Physician’s Guide to Documenting Medical

NecessityLisa Bazemore, MBA, MS, CCC-SLP

December 5, 2006

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.

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?

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

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

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

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

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

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

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

Issue Action

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

Physician Documentation

Issues Action

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 diagnosisSite the etiologic diagnosis and the rehab impairment classification (RIC)Review of systemsActive co-morbid conditions – conditions that will be addressed by the physicianList all medical problems with particular note to those that will affect the rehab outcomeIdentify functional limitationsDetermine rehabilitation potential: for functional gain & for return to independenceIdentify pre-morbid functionOther therapy receive and outcomeIdentify pre-morbid living situationEstablish general outcome goals: yours and the patient’sOrders for therapy and nursing – including rehab nursingEstimate the length of stay as it applies to goalsNote the expected discharge destinationInitiate discharge planning

Physician Documentation

Issues Action

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 programsDocument changes in plan of careDocument barriers to attaining goalsDocument 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.

 

Admission Discharge

Eating

Grooming

Bathing

UE Dressing

LE DressingToileting 

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

Justifying Medical Necessity

These words when used may not support medical necessity:

Normal MaintainedMonitoring CombativeRegression in function InsignificantPoor rehab potential CustodialInability to follow directions MinimalRefused to participate PlateauChronic/long term condition InappropriateDemented/Confused Old onsetUncooperative Stable

“Nothing to do. Continue current care and rehab”

Justification of Medical Necessity

When used appropriately, these words help justify medical necessity.

Managing Increase in functionCritical Required the skills of a therapistRisk of infection Reasonable and necessaryPrior level of function Safe and effective deliveryGains Medical complicationsAppropriate Reasonable probabilityProgress Potential for complications Improvement High risk factorMotivated Safety issuesContinued SignificantResponsive The patient has the potential

for a sudden change in status

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?

Contact me at:Lbazemore@erehabdata.com

202-588-1766