehabilitation bed • Indicate why the patient requires an intense level of rehabilitation services • List problems and services that are needed • Define why patient could not have their needs met in a skilled nursing facility AND • Document information required to ensure continuity of high quality care

Physician Documentation • Physician Buy-In for Medical Necessity • Physicians should be partnered with for the good of the patient and facility so that they: • Understand the importance of medical necessity and medical necessity documentation in rehab • Can identify how medical necessity can be assimilated into their current documentation style

Physician Documentation • What’s so special about Physical Medicine and Rehabilitation? • Combining into one Plan of Care • Medical treatments • Therapy treatments

Physician Documentation • What’s so special about Physician documentation? • CMS stated that if they could identify that the stay was reasonable and necessary through the pre-admission screening and the post-admission evaluation, they would spend less time reviewing the rest of the chart.

The Rule • Documentation Requirements • Contractors must consider the documentation in the IRF record when determining if admission was reasonable and necessary, focusing on: • pre-admission screening • post-admission physician evaluation • overall plan of care • admission orders

The Rule • Requirements for the Pre-admission Screening • CMS believes that a comprehensive pre-admission screening process is the key factor in initially identifying appropriate candidates for IRF care. • Pre-admission screening is an evaluation of the patient’s condition and need for rehabilitation therapy and medical treatment. • It is required documentation of the clinical evaluation process that forms the basis of the admission decision. • Serves as the primary documentation by the IRF clinical staff of the patient’s status prior to admission and of the specific reasons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary. • Must be detailed and comprehensive.

The Rule • Pre-admission screening should show: • That the patient has the appropriate therapy needs for placement in an IRF • The patient is expected to make measurable improvement that will be of practical value in terms of improving the patient’s functional capacity or adaptation to impairments. • That the patient’s condition is sufficiently stable to allow the patient to actively participate in an intensive rehabilitation program • The patient is able and willing to participate in an intensive rehabilitation program that is provided through a coordinated interdisciplinary team approach in an inpatient setting.

The Rule • Pre-admission screening should show: • An interdisciplinary team approach to care requires that treating clinicians interact with each other and the patient to define a set of coordinated goals for the IRF stay and work together in a cooperative manner to deliver the services necessary to achieve these goals. • That the patient requires the intensive services of an inpatient rehabilitation setting: • The patient “generally requires and is reasonably expected to actively participate in at least 3 hours of therapy per day at least 5 days per week and is expected to make measurable improvement that will be of practical value to improve their functional capacity or adaptation to impairments.”

The Rule • Scope of pre-admission assessment should include: • Patient’s prior level of function (prior to the event or condition that led to the patient’s need for intensive rehabilitation therapy) • Expected level of improvement • Expected length of time needed to reach that level of improvement • Evaluation of the patient’s risk for clinical complications • Conditions that caused the need for rehabilitation • Combination of treatments needed (one of which must be PT or OT) • Expected frequency and duration of treatment in the IRF • Anticipated discharge destination • Any anticipated post-discharge treatments • Other information relevant to the care needs of the patient

The Rule • Pre-admission screening timeline, approval and retention: • Individual elements of the pre-admission screening may be evaluated by any clinician designated by a rehab physician, as long as the clinicians are licensed or certified and qualified to perform the evaluation within their scopes of practice and training. • Each IRF may determine its own process for collecting and compiling the pre-admission screening information. The focus of the review of the screening will be on its completeness, accuracy and the extent to which it supports the appropriateness of the admission decision.

The Rule • Pre-admission screening timeline, approval and retention: • Must be completed within the 48 hours immediately preceding the IRF admission. • If the patient is not admitted within 48 hours of the screening, an update conducted in person or by telephone no more than 48 hours prior to admission is required to document changes in the patient's medical and/or functional status. • Rehabilitation physician must review and document his or her concurrence with the findings and results of the pre-admission screening prior to the IRF admission.

