Documentation: Our Best Defense for Scrutiny. Why focus on Documentation Competency? Communication of Resident Care –Among ISC clinicians, physicians,

Documentation:

Our Best Defense for Scrutiny

Why focus on Documentation Competency?

• Communication of Resident Care– Among ISC clinicians, physicians, caregivers, other health care

professionals

• Development of clinician skill set– Promotes quality resident care through assessment,

reassessment, planning and development– Objective feedback provides opportunity for growth and training

• Justifies need for services– “Paints the picture” of the medical and functional deficits of the

patient– Documentation of skilled treatment necessary to return the

resident/patient to their prior level of function

Why Focus on Documentation Competency?

• Proactive Approach to Increased scrutiny– Increased ADRs across the Country

– RACs, ZPICs, OIG, State Surveyors

• Reduces Risk of:– Payment Denial

– Legal dispute and clinical scrutiny

• Remember the old saying “If it isn’t documented . . .

it didn’t happen”!

Objectives

1. Identify Top 5 areas of documentation focus

2. Provide training and support to improve 5 key areas of documentation

3. Implement documentation strategies to withstand scrutiny

4. Reduce rate of denial and ADR request volume

5. Improve survey / audit outcomes

Objectives






Objectives






Objectives






Objectives






Who/What influences Documentation

Standards/Requirements?• CMS – Center for Medicare and Medicaid Services

– sets national guidelines

• Medicare Administrative Contracts (MACs) – a CMS contracted third party that sets local guidelines for payment– (Example: Wisconsin Physician Services)

• Regulatory Agencies – (Example: JCAHO, Rehab Agency, Home Health)

• State Practice Guidelines – (Example: TX HCSS, practice acts)

• Results of Probes, Reviews, and Audits performed by these agencies

• Primary template for documentation set by CMS and the MACs– Define payment for services– Other regulatory agencies also provide direction,i.e.,

CoPs for RA, HH, Hospice– Ongoing change of requirements and standards

• ISC Model and Standards:– Our proactive model requires strict adherence to quality

documentation to support and demonstrate medical necessity, functional deficits, skilled treatment

Who/What influences Documentation

Standards/Requirements?

Resources for Documentation Guidelines

• National Coverage Determinants (published by CMS)• Local Coverage Determinants (published by Medicare

Administrative Contractor-MAC)• State Practice Acts (State Licensing Board)• ISC chart audit forms (BSL net)• ISC Personnel

– Coordinator– Director of Therapy Services– Director of Professional Services– Regional Director of Operations– Regional Director of Appeals– Regional Director of Training– Senior Director of Operations

Essentials in Documentation

• Technical Completion/Accuracy

• Medical Necessity of Skilled Intervention

Technical Accuracy: Required Documentation Components

• All Documents (including orders) are . . .– Present

• Utilize Medical Record Checklist for Outpatient and HCC

• HCHB– Compliance with workflow

– All supporting documents scanned into system

– Timely and Dated• Ensure EACH document / note has a date and is completed

on the date of service

• Ensure EACH order is signed and dated by clinician or physician

• Follow regulatory requirements for timelines

Technical Accuracy: Required Documentation Components

(continued)

• Complete: NO spaces left blank• Indicate “not assessed” or strike through the item

(paper documentation only)• Organized (See Chart Set-up in Documentation Manual) • Signature, Credentials and printed name

• (e.g. John Smith, PT John Smith, PT)• Legibility

• Auditor should be able to clearly read documentation• Avoid overcrowding the forms

Documentation Timeline Expectations

Requirement Home Health Outpatient/HCC

Orders Verbal orders required prior to initiation of eval and/or any changes in POC

Signed & dated MD orders required prior to initiation of eval & tx. and/or any significant changes to POC

Evaluation/Assessment Perform w/in 48 hours of referral

Perform w/in 48 hours from receipt of order

Completion of Initial Evaluation Certification Form

On Date Services Provided On Date Services Provided (no later than 9:00 A.M. following day)

OASIS Completion 4 calendar days from SOC N/A

Physician Signed & Dated Evaluation Form

Must have by End of Episode or prior to billing of claim

Within 30 days from SOC; should f/u at 14-day assessment if not received to ensure compliance

