Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

Medicare Documentation for the Rehabilitation Patient: Evidence of ProgressHARMONY UNIVERSITY

The Provider Unit of Harmony Healthcare International, Inc.

(HHI)Presented by:

Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QTDirector of Rehabilitation & Reimbursement

Education

Speaker Bio (Keri Hart)

30 Years Experience in Long-term Care

Corporate Director of Clinical Reimbursement ServicesMDS Corporate Rehab DirectorRehab DirectorSLP

Cognition (Dementia and Head Injury)Head and Neck (Dysphagia and Voice)

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Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenter:Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QT

Director of Rehabilitation & Reimbursement Education


Harmony Healthcare International, Inc.

Medicare Documentation for the Rehabilitation Patient: Evidence of Progress Disclosure

Speaker: Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QTDirector of Rehabilitation & Reimbursement

Education

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose

Copyright © 2013 All Rights Reserved 4

Harmony Healthcare International, Inc.

Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

Criteria for Successful CompletionComplete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form.

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Objectives:

The learner will be able to define skilled coverage criteria. The learner will be able to define key elements of Documentation. The learner will be able to provide examples of Rehabilitation Documentation to support Medicare coverage criteria. The learner will be able to provide examples of Nursing Documentation to support Medicare coverage criteria.


Increase in Medicare Documentation Reviews

Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs)

Lower 14Billing inconsistenciesICD-9 Coding triggers

Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's

Number of "Help Letters“ was astoundingly highInvestigations into potential fraudulent billing practices increasedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7

Increase in Medicare Denials

Denials due to conflict between Nursing Notes, MDS and Rehabilitation documentationDocumentation by Nursing of Medical Complexity supports need to receive rehabilitation at a SNF level of care


OIG Report November 2012

In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF servicesSubmission of inaccurate, medically unnecessary, and fraudulent claims Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments Increase and expand reviews of SNF claimsUse CMS fraud prevention system to identify SNFs billing higher paying RUGsMonitor compliance with therapy assessments (COT)Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9

OIG Report November 2012

OIG recommendations (CMS concurred):Increase and expand reviews of SNF claimsUse CMS fraud prevention system to identify SNFs billing higher paying RUGsMonitor compliance with therapy assessments (COT)Change the current method for determining how much therapy is needed to ensure appropriate paymentsImprove the accuracy of MDS items Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10

Physician CertificationPhysician Certification Frequency

Admission14th DayEvery 30 Days (from last certification)

Addresses all skilled qualifiersRehabNursing


Physician Certifications

Therapy CertificationPlan of Treatment/CareFrequency of ServicesPlanGoalsPhysician Involvement

Therapy Physician OrdersEvaluation Treatment clarification



“Practical Matter” Criteria

“As a practical matter, considering economy and efficiency, the daily

skilled services can only be provided in a skilled nursing

facility”



1.Outpatient services are not available in the area where the individual lives

2.Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility


“Practical Matter” Criteria3.The availability at home of a capable and

willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/resident to reside there safely

4.If the use of alternative services would adversely affect the patient/resident’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis


Reasons for SNF stay:Intensity of TherapyMedical ComplexityDeficits Less than 24-hour care would impose safety risks Less than 24-hour care would result in adverse impact on medical condition



Medical ComplexityDetails of skilled assessment, observation and interventions provided by Nursing and Rehabilitation Services

Deficits ADL Documentation accurately reflects assist provided to support deficitsRehabilitation documentation reflects deficits with tasks of increasing complexity


Clinical Eligibility Requirements

The need for skilled care must be justified and documented in the medical recordConditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF

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Relationship to HospitalizationAcute Care hospitalization diagnosis

PneumoniaConditions identified at acute

SkinHistory of conditions and diagnosis now requiring skilled assessment, observation and intervention

DiabetesCHFCOPD


Relationship to Hospitalization

Although a deficit or problem exists, documentation must reflect the relationship to hospitalization or problem that arose in the SNFDocumentation should be clarified to ensure the reviewer can see the connection“New onset of difficulty swallowing upon return from hospitalization”No longer able to….


Therapy Documentation to Support

Related to hospitalization or problem that arose during SNF stay:

Detail in reason for referralAddress in narrative summaryPrior level of function reflects a change compared to prior to hospitalization

Chronic conditions:How has the condition changed?What is the functional impact?