The Rule • Pre-admission screening timeline, approval and retention: • IRF is responsible for developing a thorough pre-admission screening process for patients admitted to the IRF from the home or community-based environment which includes all the required elements described. • Pre-admission screens cannot be done over the telephone; however, updates can be done over the telephone. Pre-admission screenings can be done from faxed patient records. • Must be retained in the patient’s record.

The Rule • Requirement for a Post-Admission Physician Evaluation • To be completed by a rehabilitation physician within 24 hours of admission • Document the patient’s status on admission to the IRF • Compare it to that noted in the pre-admission screening documentation • Begin development of the patient’s expected course of treatment that will be completed with input from all of the interdisciplinary team members in the overall plan of care • Identify any relevant changes that may have occurred since the pre-admission screening • Provide guidance as to whether or not it is safe to initiate the patient’s therapy program • Support the medical necessity of the IRF admission • Include a documented history and physical exam, as well as a review of the patient’s prior and current medical and functional conditions and comorbidities

The Rule • Requirement for a Post-Admission Physician Evaluation • It would be useful for the post-admission physician evaluation to: • Describe the clinical rehabilitation complications for which the patient is at risk and the specific plan to avoid them • Describe the adverse medical conditions that might be created due to the patient’s comorbidities and the rigors of the intensive rehabilitation program, and the methods that might be used to avoid them • Predict the functional goals to be achieved within the medical limitations of the patient

The Rule • Requirement for a Post-Admission Physician Evaluation • Serves as a combination medical/functional resource for all team members in the care of the patient as they prepare to contribute to the overall plan of care • Requires the unique training and experience of the rehabilitation physician, as he or she performs a hands-on evaluation of the patient • Does not require the physician to obtain input from the interdisciplinary team prior to completing, although it would be in the best interest of the patient if team member input were provided • The document must be retained in the medical record

The Rule • Requirement for a Post-Admission Physician Evaluation • The conclusion of a post-admission evaluation may result in a change from the pre-admission conclusion that the patient is appropriate for IRF care – in such cases, appropriate action should be taken. • The rehabilitation physician must note the discrepancy and document any deviations from the pre-admission screening • For example, patient believed to be able to tolerate 3 hours per day, but only tolerates 2 hours on day one due to pain from the ambulance trip to the IRF. In this case the reason for the temporary change must be noted in the patient’s medical record – no need to discharge

Physician Documentation • Admission Post-Admission Assessment Format • Patient Name/History #; Room # • Date of Admission: • History of Present Illness: • Medical History (Include onset date, chief complaint and functional implications) • Allergies: • Medications: (Reconcile home meds, MAR and discharge summary meds) • Past Medical History: • Social History: • Family History: • ROS: • Physical Exam:

Physician Documentation • Admission Post-Admission Assessment Format (continued) • Assessment/ Plan: • Compare current status with status as notes on the pre-admission screening form • Provide guidance as to whether or not it is safe to initiate the patient’s therapy program • Impairment (Reason for admission) • Etiologic diagnosis (Pathophysiologic reason for reason for admission)

Physician Documentation • Admission Post-Admission Assessment Format (continued) • Medical Necessity – “The etiologic diagnosis and comorbidities listed below require the 24 hour availability and frequent intervention of a physician with specialized training in rehabilitation.” • List of comorbidities & interventions • Describe the clinical rehabilitation complications for which the patient is at risk and the specific plan to avoid them • Describe the adverse medical conditions that might be created due to the patient’s comorbidities and the rigors of the intensive rehabilitation program, and the methods that might be used to avoid them

Physician Documentation • Admission Post-Admission Assessment Format (continued) • Rehab Necessity (Medical Impact on Function) – • Treatment plan: • Include nursing (“24 hr. rehab RN for bowel program, therapy carryover, pt edu., skin,…”) • Include therapy (“Intensive therapy for 3 hours/day 5 days/week. Interventions: PT to address…, OT to address…, etc.” OR “Refer to complete admission orders for interventions”) • Include weekly team conferences to coordinate plan of care. • Rehabilitation Goals: • Prognosis: • Estimated LOS: • Planned Discharge Disposition:

