Lec 8 - Documentation To Support Payment/Reimbursement Functional Limitation Reporting Flashcards
Purposes of documentation (8):
- Record of patient care
- Tool for planning and provision of services
- Communication vehicle among providers
- Provides info to others about abilities, body of knowledge, and the services
- Demo compliance with federal, state, payer, and local regulation
- Provides historical account of pt encounters that can be used as evidence in potential legal situations
- Demo appropriate service utilization and reimbursement for many third-party payers
- Policy or research purposes, including outcomes analysis
Internal audiences for documentation (7):
- You (at a later date)
- Colleagues
- Other staff
- Other HCP
- Referral sources
- Students
- Patients/families
External audiences for documentation (5):
- Third party payers
- Reviewers
- Case managers
- Lawyers
- Researchers
Relationship btw documentation and payment: Documentation demonstrates:
- Medical ____________
- Potential for ___________
- Services provided as ________
- Services meet _____________
- Medical necessity
- Potential for improvement
- Services provided as billed
- Services meet accepted standards
Preventing Denials: Requires process to ensure claims are ______ and _______ (“_____”) before submitting
Complete
Accurate
Clean
Preventing Denials: Denials and appeals process add ____ to the provider - administrative time, loss of professional ______ _______ ______
COST
Productive billable time
Preventing Denials:
Reasons for denials: Low hanging fruit:
1. Payors will look at areas where there are known deficiencies to ________ amount paid on claims
2. Known deficiencies in PT documentation: ____ documented = ____ done = _____ paid for
3. Anecdotal reports that PTs are less likely to appeal _______
- REDUCE
- NOT, NOT, NOT
- DENIALS
Common reasons for denials:
Documentation deficiencies: (5)
- Poor documentation
- Lack of sufficient progress in reasonable time frame
- UNSKILLED
- Amt, freq, duration = not reasonable
- Services not effective, duration not reasonable
Common reasons for denials: PREVENTING DENIALS (3):
- Document SKILL - initial and ongoing
- Measure and quantify information in MEANINGFUL WAY
- Avoid use of JARGON
Defensible Documentation:
APTA member resource for __________
Documentation skills
Defensible Documentation: It is the therapist’s responsibility to be aware of any:
_______-specific,
_______-specific,
_______-specific,
and/or _____ specific documentation requirements
Payer
Setting
Employer/organization
State
Defensible Documentation: Resources for clinicians:
5
- Medicare manuals
- Medicare Admin Contractors Local Coverage Decisions
- Payer specific websites
- State practice acts
- APTA Guidelines for Documentation
Documentation and Medical Necessity - Payer Expectations: 5 questions you should be asking:
- What is wrong with the pt?
- What is planned for the pt?
- What skilled interventions are required and what specific services are being provided?
- What progress is being made toward D/C?
- What is the final result of the services delivered, patient prognosis, and status at discharge?
Details on what is wrong with the pt?
Exam/eval
Diagnosis
Details on what is planned for the pt?
POC
Goals
Prognosis
Details on what skilled interventions are required and what specific services are being provided?
Daily notes
Details on what progress is being made toward D/C?
Daily notes, progress reports, re-eval
Details on what is the final result of the services delivered, PT prognosis and status at D/C?
D/C summary
Most payers look to \_\_\_\_\_\_\_ to set the standard for issues relating to: 1. 2. 3. 4. 5.
MEDICARE
- Documentation: explicit requirements
- Reimbursement
- Fraud and abuse
- Skilled care
- Utilization
Documentation requirements for therapy services:
Therapy services shall be payable when the medical record and the info on the claim form consistently and accurately report _____________
Covered therapy services
Documentation requirements for therapy services: Documentation must be ______, ______, and ______ to justify the services billed
Legible
Relevant
Sufficient
Documentation requirements for therapy services: Medicare requires that the services billed be supported by __________ that _________ _________
Documentation that justifies payment
Documentation requirements for therapy services: Identify ________ expectations
MINIMAL
Initial examination includes? (3)
History
Systems review
Tests and measures
Evaluation includes what? (4)
Diagnosis
Prognosis
POC/Goals/Interventions
Discharge disposition/planning
Components of documentation: (3)
Visit/encounter/session note
Re-examination/progress note
Discharge/discontinuation summary
What is the most critical component of documentation?
Initial Evaluation
An IE establishes ___________ through documentation of ___________ findings and _________ patient self-report
Medical necessity
Objective
Subjective
I.E. should list complexities present, impact on ________ and/or plan for _____________
Prognosis
Intervention
Medicare documentation of I.E.
