A higher level of scrutiny regarding the content of therapy documentation has been noted in the published findings of government funded auditing agencies. Harmony (HHI) has assisted numerous facilities in the audit process and has identified trends in risk areas as well as frequent denial reasons through analysis of government agency audit findings. An area requiring serious attention by SNF Administrators and Rehabilitation managers is documentation in the medical record supporting the patient’s medical necessity for Part B Rehabilitation services.
A trend has been noted in the lack of documentation that tells the story from the start of Part B Rehabilitation services in the medical record, particularly when the patient has transitioned to Part B services from Medicare Part A services. Rehabilitation providers should perform an evaluation for each discipline at the time this transition. Many times therapists avoid additional documentation due to time constraints and the lack of reimbursement for the task of completing a comprehensive evaluation. SNF Administrators and Managers must consider the future consequences of these decisions.
Documentation must be as complete as possible to allow medical reviewers to determine the appropriateness of the billed services. When a patient has received Medicare Part A services for 100 days, the most common scenario for this transition, the reviewer may have difficulty determining the appropriateness of services without an evaluation and appropriate documentation of G codes, baseline on initiation of services under a new payer source, updated goals and documentation going forward that documents progress to support the medical necessity of the services provided.
Problems with medical records often include:
- Rehabilitation evaluations from 100 days prior that does not relate to the patients current status. The patient has often surpassed the initial goals developed during the Admission to Medicare Part A services.
- Documentation from the Medicare Part A stay is not included at all in the facility prepared response to an Additional Documentation Review (ADR) for Part B services.
- G codes are missed at the initiation of Part B services as the therapist does not recognize timely the transition of payer source.
The G code severity modifier reflects the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge.
In selecting the severity modifier, the clinician:
- Uses the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate.
- Uses his/her clinical judgment to combine the results of multiple measurement tools used during the evaluative process to form clinical decisions to determine a functional limitation percentage.
- Uses his/her clinical judgment in the assignment of the appropriate modifier.
- Uses the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation.
As you can see, the appointment of appropriate G codes requires a comprehensive assessment by the therapist therefore supporting the time and resources required to assist the facility in insulating appropriate payment for services at the time of review by a contracting government agency.
The Rehabilitation evaluation at the transition of Medicare Part A to Medicare Part B for therapy will ensure the medical record reflects:
- Clarity: Evidence of the need for further skilled care.
- Content: 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.
Considering the basics of documentation and utilization of objective measures will establish a patient specific assessment and plan of care. Documenting complex treatment approaches that can only be provided by a skilled therapist is one way to support the need for skilled services. In addition, documenting the medical complexity of the patient will also support that the unique skills of a therapist are required. When establishing a plan of care and reflecting treatment interventions to justify daily skilled services, ensure the critical thinking skills of the therapist are clearly communicated and are evident in objective and measurable outcomes. Quantifying progress will justify the need for continued treatment.
With the ever changing healthcare industry, the importance of having accurate, clear and comprehensive documentation that paints an accurate clinical picture of the resident is imperative for facilities to continue to receive accurate reimbursement for the quality care that is being provided. Harmony (HHI) recommends providing ongoing education and training to facility staff to ensure all members of the Interdisciplinary team are documenting the skilled care they are providing. Harmony (HHI) is available to assist the facility with this education upon request. You can contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.