Physician Documentation • Assessment / Problem List should include: • Rehabilitation diagnosis (primary functional limitation, primary impairment and cause) • Complications and coexisting conditions • Symptoms that will require treatment • Chronic medical conditions • Potential conditions that require preventive measures, restrictions and/or precautions • Functional deficits to be treated by the program

Physician Documentation • What is the plan? • The preliminary plan supports medical necessity by describing the “treatment for the condition” • Indicates the decision to admit the patient • Provides evidence of the complexity of the interdisciplinary program • Lists the interventions to be provided by each team member • Implies the skill level required to provide such services

Physician Documentation • Things to avoid in the assessment and plan: • Do not use the same statement for all patients admitted • Less is not more • Writing efficiently can help control length • Limiting the list to medical conditions only • Forgetting to document what nursing will do • Forgetting to document what therapy will do • Comments like: • “Medically stable” • “No medical issues” • “Uneventful course”

Physician Documentation • Document therapy treatment status, goals and plan in the plan • Examples • We will initiate comprehensive rehabilitation program with physical therapy, occupational therapy, recreational therapy, 24 hour rehabilitation nursing and physicians. She will benefit from this comprehensive rehabilitation program to address ADLs and mobility status post surgery as she is currently requiring moderate assistance for ADLS and mobility. • Hypertension – Will monitor and adjust dosing of Norvasc and hydrochlorothiazide due to recent uncontrolled pressures. • Postop anemia – Hemoglobin has been stable at 9, will continue to monitor and consider adding iron supplementation if this continues to be an issue. Will hold off for now as patient has constipation and iron can be constipating. • Rehabilitation therapies – Goals to manage pain, increase ambulation and ADLs to goal of independent level and to work on range of motion with CPM machine. Assess for equipment needs and home safety.

Physician Documentation • Link medical and therapy issues to show how they interrelate • A 72-year old female, previously modified independent, following cerebellar infarct now has decreased balance and coordination. She is now unable to return to prior level of function. Needs inpatient rehab, physical, occupational and speech therapies for decreased function and cognition. Rehab physician management is needed therapy plan of care, management of pain control with non-narcotic use, management of chest pain and monitoring for complications following stroke. Rehab nursing to work on bowel and bladder training, transfers, education. • Physical therapy to work towards improvement of bed mobility, transfer training, balance/coordination with gait to a modified independent level • Rehab nursing to support therapy goals, return to modified independent with bowel/bladder, educate on prevention of stroke • Occupational therapy… Speech therapy…

The Rule • Requirement for Evaluating the Appropriateness of IRF Admission / Inpatient Rehabilitation Facility Medical Necessity Criteria • Must reasonably be expected to actively participate in, and benefit significantly from, the intensive rehab therapy program. • This occurs when the patient’s condition and functional status are such that: • The patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient’s functional capacity or adaptation to impairments) as a result of the rehabilitation treatment and • such improvement can be expected to be made within a prescribed period of time.

The Rule • Requirement for Evaluating the Appropriateness of IRF Admission / Inpatient Rehabilitation Facility Medical Necessity Criteria • The patient requires physician supervision by a rehabilitation physician (defined as a licensed physician with specialized training and experience in inpatient rehabilitation). • The information in the patient’s IRF medical record must document a reasonable expectation that at the time of admission to the IRF, the patient’s medical management and rehabilitation needs require an inpatient stay and close physician involvement. • Means that the rehab physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay in the IRF to… • Assess the patient both medically and functionally (with an emphasis on the important interactions between the patient’s medical and functional goals and progress), as well as… • Modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process.

The Rule • Requirement for Evaluating the Appropriateness of IRF Admission / Inpatient Rehabilitation Facility Medical Necessity Criteria • Candidates for IRF admission should be assessed to ascertain the presence of risk factors requiring a level of physician supervision similar to the physician involvement generally expected in an acute inpatient environment, as compared with other settings of care (proposed rule). • Per CMS, during the past 25 years, it was often assumed that “close medical supervision” was demonstrated by frequent changes in orders due to a patient’s fluctuating medical status. Currently, however, patients’ medical conditions can be more effectively managed so that they are less likely to fluctuate and interfere with the rigorous program of therapies provided in an IRF. • All IRFs may increase the frequency of the physician visits as they believe best serves their patient populations.