- _____ dx and ______ dx
- Support for _____, ______, _____
- Identification of medical care before ___________, if any
- Identification of _______, including where patient lives, who they live with
- Provision of ______, _______ physical function
- _______, __________ with other providers
- THERAPY AND MEDICAL
- Illness, disease, injuries
- Current episode
- Social support
- Objective, measurable
- Communication, consultation
Key Factors for Medicare Documentation of I.E.:
Demographic information including:
Age
DOB
ICD10 diagnosis
Facility and patient ID numbers
Key Factors for Medicare Documentation of I.E.: Date of onset of symptoms or exacerbation of chronic symptoms required new _____
EOC
Key Factors for Medicare Documentation of I.E.: Medical history including impact of ________ on POC
Unrelated conditions
Key Factors for Medicare Documentation of I.E.: Reason for _________
Therapy intervention
Key Factors for Medicare Documentation of I.E.: Current status, including:
Subjective
Objective Evals
Relation between impairments and functional limitations
Key Factors for Medicare Documentation of I.E.: Signature with ___________ and _______
Professional designation
Date
Contents of POC (minimum): 3 things:
Diagnoses
Long term treatment goals
Therapy services
Therapy services include:
Type (discipline)
Amount (times per day)
Duration (number of weeks, or treatment sessions)
Frequency (times per week)
What does ABCDE stand for?
Actor Behavior Conditions Degree Expected time
Session notes should include:
Patient ______
Self report
Session notes should include:
__________ ________ performed
Skilled interventions
Session notes should include:
______ ________ to intervention
Adverse responses
Session notes should include:
Additional or continued _____________ with other providers
Communication
Session notes should include:
Significant changes in ___________
Clinical status
Session notes should include:
Equipment provided, instructed in ____ or ______
Use or application
Demonstration of skilled intervention and progression/ongoing assessment in daily notes:
____ and _____of skilled assistance given to patient
Type and level
Demonstration of skilled intervention and progression/ongoing assessment in daily notes:
Clinical _________ ________
Decision making
Demonstration of skilled intervention and progression/ongoing assessment in daily notes:
Continued analysis of patient ______-
Progress
Demonstration of skilled intervention and progression/ongoing assessment in daily notes: Change in function as a result of _________, progress towards _______
Intervention
Goals
Support for timed interventions: Requirement to support reporting of ________ and ________ in clinical documentation
Timed procedure
Modality codes
Support for timed interventions:
Based on _____
CPT
Support for timed interventions: Time reported is what?
The total treatment time and ONE-ON-ONE contact time with the patient
SOAP notes/flowsheets:
SOAP notes are often ________, and then must include _______
Incomplete
Skilled Assessment
Flow sheets record INTERVENTIONS but do not allow what?
Space to document:
Skill, assessment of patient status, plans for ongoing care
A flow sheet may be a component of record, but does it satisfy documentation requirements alone?
NO
Re-certifications: Whenever need for significant modification of plan, or at least every _____ days if medically necessary treatment continues to be required
90
Re-certifications: Physicians/NPPs may require a physician/NPP visit for a _______ prior to certification
Examination
Re-certifications: Does Medicare require a visit for recerts?
NO
Unless NCD requires
Billable Re-examination: Occurs with \_\_\_\_\_\_\_\_\_\_ in patient status Failure to respond as expected Need for new \_\_\_\_\_ And/or other requirements
Unexpected change
POC
Billable Re-examination: Addresses _____ where program has or has not been demonstrated
GOALS
Billable Re-examination: May establish new ___ and ___
Timeframes and goals
Billable Re-examination: Reasons for lack of ______ documented
Progress
Billable Re-examination: Changes to _______ are documented
Interventions
Progress Reports: True or false - progress reports are always required, even with clear documentation in daily notes
FALSE - they are not required if session notes document clear objective evidence of progress towards goals
Progress reports: If session notes are not clearly documented, Medicare requires progress report at least once every ___ treatment days
10
Progress reports: Documents progress made towards ____ or lack of progress and ____
Goals
Reasons
Progress reports: Are these notes required to be signed by a physician/NPP?
NO
Discharge/discontinuation summaries: Summarizes _______ including treatment, progress towards goals, final disposition of goals, recommendations for plans for pt moving forward
Episode of Care
Discharge/discontinuation summaries: this is the ______ opportunity to document medical necessity for an EOC
FINAL
Suggestion for Skilled Care:
Provide a brief assessment of response to intervention at ________
EVERY VISIT
Suggestion for Skilled Care:
Document _________ process
Clinical decision making
Suggestion for Skilled Care:
Be sure that documentation is not ______
Repetitive
Suggestion for Skilled Care: Be sure that there is no doubt that only a ___________ could provide the treatment
SKILLED PT
Suggestions for Medical Necessity: Document complications and safety issues as a result of patient/client status including these three things:
- Fall risk
- Reduced mobility
- Inability to complete ADL
Risk Management/Compliance: Follow documentation policies, ensure that documentation meets _______
Minimum requirements
Risk Management/Compliance Record only on ________ forms and write ______
Proper
Legibly
Risk Management/Compliance: What should you do for every note?
