8) Defensive Documentation

Question 1

What are the purposes of documentation?

Answer 1

1) Record pt care
2) Helps PT w/planning
3) Communication vehicle btwn providers
4) Provides info to others about our abilities, body of knowledge, and services we provide
5) Shows compliance w/federal, state, local, & payer regulations
6) Gives historical account of pt care that can serve as evidence in legal situations
7) Shows appropriate service utilization and reimbursement
8) Used in outcomes analysis

Question 2

How long is the statute of limitations and what does this mean?

Answer 2

7yrs → The length of time medicare can look back in your documentation

Question 3

Who are the different audiences for documentation?

Answer 3

Internal

• You at a later time
• Colleagues/Other staff
• Other HCP’s
• Referral sources
• Students
• Pt’s and their families

External

• 3rd party payers
• Reviewers
• Case managers
• Lawyers
• Researchers

Question 4

What 4 things does documentation demonstrate?

Answer 4

1) Medical necessity
2) Potential for improvement
3) Services provided as billed
4) Services met accepted standards

Question 5

What is the best way PT’s can prevent denials?

Answer 5

Submit clean claims → Get it right the 1st time

Question 6

Why are denials so common?

Answer 6

• PT’s are low-hanging fruit → We have a reputation in the insurance world for bad documentation so we’re an easy target
• Deficiencies in documentation → Not documented, not done, not paid for
• PT’s are supposedly less likely to appeal denials → Again, easy target

Question 7

What patterns are typically seen in deficient documentation?

Answer 7

• Lack of sufficient progress in reasonable time frame
• Unskilled care
• Amount, frequency, or duration not reasonable
• Services were not effective or specific to pt’s condition

Question 8

Why should we avoid using lingo or jargon in documentation?

Answer 8

If insurance companies don’t understand it, they’ll just deny it

Question 9

When Medicare does chart audits, what are they looking for?

Answer 9

Outliers

Question 10

What can happen if you don’t follow Medicare’s rules?

Answer 10

You can get:

• A fine
• Prison time if it’s really bad

Question 11

Look-Back Period

Answer 11

After a bad audit, Medicare can demand their reimbursement back

Question 12

Where does electronic billing and data put PT’s at risk?

Answer 12

Look-Back Period

Question 13

What is the APTA Defensible Documentation Guide?

Answer 13

Designed to provide PT’s w/info and legal requirements of documentation

Question 14

According to the APTA Defensible Documentation Guide, whose responsibility is it to be aware of documentation requirements?

Answer 14

The PT’s

Question 15

Who do payers generally look towards to set the standards for issues relating to documentation, reimbursement, fraud/abuse, skilled care, and utilization?

Answer 15

Medicare

Question 16

True or False: If you don’t like a private insurance company’s rules, you can contact them to discuss your opinions.

Answer 16

True

Question 17

What is the only type of documentation a PTA can do?

Answer 17

Daily Note

Question 18

What is the most critical component of documentation?

Answer 18

The Initial Eval

Question 19

What is the purpose of documentation for an IE?

Answer 19

Establishes medical necessity through documentation of objective findings and subjective pt reports

• Justification for why pt needs your proposed POC

Question 20

What are the key things medicare looks for in IE documentation?

Answer 20

• Pt Demographics
• Onset of sx’s
• MHx
• Reason for therapy interventions
• Pt’s Current Status
• PT’s dated signature

Question 21

How long is a POC good for in Medicare’s world?

Answer 21

90 days

Question 22

What needs to be included in a POC?

Answer 22

• Dx
• Long-term goals
• Description of therapy services (discipline, amount per day, duration, & frequency)

Question 23

What details need to go into a session note?

Answer 23

• Subjective (Pt self-report)
• Performed skilled interventions
• Adverse responses to intervention (Assessment)
• Communications w/other providers
• Changes in clinical status (Objective & Assessment)
• Equipment given & instructions given

Question 24

How is time documented?

Answer 24

CPT Codes

Question 25

Do flow sheets satisfy documentation requirements alone?