Physician Documentation – Progress Notes • Proving medical necessity during the stay • Close medical supervision means patient requires medical care daily • Evidenced through physician visits and progress notes • Do each of these visits demonstrate active intervention by the physicians on the medical and rehabilitation needs of the patient? • Are there changes in orders for the rehabilitation intervention?

Physician Documentation – Progress Note • Daily Progress Note • Subjective • Objective • Assessment / Plan • Medical issues being followed closely • Issues that 24 hours rehabilitation nursing is following • Rehab progress since last note • Justification for continued stay • Continue current care and rehab or adjustment to plan of care

Physician Documentation – Progress Note • Saying it: • 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

Physician Documentation – Progress Note • Remember to include • 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

Physician Documentation – Progress Note • Documentation about therapy treatment status, goals and plan in the same document as the medical treatment plan • Examples • Therapy progress is delayed due to new onset cognitive issues, I will order a speech therapy consult • Pain is limiting progress in all disciplines so we will increase the patient’s pain medications to include . . . • Missed 1 hour of therapy due to nausea and vomiting, will add Phenergan PRN for reoccurrence

Physician Documentation – Progress Note • Link medical and therapy issues to show how they interrelate • Example • Hypertension remains uncontrolled despite adjustment in Norvasc. This has resulted in fatigue and discomfort that have caused the patient progress slowly with PT and OT. Will consult cardiology to assist with control of hypertension and remove this barrier to intensive therapy participation. • Missed 1 hour of therapy due to nausea and vomiting per PT, will add Phenergan PRN for reoccurrence and monitor participation in intensive rehab via conversations with therapy.

Physician Documentation – Discharge Summary • 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 improvement: • 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. • Discharge diagnosis and comorbidities: • Discharge follow-up: • Discharge medications: • Discharge labs: • Discharge therapy with outpatient/home health care/no therapy needed

The Rule • Requirement for an Individualized Overall Plan of Care • Essential to providing high-quality care in IRFs since comprehensive planning of the patient’s course of treatment early on leads to a more coordinated delivery of services to the patient. Such coordinated care is a critical aspect of the care provided in IRFs. • Requires that an individualized overall plan of care be developed for each IRF admission by a rehabilitation physician with input from the interdisciplinary team by the end of the fourth day following the patient’s admission to the IRF. • Must support the determination that the IRF admission is reasonable and necessary. • Must be maintained in the medical record.

The Rule • Requirement for an Individualized Overall Plan of Care • Synthesized by a rehabilitation physician from: • Pre-admission screening • Post-admission physician evaluation • Information garnered from the assessments of all therapy disciplines • Information from the assessments of other pertinent clinicians

The Rule • Requirement for an Individualized Overall Plan of Care • Purpose is to support a documented overall plan of care. The overall plan of care must detail: • Estimated length of stay • Patient’s medical prognosis • Anticipated functional outcomes • Anticipated discharge destination from the IRF • Anticipated interventions that support the medical necessity of the admission • Based on patient’s impairments, functional status, complicating conditions, and any other contributing factors. Should include these details about the PT, OT, SLP, P/O therapies expected: • Intensity (# of hours/day) • Frequency (# of days/week) • Duration (total # of days during IRF stay)

The Rule • Requirement for an Individualized Overall Plan of Care • Individual clinicians will contribute, but it is the sole responsibility of a rehabilitation physician to integrate the information that is required in the overall plan of care and to document it in the patient’s medical record. • If the overall plan of care differs from the actual length of stay and/or expected intensity, frequency and duration, then the reasons for the discrepancies must be documented in detail in the patient’s medical record. • Good practice to conduct the first interdisciplinary team meeting within 4 days of admission to develop the overall individualized plan of care. It is the IRF’s choice to develop the internal process.

Questions? Lisa Werner Bazemore, MBA, MS, CCC-SLP lbazemore@erehabdata.com 202-588-1766

Physician Documentation Tips