What is Skilled Care?

Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLPMust be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result

“General supervision” requires initial direction and periodic inspection of activity

Ordered by a physicianServices are needed and provided on a daily basis


Daily BasisThe patient requires these skilled services on a daily basis (see §214.5)

Nursing 7 DaysTherapy combination PT, OT and/or SLP 5 days of 7

Supporting Documentation:Daily Therapy NoteDaily Nursing NotesTreatment Sheets


Basic Medicare Requirements

If not supported by the documentation in the patient’s record, a stay in an SNF, even though it might include the delivery of daily skilled services, is not covered

For Example: Payment for a SNF level of care may not be made if documentation supports a patient’s need as intermittent rather than daily skilled serviceCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24


Skilled Care

Skilled RehabilitationDirect Skilled Nursing ServicesManagement and Evaluation of a Care PlanObservation and AssessmentTeaching and Training

Medical NecessityThe services provided requires the skills of a therapist:

Modalities (Diathermy, Ultrasound)AssessmentManagement and progression of the plan of care

The patient is medically complex and requires the skills of a therapist


Skilled Rehabilitation

Evaluations; ReevaluationsEstablishment of treatment goals to address each problem identified in the evaluationDesign of a plan of care , including establishing procedures to obtain goals, determine frequency and duration of treatment


Skilled Rehabilitation Continued assessment at regular intervalsInstruction leading to establishment of compensatory skillsSelection of devices to replace or augment a functionPatient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family is ongoing through treatment and instructions may be modified intermittently if the patient’s status changes. 28Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved

Treatment ModalitiesSelf care trainingTherapeutic activitiesMobility trainingTransfer trainingNeuromuscular reeducationGait trainingOrthotic/prosthetic trainingUE splintingManual therapy

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29Copyright © 2013 All Rights Reserved

Treatment ModalitiesBalance trainingTherapeutic exerciseElectrical stimulationUltrasoundModalitiesWound managementWheelchair managementPatient/caregiver education and trainingCompensatory techniques

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30Copyright © 2013 All Rights Reserved

Treatment ModalitiesHome management trainingCommunity reintegrationSafety educationAdaptive equipment trainingCognitive retrainingVisual motor/ perception trainingDysphagia managementCognitive-linguistic treatment for newly impaired

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ReservedCopyright © 2013 All Rights Reserved


EvaluationDecline from prior level of functionRelationship to hospitalizationDeficitsRisks without therapyMedical Complexity

Daily Treatment Notes to Support daily provisionMD involvement:

Signed Plan of TreatmentPhysician orders



Documentation that the skills of a therapist are required:

Why restorative nursing cannot address identified issues?Assessment and changes to the treatment regimeMedical Complexity



Direct Skilled NursingIV (parental) medicationsN/G, gastrostomy tubes, jejunostomy tubesApplication of dressing with prescription medications and aseptic techniqueTreatment of pressure ulcer grade III or worseInitial phases of a regimen involving medical gases such as bronchodilators and oxygen therapyNew Colostomy CareBowel and Bladder Training


Management and Evaluation of a Care Plan

“Constitute skilled services when, because of the patient’s physical or mental condition, those activities require the involvement of technical or professional personnel in order to meet the patient’s needs, promote recovery and ensure medical safety.” (Final Rule 7/31/99)


Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s

Medical needs Promote recovery Ensure medical safety


This area includes The sum total of unskilled servicesPotential for serious complicationsHigh probability of relapseRecovery and safety Meet medical needs Includes resident’s overall condition

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Management and Evaluation of a Care PlanAlthough any of the required services could be

performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel.



Skilled Observation and Assessment

Reasonable probability for complications or potential for further acute episodes of the patient’s changing condition needed to identify and evaluate the patient’s need for modification of treatment or additional medical procedures until his or her condition is stabilized

Skilled Observation and Assessment

If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services are still covered so long as there was reasonable probability for such a complication or further acute episode

“Reasonable probability” means that a potential complication or further acute episode is a likely possibility


Skills of a Therapist or a Nurse



Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently



Documentation must support:Description of skilled treatment Changes made to the plan of care due to assessment of the patient’s needsMedical complexity


Patient Education Services

Patient Education Services: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimenSkilled if the use of technical or professional personnel is necessary to teach a patient self-maintenance