Answer 25

No

Question 26

Explain recertification

Answer 26

• Needed for Medicare Part B in order to continue tx, when there’s a need for significant modification to POC or every 90 days to prove that tx is medically necessary
• Some physicians/NPP’s require an office visit before they sign off

Question 27

What is a billable re-examination?

Answer 27

• Happens when:
  
  • There’s an unexpected change in the pt’s status
  • Pt doesn’t respond to tx as expected
  • Need for new POC
  • Other requirements
• Can establish new timeframes/goals
• Must document reasons for lack of progress

Question 28

Describe Progress Reports

Answer 28

Ongoing summary of pt progress

• Not required if session notes document clear objective evidence of progress towards goals
  
  • If there’s no clear evidence, Medicare requires a progress report every 10 visits

Question 29

Do physicians/NPP’s have to sign off on progress reports?

Answer 29

No

Question 30

What is the purpose of D/C summaries?

Answer 30

To discuss pt’s condition at the last visit and state why they’re being d/c

• Summarizes episode of care, including tx, progress towards goals, final state of goals, and recommendations for pt moving forward

Question 31

Documentation of what things can help prove medical necessity?

Answer 31

• Complications
• Fall risk
• Decr mobility
• Inability to complete ADL’s

Question 32

How can you ensure compliance of documentation?

Answer 32

• Know policies & follow documentation rules
• Use only the proper forms
• Write legibly
• Sign and date every note
• Do it ASAP
• Don’t go crazy w/abbreviations
• Make revisions to signed notes according to facility policy
• Describe sx’s as pt reported them
• Use quotes properly
• If pt reports adverse situation, respond accordingly by documenting it → Nothing good comes from hoping it will go away
• Be objective and factual
• Don’t include personal opinion or emotion
• Document in chronological order
• Document all (attempted) communication w/pt
• Document any handouts provided

Question 33

Incident Report

Answer 33

Used to document an unexpected event that caused harm; An internal quality report for risk management

• Doesn’t go in pt’s medical record unless it is directly related to their condition

Question 34

Describe the legalities of incident reports

Answer 34

• Should be devo’ed w/an attorney’s help
• Facility should have standard policies for:
  
  • When incident report is required
  • Who can fill it out
  • Who signs the forms
  • Who reviews the forms
  • What actions are taken as a result of the report

Question 35

What does the NJ Practice Act and regulations do for documentation?

Answer 35

Provides direction on the requirements

Question 36

Explain Functional Limitation Reporting

Answer 36

• Requirement for reporting pt’s fxnl status on claims
• Required at eval, on/before 10th visit, every re-eval, and at d/c for Medicare part B
• Uses non-payable G-codes and modifiers

Question 37

True or False: Anyone billing for outpatient therapy services under Medicare part B must use G-codes otherwise claims will be denied.

Answer 37

True

Question 38

Middle Class Tax Relief Act of 2012

Answer 38

Required CMS to collect info about beneficiaries’ fxn and condition, therapy services administered, and outcomes in order to reform payment for outpatient therapy services

Question 39

Who has to submit fxnl limitation data to CMS?

Answer 39

Any HCP’s who are providing outpatient therapy services and billing under Medicare Part B

• Also applies to PT, OT, and SLP’s in hospitals, SNF’s, HHA’s, and in private offices of physicians and NPP’s

Question 40

Are G-codes payable?

Answer 40

No

Question 41

How do you determine the pt’s primary fxnl limitation?

Answer 41

Select the G-code category for the fxnl limitation that most closely relates to the pt’s primary fxnl limitation

• If the pt has multiple, PT needs to determine which one is the primary limitation; Can be:
  
  • The most clinically relevant to a successful outcome
  • Would yield the quickest/greatest progress
  • Greatest priority for pt

Question 42

What needs to be submitted on a claims form w/a G-code?

Answer 42

• The G-Code
• A severity modifier
• Completion of billing units
• Corresponding therapy modifier
• A nominal charge ($0.01) for each line w/the fxnl limitation G-codes
• Another non-bundled service