Daily Visit Notes Point of Service / By Daily Close

Point of Service / By Daily Close

Top 5 Focus Areas for Medical Necessity

• Medical and Treatment Diagnosis supported

• Prior Level of Function

• Skilled Intervention

• Goals Progressed

• Patient’s Response / Progress

Diagnosis Supported

• Objective measures, tests, and assessments

• Medical History

• Medical Questionnaire

• Physician’s Order includes diagnosis

Diagnosis Supported Examples by discipline

• PT Treatment Dx: Gait Abnormality– Objective tests: TUG, DGI, Tinetti, Berg– Medical History/Medical Questionnaire: prior CVA in 2003

• OT Treatment Dx: Lack of Coordination– Objective tests: PPT, 9-hole peg Test, etc.– General Medical Questionnaire: History of Athritis

• ST Treatment Dx: Cognitive-Linguistic– Objective tests: SPMSQ, GDS, BCRS, etc.– Physician order: Dementia diagnosis

• SN Dx: COPD– Objective tests: Borg RPE (Rate of Perceived exertion)– Medical History: COPD

Where to document Diagnosis - HCHB

Diagnoses - Tap diagnoses.

To Add a Diagnosis - Tap “add.” Then tap “select…” next to code. The default value for the diagnosis code is Home Health (most frequently used diagnoses). If the diagnosis you are searching for does not appear within the search, tap on the down arrow next to “Home Health” and change to “all.” The second box is a drop-down box that allows a search by ICD code or description. The default value is ICD code. Tap on the down arrow to change from code to description. In the third field, type the code or description and tap “search.” (Remember to use the decimal if you are typing in a numeric code greater than 3 numbers).

Where to Document Diagnosis – Outpatient and HCC

• Evaluation Certification Form, Page 1, #’s 15-16

1. Patient’s Last Name

Simpson 2. First Name MI

Marge Q 3. HI CN

123-12-1234 4. Provider #

000100

5. Provider Name Innovative Senior Care

6. DOB 01-01-1931

7. Age 81

8. Sex

M F

9. Current Living Environment

AL I L SNF Other_________

10. Prior Living Environment (3 months prior)

AL 11. Hospitalization Related to this Episode of Care NA FROM TO

12. Prior therapy (related to this condition/dx) N/A DATE 12/1/11-12/28/11 HH PT/OT RESULTS Improved transfers and mobility in apt

13. SOC Date 01/ 03/ 2012

14. Are the services of a caregiver/ family member required? Yes (I f yes check below) No

Assistance provided for: amb in room/apt amb outside of room/apt transfers other ________________________________

15. Medical DX

1. I CD9 #_249.6 Description____Peripheral Neuropathy __________________ Onset Date _12/20/11___

2. I CD9 #_250.93___ Description____DM II uncontrolled Onset Date _12/20/11__

3. I CD9 #_250.72 __ Description____DM peripheral circulatory disorder ______________ Onset Date _12/20/11__

17. Rehab Potential

_good____ 16.

Treatment DX

1. I CD9 #_781.2____ Description____abnormality of gait _______________________ Onset Date _12/20/11___

2. I CD9 #_781.3 ___ Description____Lack of coordination Onset Date _12/20/11___

3. ICD9 #_719.57___ Description____joint stiffness – bilateral ankles_________________ Onset Date _12/20/11___

18. Reason for Referral (state change in function) _ Multiple falls related to loss of protective sensation. Does not have any compensatory techniques________

Patient’s Goal _Ambulate with her cane without pain or fear of falling_________________________________________________________________________________

History related to this treatment _ She has a History of PVD with several grafts to both lower exremities, recent discovery of several small vasular infarcts in her brain with vision loss. She also has pain and stiffness in both shoulders and upper back area . _____________________________

To what extent is pt/guardian aware of therapy dx/prognosis? Fully Somewhat Not at all Concerns addressed? Yes (If Yes, how?__education provided on benefits/ risks of therapy _____________________________) No N/ A

Expectation for Positive Prognosis Aware of diagnosis Stimulable Motivated Family Support Previous I nterventions were Positive Other ___________________________________

Able to follow: 1 2 3 step commands I s a cognitive therapy referral needed? Yes No Referral to: ST OT _______________________________

Pain: Location__feet__________________________ Rating__7____/10 Location__Right leg______________________ Rating_ 7_/10 NA – No pain reported

Pt is unsafe in the following activities: Ambulation ( Level Surfaces, Unlevel Surfaces) Transfers W/C Mobility Stairs Other ___________________