Skilled Services Categories: Patient Education Services

Colostomy careInsulin administrationProsthesis managementCatheter careG-tube feedingsIV access sites

Braces, splints and orthoticsWound dressings and skin treatmentsMedication ManagementOrthopedic Precautions



Universal DocumentationGuidelines

LegibleDatedStandard abbreviations

Joint Commission is commonly used as a standardFacility policyUnderstood by all readers

Detail-orientedClear

Handwriting Legibility


Handwriting LegibilityDocumentation that is illegible or indecipherable can result in denial of paymentIllegible handwriting is defined as the inability of two out of three individuals not being able to read an unfamiliar chart entrySomeone can read what you wrote on the first attempt

Legible does not mean several people standing around the nursing station can figure out what it was supposed to sayCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48

Electronic Medical Record (EMR)


Electronic Medical Record (EMR)

Electronic signature must meet requirements:

Sole usage (e.g., PIN required)Name and designation

EMR still requires the user to understand the requirements for Medicare

Canned documentation may not support the services provided


Basics of Documentation

Clarity: Evidence of the need for further skilled careContent: Describe what you have done. There is a beginning, middle and end of every good note. Communication:

Document any changes in the patient Document what needs to be changed regarding the plan of care


Documentation Using Skilled Terminology


AcuteBeginning to respondDescription of a balance deficitEvaluatedMeasured amountReddened areaContinues to progressDifficulty withIncapable ofSelf help devices

New skills added

Techniques or strategiesFunctional outcomesEvaluateIncreased carryoverIncreased generalizationIndividualizedCondition is complicated byHigh risk forGoal achieved

Documentation Using Skilled Terminology


AnalyzingEstablishingModifyingImplementingHierarchy of tasksSkilled teaching or

feedbackOptimum performanceCompensatory skillsSkilled activities

Active skilled program

Significant practical improvementChange in living environmentSafe and effectiveComplexity of performanceAdaptive proceduresCustomizedIncreased consistency

Non-Supportive Documentation


Generalized weaknessChronicStabilizedGood, fair, poor, or other general termMonitoredScant, little, much, greatSlight improvementSlightly redSlow progressNo problem

RoutinePracticeGeneral Conditioning ExercisesMaintenanceRepetitiousRefuses toMaking slow progressUnable to learnReinforced previously taught..

Objective EvidenceObjective evidence consists of:

Standardized patient assessment instrumentsOutcome measurements toolsMeasurable assessments of functional outcomeNot required, but their use will enhance the justification for needed therapy

Use of objective measures at:The beginning of treatmentDuring and/or after treatmentQuantify progress and support justifications for continued treatmentCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55

Functional Outcome MeasuresCMS Referenced Instruments:

National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing AssociationPatient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)Activity Measure – Post Acute Care (AM-PAC)OPTIMAL by Cedaron through the American Physical Therapy Association


Concept of Medical Necessity

Medical Complexity:The service is so complex that the skills of a therapist are required (modalities)The patient is so complex that the services require the skills of a therapist

Both require documentation to supportDescribe why and/or how complicating factors (complexities) affect treatment


Concept of Reasonable and Necessary

Services meet accepted standards of medical practice Specific and effective treatment for the condition A level of complexity/sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist (or supervised PTA/OTA)Patient’s clinical condition requires the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58

Concept of Reasonable and Necessary

The following are not considered reasonable and necessary:

Services provided for general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes Services that are not provided under a therapy plan of care, or are provided by staff who are not qualified or appropriately supervised, are not covered or payable therapy services


Functional Impact

Skilled rehabilitative therapy occurs when, “The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation”Documentation should focus on functional abilities and deficits

EvaluationGoalsProgress


Importance of Evaluation

The initial evaluation sets the stage for all subsequent therapy services Poor evaluation documentation risks that ALL subsequent therapy services will be denied Poor evaluation limits potential goals as therapy progresses


Importance of EvaluationJust because Medicare Part A does not allow time spent on evaluation to be counted toward RUG minutes doesn’t mean we shouldn’t fully assess:

Get them on the matFull ADLsFull meal assessment

Document reason for functional deficits in descriptive terms

Additional data can be obtained through diagnostic treatmentRegistered therapist treats during initial visits



The Importance Prior Level of Function

Medicare supports skilled intervention to assist the patient to attain their highest/prior level of functionPLOF is vital to supporting medical necessity for skilled rehabilitation and support the intensity of services renderedEvidence of a Change in ConditionEvidence of the potential to achieve a higher level of function

How to Document PLOFGather as much information regarding the patient’s functional level prior to recent illnesses. Be Specific.

