Physician’s Guide to Documenting Medical Necessity

1. Physician’s Guide to Documenting Medical Necessity Lisa Bazemore, MBA, MS, CCC-SLP December 5, 2006

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 • Leadership • Understand weaknesses and strengths • Establish systems for review • Push for documentation improvement through patient advocacy.

3. Industry Trends • From the beginning of the 75% rule modification in July 2004, over 113,000 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 113,000 patients who would have benefited from inpatient rehabilitation did not receive it. • Why?

4. Industry Trend • 75/25 Rule – average compliance is 65% and many units are unnecessarily well above this compliance level • Mixed messages scared too many physicians/medical directors/program directors into denying patient’s admission • Improved physician documentation may have resulted in fewer denied admissions • Fear of the denial process • RAC audit process

5. Medical Necessity Let’s Try to Define Medical Necessity There is not one specific aspect of care or one specific service that defines medical necessity Rather it is a combination of aspects of care that together comprise medical necessity Together these aspects determine which services are covered or could possibly be denied

6. 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

7. Medical Necessity • Services are relevant to a patient’s diagnosis, symptoms, condition or injury • Services provided are within the standards of practice for a specific condition or diagnosis • Services require the skills of the specific professionals within your setting • Services that are provided in your setting possibly would not be furnished in the same quality or quantity or time frame in another setting

8. Medical Necessity • Services are consistent with patient’s symptoms, diagnosis, condition or injury • Services are recognized as the prevailing standards and are consistent with generally accepted professional medical standards of the provider’s peer group • Services treat a condition which could result in physical or mental disability • There is not another setting which is more conservative or substantially less costly

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 a decrease in UTI’s and other 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. 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.

17. 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

18. 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

19. 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

20. 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

21. 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”

22. 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

23. 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.

24. 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

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