Prior Level of Function

• Describes the patient’s highest functional abilities prior to the onset of their complaint, incident or decline in functional capacity– Usually within 3 months of the onset

• Must be discipline and treatment specific – i.e. ST describes prior communication abilities,

while OT describes prior ADL planning abilities since that is their focus of treatment

• Include PLOF for each functional focus or deficit that is being treated

Prior Level of Function Examples

• PT– “Pt. amb. Independently 1000’ with std. cane on in/outdoor

surfaces without loss of balance”

• OT– “Pt. donned/doffed clothing independently without shortness of

breath, fatigue or loss of balance in less than 5 minutes”

• ST– “Pt. tolerated unrestricted diet consistency without

signs/symptoms of aspiration”

• SN– “Pt. managed medications independently”

Where to document PLOF - HCHB

PATIENT NOT DEEMED HOMEBOUND

OTHER/NARRATIVE

FORM: Q: INDICATE REASONS CLIENT IS HOMEBOUND:... - A: OTHER - SPECIFY

INDICATE OTHER HOMEBOUND STATUS REASON: TYPE: TEXT - MULTISELECT: N

N/A [INSURANCE]

HEALTH HISTORY - 3 (ADD-ON: OT/PT/ST) NEW *Effective From 12/08/2010 To 01/01/2100

INDICATE PATIENT PRIOR LEVEL OF FUNCTION - PRIOR TO THIS EPISODE OF ILLNESS (MARK ALL THAT APPLY): TYPE: LIST - MULTISELECT: Y

INDEPENDENT IN COMMUNITY

INDEPENDENT AT HOME

INDEPENDENT WITH USE OF ASSISTIVE DEVICES

OTHER/NARRATIVE

FORM: Q: INDICATE PATIENT PRIOR LEVEL OF FUNCT... - A: OTHER (SPECIFY)

INDICATE OTHER PRIOR LEVEL OF FUNCTION: TYPE: TEXT - MULTISELECT: N

ENVIRONMENTAL - 9 (ADD-ON: OT), (D/C FROM DISCIPLINE: OT), AND (VISITS: OT) *Effective From 12/08/2010 To 01/01/2100

ARCHITECTURAL ASSESSMENT/HOME EVALUATION ASSESSED? TYPE: LIST - MULTISELECT: N

NO

FORM: ENVIRONMENTAL - A: 0 - NO

INDICATE REASON ARCHITECTURAL ASSESSMENT/HOME EVALUATION NOT ASSESSED: TYPE: LIST - MULTISELECT: N

NOT APPROPRIATE AT TIME OF EVALUATION

NOT APPLICABLE

YES

FORM: ENVIRONMENTAL - A: 1 - YES

Where to Document PLOF – Outpatient and HCC

• Outpatient/HCC Evaluation Certification Form: Page 2, Space #20

Skilled Intervention

• MUST be documented in each visit note

• All services documented must show a level of skill and complexity that only a skilled therapist, therapy assistant or nurse can provide

• Should include specific goal-directed actions the therapist or nurse provided during the visit to achieve functional outcomes

Skilled Intervention Examples

• “PT instructed patient in safe, sit-to-stand transfer sequence, pt. return demonstrated with 50% accuracy”

• “ST facilitated production of multi-syllabic words in isolation with focus on accuracy”

• “OT designed compensatory tools to aid in appropriate sequencing of dressing tasks”

• “SN instructed use of Medication reminder tool to aid in independence with medication management”

Skilled Intervention Action Words

Where to document Skill -Outpatient and HCC

Where to document Skill -HC HB

• Login to PointCare – Tap on the PointCare application on the device – review agent

ID, password, version and server

– Interventions for today’s visit. What you taught, what you did. Interventions are disease-specific and were selected at the SOC visit

– All interventions appear at all therapy/nursing subsequent visits unless an exception code is used to discontinue them

– Therapy Goals/Status – Therapy/Nursing specific items are tracked from status/goals perspective

Short Term Goals•Smaller objective, functional goals that will be progressed and revised throughout the POC to achieve the LTG

Short-Term Goals Progressed

• Listed with anticipated time for completion • Written as “patient will . . . ” describing expected

outcomes• Objective/measurable (e.g. time, level of

assistance, number of errors, etc.)• Functional (Must answer “For what functional

purpose does this goal help the patient achieve”) • Related to the care setting (IP/OP/HH) and

expected D/C location

Short-term Goals Progressed (cont.)