Onset of illness on re-admissionAddress all Goals areas:

SettingDistanceDeviceDiet

Paint a picture to portray the patients lifestyle prior to onset of illnessFocus on function


Prior Level of Function Example

Admission after an acute CVA:PT: Independent with all mobility without a device for unrestricted distances. Independently climbs a flight of stairs to enter home.OT: Independent with all ADL and IADLs without an assistive device or adaptive equipment. Lives alone in own homeSpeech: Lives independently in own home alone managing all medical and financial affairs. Communicates in high level conversation with no reported difficulty


Nursing Documentation PriorLevel of Function

Document information obtained from resident and family

Admission AssessmentWeekends

Document patient reported goalsDocument specific abilities prior to onset of illness…”no longer able to wash face and comb hair”Daughter reports the patient is lived completely independently and did not use a device to ambulate


What is Rehab PotentialThe patient’s potential to achieve goals set by the therapist

Not related to medical prognosisGoals should be achievable with good to excellent potential to achieve

Rehab potential set to Fair, guarded or Poor would indicate to Medicare that the therapist does not believe in their planInclude “Due to” or “Given the patient’s…”


Nursing Documentation Rehab Potential

Focus on the potential to achieve goalsRecent onsetIntact abilities“Given the patient’s level of intact cognition…”“Given the recent onset of decline, the patient evidences good rehab potential”


The Importance of Reason for Referral

Details the specifics of why skilled therapy services are warrantedClarifies the events that led to a therapy referral

Establishes the relationship to recent hospitalizationDetails the event that prompted evaluation

Clarifies the specifics of the decline in function from prior level of functionPoints the reviewer to specific areas of the medical recordCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69

Reason for Referral Nursing and Therapy Examples

“Significant decline in function status post an acute CVA on 9/1/13”“Evidences decreased ability to safely ambulate after a 3 week hospitalization for an MI on 9/1/13”“..recurrent Pneumonia despite medical intervention indicating potential Dysphagia”“new onset of cognitive deficits impacting ability to progress in medically necessary PT and OT ”“change in cognitive status after resolution of ……“New onset of slurred speech impacting ability to communicate”


The Importance of Measuring Functional Deficits

Supports Medical NecessityEstablishes the physical and cognitive baseline data necessary for assessing expected rehabilitation potential, setting realistic goals, and measuring progress

Baseline from which to measure progress


Level of AssistDevices and Adaptive Equipment Assessed

Diet TexturesNumber of Caregivers to AssistFunctional Levels:

Maximum Assistance: The need for 75 percent assistance by one person to physically perform any part of a functional activityModerate Assistance: The need for 50 percent assistance by one person to physically perform any part of a functional activityMinimal Assistance: The need for 25 percent assistance by one person to physically perform any part of a functional activityContact Guard: Contact Assist to provide cues or guided maneuvering


Supervision

Supervision: Cueing Reviewers may view this level of care as restorativeEnsure documentation of deficits are clearly statedAnalyze task to determine if the patient is not receiving hands on assist for a portion of the task

Describe CueingConstant (max)Frequent (mod)Occasional (mod)Rare (min)



SupervisionDescribe Causes of Cueing

TechniqueSequencingPacingInitiation

Describe Type of CueingVerbalTactileVisual

How to Measure Functional Deficits

Current level of function for each functional deficit to be addressed in therapy

Define/describe the behavior without using min/mod/max assist if needed

Objective measures of functionBe descriptiveAmount and type

Describe underlying impairmentsReason for functional impairment/limitation


Reasons for Functional Limitations

Examples of reasons for functional limitation:

Lack of awareness of sensory cuesImpaired attention spanImpaired strength and or coordinationAbnormal muscle toneRange of motion limitationsImpaired body schemePerceptual deficitsImpaired balance/head controlEnvironmental barriersDelayed initiation of swallow


Reasons for Functional Limitations

Safety Issues Related To:Poor postureImproper gaitWeak grip, arthritis Dysphagia Poor communication skillsParalysis/paresisPerceptual deficitsVestibular disorderCognitive disorderCOPD, emphysema


How to Measure Functional Deficits

Standardized Measurement ToolsBorg Scale= 5 (Severe Breathlessness)Berg Functional Balance Scale 39/56 (Medium Fall Risk)Western Aphasia Battery(WAB) 29.9/100 (Moderate to Severe Broca’s Aphasia)

Functional Outcome MeasuresComposite Scale


Complexity of TaskEnvironment

In roomIn dining roomDistraction

Patient ConditionEnd of the day versus beginningWith pain (how often does this occur?)With shortness of breath (how often does this occur?)

