Relationship btw documentation and payment: Documentation demonstrates: 1. Medical ____________ 2. Potential for ___________ 3. Services provided as ________ 4. Services meet _____________

1. Medical necessity 2. Potential for improvement 3. Services provided as billed 4. Services meet accepted standards

Lec 8 - Documentation To Support Payment/Reimbursement Functional Limitation Reporting Flashcards by Jessica Deak

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

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Internal audiences for documentation (7):

You (at a later date)
Colleagues
Other staff
Other HCP
Referral sources
Students
Patients/families

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External audiences for documentation (5):

Third party payers
Reviewers
Case managers
Lawyers
Researchers

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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

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Preventing Denials: Requires process to ensure claims are ______ and _______ (“_____”) before submitting

Complete
Accurate
Clean

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Preventing Denials: Denials and appeals process add ____ to the provider - administrative time, loss of professional ______ _______ ______

COST

Productive billable time

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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

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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

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Common reasons for denials: PREVENTING DENIALS (3):

Document SKILL - initial and ongoing
Measure and quantify information in MEANINGFUL WAY
Avoid use of JARGON

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Defensible Documentation:

APTA member resource for __________

Documentation skills

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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

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Defensible Documentation: Resources for clinicians:

Medicare manuals
Medicare Admin Contractors Local Coverage Decisions
Payer specific websites
State practice acts
APTA Guidelines for Documentation

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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?

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Details on what is wrong with the pt?

Exam/eval

Diagnosis

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Details on what is planned for the pt?

POC
Goals
Prognosis

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Details on what skilled interventions are required and what specific services are being provided?

Daily notes

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Details on what progress is being made toward D/C?

Daily notes, progress reports, re-eval

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Details on what is the final result of the services delivered, PT prognosis and status at D/C?

D/C summary

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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

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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

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Documentation requirements for therapy services: Documentation must be ______, ______, and ______ to justify the services billed

Legible
Relevant
Sufficient

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Documentation requirements for therapy services: Medicare requires that the services billed be supported by __________ that _________ _________

Documentation that justifies payment

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Documentation requirements for therapy services: Identify ________ expectations

MINIMAL

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Initial examination includes? (3)

History
Systems review
Tests and measures

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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. 1. _____ dx and ______ dx 2. Support for _____, ______, _____ 3. Identification of medical care before ___________, if any 4. Identification of _______, including where patient lives, who they live with 5. Provision of ______, _______ physical function 6. _______, __________ with other providers

1. THERAPY AND MEDICAL 2. Illness, disease, injuries 3. Current episode 4. Social support 5. Objective, measurable 6. 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?

Re-certifications: Whenever need for significant modification of plan, or at least every _____ days if medically necessary treatment continues to be required

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

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?

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:

1. Fall risk 2. Reduced mobility 3. 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)

1. Is more clinically relevant to successful outcome 2. Would yield the quickest and/or greatest functional progress 3. 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?

1. Another separately payable (non-bundled) service 2. The G-code for the functional limitation 3. A severity modifier 4. Completion of the units field with "1" unit of service 5. The corresponding therapy modifier indicating the discipline of the plan of care (GO, GP, GN) 6. A nominal charge ($0.01) for each line with the functional limitation G codes

Lec 8 - Documentation To Support Payment/Reimbursement Functional Limitation Reporting Flashcards

(116 cards)