Short – Term Goals Progressed Examples

Outpatient: “In 2 weeks, pt. will amb. 150’ with 4w/w supervised with minimal shortness of breath to increase functional ambulation tolerance”– How would you change or progress this goal?

• Distance• Device• Level of supervision• Amount of perceived shortness of breath (Borg scale)• Ambulation destination (bathroom, dining room, grocery store, etc.)

Home Health: “In 3 visits, pt. will verbalize 2/5 safety precautions for safe O2 use in the home”– How would you change or progress this goal?

• Number of items verbalized correctly• Demonstration versus verbalization

Home Health vs. Outpatient Goals

Home Health•Safety in home with ADL function•Pain management•Stabilize medical condition•Perform ADLs safely with use of adaptive devices/assist•Judgment related to safety

Outpatient•Ability to maximally function in/out of home environment•Increased strength/ endurance for outside activity•Maximize independence with ADL function•Higher level executive function

Where to Document Short-Term Goals in HCHB

• The NDPs (Nursing Diagnoses/Problem Statements) establish each discipline’s 485 orders and 485 goals as well as set up the care plan for all future visits in the episode

• NDPs are established by the evaluating RN or therapist in the field, however, office users can also edit NDPs from two different screens:

(1) While Reviewing Evaluation Documentation visits; or

(2) Via Clinical Input by right clicking on the visit from the applicable Visit Note. If the second is used, the patient’s care plan is updated the day after the Interventions and Goals were regenerated in HCHB

• Interventions and Goals will be generated (or regenerated if the NDP is edited) for all visits of that discipline that have not yet been started

Where to Document Short-Term Goals in Outpatient/HCC

• Evaluation Certification Form: Page 2, #24

Patient’s Response / Progress Documented

• Response and Improvement is evidenced by – Successive objective measurements– Subjective measures (evidence-based)

• Visual Analog Scale (VAS)

• Documented in progress notes and summaries

Patient’s Response / Progress Examples

• PT: “Pt. demonstrated increased tolerance of UE exercises using 1lb. with increased repetitions to 15

• OT: “Pt. requires 50% less verbal cues /prompting for safety and sequencing of dressing tasks.

• ST: “Pt. improved short-term recall to from 5/10 to 9/10 items”

• SN: “Pt. now demonstrates 5/5 safety precautions in use of O2 in the home.”

Where to Document Patient Response/Progress - HCHB

• Login to PointCare (Tap on the PointCare application on the device – review agent ID, password, version and server)

• Therapy Goals/Status - Therapy-specific items are tracked from status/goals perspective. Only select those items necessary for the patient. – If the goal and the status are the same, a red exclamation mark will appear

in the carryover status. Carryover if you want to continue to monitor that item.

– Can enter remarks. Tap set remark, enter remark, tap set remark.

– Goals can be updated by a therapist only – not by an assistant

– This becomes the “O” of the soap note – objective

• Therapy Assess/Plan – Free text boxes. Becomes the “A” and “P” part of the SOAP note – assessment / plan. Give a short assessment of the visit and the plan for next visit

Where to Document Patient Response/Progress – Outpatient and HCC

• Daily Visit Notes– Pt. Comments– Weekly Summary of Progress– Exercise Record

• 14-day Progress Summary

• Discharge Summary

Patient’s Response / Progress Example – Exercise Record

• Note progress in repetitions, seconds, etc.

Patient’s Tx Wk (ex: Tues – Mon or Fri to Thurs) ____________________ to ________________________Friday to ThursdayRecord reps, w eights, time, etc. to document progress and increased levels of diff iculty.

Exercise

Date 10/20/06 Date 10/23/06 Date 10/24/06 Date 10/25/06 Date 10/26/07

Lingual lateralization x5 reps x10 reps x15 reps x20 reps x20 reps

Lingual Resistance 2 seconds 2-3 seconds 5 seconds 5 seconds 10 seconds

EXERCISE RECORD PT OT ST Patient's Name _____Susan Smith_________

Final Thoughts

Good Documentation tells the

patient’s story.

In any care setting. . . we can demonstrate the value and necessity of our service by describing the patient’s functional decline AND how the skilled services we

provide helps to meet their needs, achieve meaningful independence, and quality of life.

Remember: Documentation is our Best Defense!!

Innovative Senior Care

Rehabilitation…Fitness…Education