Welcome and Thank You for Joining Us Today!

1. Welcome and Thank You for Joining Us Today! • Some reminders about the functions of today’s phone/webcast presentation: • This is a RECORDED PRESENTATION of the “Changes in Physical Therapy Documentation” webcast with Nita Barchus, P.T. For the phone bridge, there are functions available to ALL callers: • On your phone, press *2 to raise your hand to ask a question • The phone bridge is in Q&A Mode - All guests are muted (guests MUST press *7 to talk) • The text chat room will be disabled during the LIVE Q & A session. You are encouraged to submit your text questions using the link on the webcast page in the upper left corner. • During the live Q & A session we are assuming that all callers have completed listening to the recorded webcast. You are welcome to email Nita directly with your comments, suggestions for future sessions and questions at nita.megassociates@gmail.com • Copies of today’s slides are available to download directly from the link provided on the webcast page. PLEASE TAKE THE TEST BEFORE THE SURVEY AND WAIT UNTIL THE END OF THE PRESENTATION!

2. Changes in Physical Therapy Documentation Nita Barchus, P.T. MEG Associates Consulting Group, Inc.

3. Changes in Physical Therapy Documentation • OBJECTIVES • Explain the essential components of therapy documentation for reimbursement • State what to include in reassessments • Demonstrate how to document for a nurse reviewer if you are a therapist • Perform an appropriate therapy documentation review if you are a nurse

4. Changes in Physical Therapy Documentation • OUTLINE • Essential components for reimbursement • OASIS • Therapy Evaluation • Revisit Notes • Reassessments • DC Summary • How to review therapy documentation if you are a nurse • Q and A

5. Essential Components for Reimbursement

6. Essential Components for Reimbursement • The Basic Requirement has not changed: Treatment must be Reasonable, Necessary, and Require the Skills of a Therapist

7. Essential Components for Reimbursement How does Medicare determine whether therapy treatment is reasonable and necessary?

8. Essential Components for Reimbursement OASIS • The Start of Care OASIS is the place to begin documenting that therapy treatment is reasonable and necessary • This is the first information Medicare receives from your agency about the patient • Whether completed by a nurseor atherapist it must show that therapy is reasonable and necessary

9. Essential Components for Reimbursement OASIS • M1020 Diagnoses List must include one or more diagnoses to explain why the patient is receiving therapy • M1800s ADLs and IADLs Should indicate that assistance is required – if the patient is independent in all, then he/she probably does not need therapy

10. Essential Components for Reimbursement OASIS • M1800s (cont’d) Answers must be consistent with the therapist(s) evaluations - Interdisciplinary communication will be required between the nurse and therapists There is often a discrepancy between the nurse’s answer to M1860 Ambulation/Locomotion and the physical therapist’s evaluation

11. Essential Components for Reimbursement OASIS (M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. 0 – Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device). 1 – With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings. 2 – Requires use of a two-handed device (e.g. walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces. 3 – Able to walk only with the supervision or assistance of another person at all times. 4 – Chairfast, unable to ambulate but is able to wheel self independently. 5 – Chairfast, unable to ambulate and is unable to wheel self. 6 – Bedfast, unable to ambulate or be up in a chair.

12. Essential Components for Reimbursement OASIS • M1900s Prior Level of Function ADL/IADL and Fall Risk • If PLOF was dependent with ADLs and IADLs, the therapist(s) must be careful to set realistic goals, and must include caregiver training

13. Essential Components for Reimbursement: Therapy Evaluation

14. Essential Components for Reimbursement Therapy Evaluation • Must document functional limitations (such as assistance required/ safety concerns with bed mobility, transfers, gait, stairs, dressing tasks, making needs known, swallow) • Remember: This will be reviewed by a nurse; so functional limitations, treatment plan, goals must all be to written so that it is apparent to a nurse that PT/ OT/ ST is reasonable and necessary

15. Essential Components for Reimbursement Therapy Evaluation • Must list functional goals • Examples: • The patient will transfer from the bed to the BSC with SBA in 2 weeks • The patient’s balance will improve to low fall risk, as evidenced by an improvement in the Tinnetti score to >24 points • The patient will perform upper body dressing with min assist