SequenceDressing after rising from bed and toileting


Nursing Documentation of Function

Focus on:Functional tasks requiring assistPartial task completion by caregiversComplex tasks that pose a challengeFunctional impact of pain, dyspnea, anxiety etc.Risk assessment outcomes

“Patient ambulated to the dining room with Limited Assist for the first time since returning from the hospital”Patient with limited ability to prticipate in ADLs due to increased pain with movement”


The Importance of Summarizing Findings

Supports Medical NecessityEvidences the critical thinking process

Don’t leave it up to the reviewer to determineTell a story

Evidences individualization of the plan of care


How to Summarize Findings

Be descriptiveChart your thinking

Guide the reviewerState the obvious

It may only be obvious to you!Focus on the relevantIndividualize

Avoid canned phrasesAvoid negative statements


The Importance of Functional Rehabilitation Goal Writing

Guides the reviewer through progressReflects the logical plan of care based on the evaluation findingsSupports medical necessity“The skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation”



What is a Measurable Rehabilitation Goal

Long-Term GoalsLevel you expect patient to be at discharge

Short-Term Goals (2 to 4 weeks)Incremental steps toward the long term goals.Think beyond diet texture, transfers, ambulation, and ADLs

Based on deficits identified on assessment and in nursing documentation


Performance SkillsMotor skills: moving and interacting with task, objects, and environment

PostureMobilityCoordinationStrengthEffortEnergy


Performance SkillsProcess Skills: managing and modifying action when completing tasks

EnergyKnowledgeTemporal organizationOrganizing space and objectsAdaptation


Performance SkillsCommunication Skills: conveying intention and need and coordinating social behaviors

PhysicalityInformation exchangeRelations


Duplication of Services



Rehab goals can appear to be demonstrating a duplication of services. High risk of denial.Commonly seen goal areas:

Bed mobility (PT/OT)Functional transfers (PT/OT)Functional mobility/Ambulation (PT/OT)Cognition (OT/ST)Safety (PT/OT/ST)Standing balance (PT/OT)



The goals must be written to differentiate the skilled area to be addressed by each disciplineHigh Risk of DenialMost reviewers are NOT therapists



PT Goal: Pt. will demonstrate Good Functional BalanceBetter Stated As:Pt. will be able to I ambulate around obstacles in their room without loss of balance



OT Goal: Pt. will demonstrate Good Functional Balance for ADLsBetter Stated As:Pt. will I complete Grooming task standing at sink without loss of balance

The Importance of Progress Reports

Required for PaymentJustifies outcome of skilled therapy interventionSupports the need to continue skilled therapy intervention


What is a Progress ReportThe minimum Progress Report Period is at least once on or before the 10th treatment day No later than 30 daysRecommended weekly

The beginning of the first reporting period is the first day of the episode of treatmentService provided on the first day of treatment is the evaluation, re-evaluation or treatment.

The Progress Report Period requirements are met when both the Progress Report and the Therapist’s active participation in treatment have been documented

Copyright © 2013 All Rights Reserved 94Harmony Healthcare International, Inc.

Assistants and Progress Reports

The PT, OT or SLP clinician must write a Progress Report during each Progress Report Period regardless of whether the assistant writes other reports. Must provide treatment.