Date, time, and sign
Risk Management/Compliance: Record info as close as possible to the ___________
Time of care delivery
Risk Management/Compliance: Use only approved ______
Abbreviations
Risk Management/Compliance: Do not change documentation after the fact! Revisions have to made according to _______
Facility policy
Risk Management/Compliance: Describe symptoms as _________, use quotations properly
Elicited/reported
Risk Management/Compliance: If patient reports adverse situation, what should you do?
Respond accordingly and document response/assessment of situation
Risk Management/Compliance: Be objective and factual, do not allow ______ or ______ to be part of the medical record
Opinion or emotion
Risk Management/Compliance: Report in organized factual manner with adequate detail in ______ order
Chronological
Risk Management/Compliance: Document all _________ involving patient info
Phone calls
Risk Management/Compliance: Should you document handouts, instructions and follow up information?
Yes
Risk Management/Compliance: If interpretive services are needed, what should you do?
Document it
Risk Management/Compliance: Follow _______ for communication, electronic documentation
Regulations
Risk Management/Compliance: Document all attempts to contact ________ and/or _________, communication about patient
Referral
Payment source
Risk Management/Compliance: Release records according to _____
Policy
Risk Management/Compliance: Provide documentation for each _______
PT VISIT
Risk Management/Compliance: Report incident apart from medical record using proper __________
Incident report form
Incident Reports: Dependent on _____ and ______ policies
Setting
Institutional practice
Incident Reports: Should be developed in consultation with _____
Attorney
Incident Reports: Standard report and policies should be in place regarding (5):
When required Who can fill it out Who signs the form Who reviews the forms What actions are taken as a result of the report
NJ PT Law and Regs:
Provide direction on required ________
Documentation
NJ PT Law and Regs: Violation of law/regs are responsibility of _______
Licensees
Functional Limitation Reporting Overview: Requires reporting of Medicare patient’s __________ on claims
Functional status
Functional Limitation Reporting Overview: At eval, on or before ____ followup visit, with a ______ at discharge
10th
Re-eval
Functional Limitation Reporting Overview: Utilizes non-payable _____ and ______
G codes
Modifiers
As of 7/1/13, all those billing OP therapy services under Medicare Part ___ must begin or continue submitting _____________ (G-codes) for any _______, or claims will be returned ________
B
Functional limitation data
Beneficiary
Unpaid
____ was mandated to collection information regarding beneficiaries’ function and condition, therapy services furnishes, and outcomes achieved on the _________ by the Middle Class Tax Relief Act of 2012.
CMS
Claims form
CMS intends to use this information on claims forms in the future to _________ payment for OP therapy services
REFORM
All practice settings that provide OP therapy services billing under Medicare Part B must include functional limitation data on the claim form. Name some practitioners that this includes:
PT/OT/SLP in hospitals, critical access hospitals, SNF, comprehensive OP rehab facilities, rehab agencies, HHA, private offices of therapists/physicians/NPP
Non-payable G-codes and modifiers included on the claim form to capture data on the beneficiary’s __________
Functional limitations
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
At the outset of a therapy episode of care (i.e. On the claim for the date of service of the initial therapy service)
TRUE
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
At least once every 12 treatment days, which corresponds with the progress reporting period
FALSE - every 10
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
When an evaluative or re-evaluative procedure is furnished and billed
TRUE
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
At the time of discharge for the therapy EOC
TRUE
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is necessary
TRUE
Therapists must report the functional limitation data throughout the episode of care at the following intervals: (true or false):
At the time reporting is begun for a new or different functional limitation within a different EOC (i.e. After the reporting of the prior functional limitation is ended).
FALSE - same EOC
How does a PT determine the primary functional limitation?
Select the G-code category for the functional limitation that most closely relates to the primary functional limitation being treated or one that is the primary reason for treatment
When the beneficiary has more than 1 functional limitation, the PT may need to make a determination as to which functional limitation is _______
Primary
In the cases where the beneficiary has more than 1 functional limitation, choose the functional limitation that: (3)
- Is more clinically relevant to successful outcome
- Would yield the quickest and/or greatest functional progress
- Is the greatest priority for the beneficiary
Must submit the G-code on the _______
Claim form
What 6 things must you submit with each G-code on the claim form?
- Another separately payable (non-bundled) service
- The G-code for the functional limitation
- A severity modifier
- Completion of the units field with “1” unit of service
- The corresponding therapy modifier indicating the discipline of the plan of care (GO, GP, GN)
- A nominal charge ($0.01) for each line with the functional limitation G codes
