With the spiraling cost of health care in the United States, it is critical to demonstrate the effectiveness and efficiency of therapy treatment. As payers, health care systems and the public question the efficacy and cost effectiveness of rehabilitation, objective documentation is becoming more important. Therapists must have a more scientific basis for their practice. Evidence based treatment is indeed best practice. Referrals are increasingly based on objective, value-based criteria including metric-driven rehabilitation performance, rates of successful home discharges, re-hospitalization rates and patient experience ratings.
Selecting and administering the appropriate tests and measurements to determine a patient’s status on their initial therapy evaluation provides an objective assessment of their particular strengths and needs. The initial findings along with interpretation of the data, establishes the baseline for a patient’s status. It directs the development of the plan for therapeutic intervention to achieve the goals set for the patient. This detailed, objective baseline is essential to achieve superior results from therapy.
Assessments are also necessary to evaluate the effectiveness of treatment interventions. How objective and accurate are the findings? How reliable? How valid? How does the therapist select the appropriate interventions for patients if assessments are in question or vague?
Therapists can become stagnant by seeing each patient as similar to the last hip fracture or stroke patient treated or by treating the “frequent flyer” patient based on the patient’s status from previous treatment. Meticulous attention to the details and identifying an accurate objective baseline (from which progress or decline can be measured) facilitates individualized clinically appropriate therapy and revenue that is insulated from potential denial.
Frequently reported reasons for not using standardized outcome measures include:
- The length of time for patients to complete them,
- The length of time for clinicians to analyze the data, and
- The difficulty for patients in completing them.
In addition, performance based measures relevant for patients in a skilled nursing center may not be part of a therapist’s repertoire or easy to find. Assessments that are familiar, easily administered, readily available in the clinic, easily scored and time efficient are reported to be used more often.
For rehabilitation in a SNF to be skilled it must be provided on a daily basis (at least five days per week), the services that are provided must be reasonable and necessary, the therapy services must be of a level of complexity and sophistication or the condition of the patient must be of a nature that the judgment, the knowledge and skills of a qualified therapist are required. There is no particular format required for the documentation to show that these criteria are met.
On September 5, 2012, CMS conducted a special Open Door Forum regarding the Manual Medical Review Process for Medicare Part B Therapy Claims and they reviewed a PowerPoint presentation that is used to train claim reviewers. They felt this might be helpful for providers to prepare documentation in a way that demonstrates the need for a patient to be receiving skilled services. CMS stressed providers need to “paint” a complete and thorough picture of the health and needs of the patients in order to support the skilled needs. This PowerPoint mentions assessing “objective, measureable gains” and advocates using “standardized scales and assessment tools.” With the recent requirement of G-Codes and the modifier specifying a percentage of impairment, CMS is again emphasizing the importance of objective data to support skilled interventions. A functional modifier placed at the end of the G-Code is a two letter modifier that reports the percent of the severity or complexity of the functional limitation. They are ordered alphabetically by severity as follows:
- CH: 0 percent impaired
- CI: At least 1 percent but less than 20 percent
- CJ: At least 20 percent but less than 40 percent
- CK: At least 40 percent but less than 60 percent
- CL: At least 60 percent but less than 80 percent
- CM: At least 80 percent but less than 100 percent
- CN: 100 percent impaired.
Using a standardized form of assessment that is reproducible by different clinicians reporting the G-Codes during a course of treatment yields more accurate data. Accurate G-Codes can improve the likelihood of CMS designing a Medicare Part B reimbursement system that is fair and just.
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