Reports written by assistants are not complete Progress Reports Physical Therapist Assistants or Occupational Therapy Assistants may write elements of the Progress Report dated between clinician reports



How to Write a Progress NoteEach report should compare and contrast the prior level of function and describe specific areas which reflect improvement

Within each level of function include specific performance tasks that the patient can demonstrate as a result of skilled intervention


How to Write a Progress NoteInclude:

Assessment of improvement and extent of progress (or lack thereof) toward each goalPlans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisionsChanges to long or short-term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment

How to Write a Progress Note

Avoid:Simply listing CPT code descriptorsStating general treatment interventions (Ther Ex, strengthening, balance activities)Reflecting repetitive exercises that an unskilled care giver or restorative could providedEndurance training



How to Write a Progress NoteInclude:

That the patient’s condition has the potential to improve or is improving in response to therapyThat maximum improvement is yet to be attained That there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time


How to Write a Progress NoteSummary:1) Skilled services provided since

previous report to progress towards goals

2) Current Status3) Specific progress towards each short

term goal4) Ongoing impairments to be

addressed to progress towards long-term goals


Supportive Skilled Documentation

Patient at high risk forSkilled assessment ofReasonable probabilityPotential for recurrenceMonitoring for consistency

The medical regimen is not essentially stabilizedPatient continues to require daily skilled rehab forPatient requires daily skilled evaluation of the plan of care


Non-Supportive Skilled Documentation

Plateau in progressStill requiresPatient is unable to follow directionsPatient has poor rehab potentialPatient refuses to participate in therapy (without documentation of root of refusal)Within normal limits“Slow, steady gains” described in progress notes but comparison of function is without change from one week to the next

Non-Supportive Skilled Documentation

Quoted statements from patient refusing therapy and asking to end the therapy sessions/program, yet services continued without documented improvementMonitor or observed at meals versus assessedFocus on behaviors versus what skills of a therapist were required to manage



Progress Report ExamplesOn evaluation, patient required max verbal and tactile cueing for initiation of upper body bathing while seated at the sink. At this time the patient only requires min verbal cueing and no tactile cueing to initiate upper body bathing.Progression of hip/glut strengthening exercises to now include weighted resistance


Progress Report ExamplesThe patient initiated use of their prior level device of a cane for mobility this week. The patient required minimal assist to ambulate 45 to 50 feet at the beginning of the reporting period. The patient has improved to ambulate 45 – 50 feet with CGA with the cane at the end of the reporting period.

Progress Report Examples

The patient tolerated nectar thick liquids for all meals with no evidence of aspiration. The patient was assessed with thin liquids with overt signs and symptoms of aspiration on 10% of trials. Aspiration was eliminated with patient utilization of a chin tuck with continual minimal tactile cues during the meal. Patient and care giver education was provided on use of the chin tuck compensatory swallow strategy.Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106

Nursing Documentation of Progress

Focus on:New functional abilities

Partial task completionIncreased initiation attempts

Lesser levels of careDecreased Number of assist or symptoms

“Initiated participation in care as evidenced by….”No signs or symptoms of aspiration with diet upgrade to thin liquids on 10/1/13


Monthly Progress Report

These are completed every 30 days and include components of weekly progress noted while also requiring:

Updated goals and treatment plan with identification of significant improvement in functional skills“Significant” means a generally measurable and substantial increase in the patient’s present level of functional independence, and competence compared to the level of function at the time treatment was initiated. HIM 12, 544.


Monthly Progress Report

Any change in treatment plan would require physician clarification orders

The completion of clarification orders to communicate the expected treatment plan with the physician and receive verbal approval for the treatment to continue


Discharge Progress Report

The discharge note is a Progress Report written by the clinician upon completion of each program

Supports outcome of therapy intervention for all payors


Discharge Progress Report

It is important to give a thorough synopsis beginning with a comparison between the initial level of function and discharge statusThe clinician should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode for review purposes


112

Discharge Progress ReportList all techniques and methods trialed even failed attemptsDischarge setting with cues for re-referral for skilled therapyUnanticipated discharge:

Data related to discharge not noted in the previous Progress Report will require the clinician writing the final note to rely on treatment notes and verbal reports of the assistant or qualified personnelSummary of progress is still needed to support services provided


Nursing Discharge Documentation

Supplement with:Functional Goals achievedMedical diagnosis and conditions that have resolvedPatient Education

Reoccurrence of UTIFall RiskHome Safety and Home Exercise Program developed by therapy


Skilled Coverage Criteria

There is no such thing as a “Rehab” or “Nursing Patient

One patientOne medical recordOne claim billedOne set of Medicare coverage criteria


References

Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 161, 10-26-12) CMS MDS 3.0 RAI Manual v1.11


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Medicare Documentation for the Rehabilitation Patient: Evidence of Progress

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