16. Essential Components for Reimbursement Therapy Evaluation • Plan of care • It is often appropriate to frontload visits to address the home environment in terms of fall risk factors, medical equipment needs, patient and family education and training for safety

17. Essential Components for Reimbursement: Revisit Notes

18. Essential Components for Reimbursement Revisit Notes • This is where skilled care is documented • Every note must indicate that skilled care was provided, or the visit is not billable: -Treatment plan should be adjusted every visit -Any set-back should be explained -Treatment should address functional limitations, not only therapeutic exercise -Training should be documented for gait and transfers

19. Essential Components for Reimbursement Revisit Notes • Steady progress toward functional goals must be documented • Interdisciplinary communication should be documented

20. Essential Components for Reimbursement: Therapy Reassessments

21. Essential Components for Reimbursement Therapy Reassessments • Reassessments are required at the 13th visit, the 19th visit, and at least every 30 days. (If more than one therapy discipline is seeing the patient, each must reassess close to and before the 13th and 19th visits) • The purpose of reassessments is to justify continued billing!

22. Essential Components for Reimbursement Therapy Reassessments • Medicare says each therapy discipline must “functionally reassess the patient and compare the resultant measurement to prior measurements” • Re-stating the functional goals and addressing progress, or lack of progress, toward each satisfies the requirement • Objective measurements may or may not be functional

23. Essential Components for Reimbursement Therapy Reassessments • Examples: • The patient will transfer from the bed to the BSC with SBA in 2 weeks: Good progress – pt now requires min assist. • The patient’s balance will improve to low fall risk, as evidenced by an improvement in the Tinnetti score to >24 points: Good progress – Tinnetti score at initial eval was 16/28 indicating high fall risk; current score is 21/28 indicating moderate fall risk. • The patient will perform upper body dressing with min assist: Goal met

24. Essential Components for Reimbursement Therapy Reassessments • If the measurements do not indicate progress toward the goals, and/or do not indicate that therapy is effective, but the therapy continues, the therapist must document why the physician and therapist have determined that therapy should be continued.

25. Essential Components for Reimbursement: Discharge summary

26. Essential Components for Reimbursement Discharge Summary • Because it often lays right on top of the PT/ OT/ ST section of the chart (if records are filed in reverse chronological order), it is the first thing an auditor will see when reviewing therapy records – it can be a very useful document in proving that treatment was reasonable and necessary! • If goals are not re-stated and progress addressed in the DC summary, it is probably not being used to best advantage.

27. Reviewing Therapy Documentation if You Are a Nurse

28. Reviewing Therapy Documentation if You Are a Nurse • OASIS guidelines are the same, no matter who is filling it out • Therapy Evaluation must have clear functional goals • Therapist(s) should be in right away if there are safety concerns such as fall risk; impaired mobility contributing to pressure ulcer risk or to incontinence; etc

29. Reviewing Therapy Documentation if You Are a Nurse • Therapy Revisit Notes must indicate steady progress is being made toward the functional goals • Skilled care must be evident at every visit • Handwriting must be legible • If these things are not apparent to you, chances are good they will not be apparent to the nurse who is auditing the chart for Medicare!

30. Reviewing Therapy Documentation if You Are a Nurse • Therapy Reassessments must restate goals from the initial evaluation and document what progress has been made toward those goals – Medicare requires a functional comparison between timepoints be made by the therapist

31. Reviewing Therapy Documentation if You Are a Nurse • The Discharge Summary should also restate goals and indicate which were met, and for goals that were not met, an explanation should be given

32. Now we will have an OPEN Q&A Q and A

33. Thank You for Joining Us Today! • Your feedback is welcome and encouraged! • Copies of today’s slides are available to download directly from the link provided! OR by going here: http://meg.mykate.com/index.html and click the DOWNLOAD button AFTER YOU HAVE COMPLETED THE PRESENTATION PLEASE TAKE THE TEST BEFORE THE SURVEY If you have any problems or are not able to listen to the entire RECORDED webcast, the recording will be available at the SAME LINK included in your invitation email from June 15th through June 30th . If you have further questions you can email Nita at nita.megassociates@gmail.com Email us with comments or suggestions for our moderator at dezignsbykate@gmail.com