WIXLIB

Navigating Therapy ComplianceRequirements Across The ContinuumKay Hashagen, PT, MBA, RAC-CTSenior ConsultantLW Consulting, Inc.Catherine Gill, MS, PT, MHADirector of Quality and Support Services;Compliance OfficerFranciscan VNS Home Care and Franciscan Hospice CareObjectivesMedicare Conditionsof sRequirements forTherapists in DifferentSettingsRiskReasonable & NecessaryDocumentationTraining andMonitoringCompliance forTherapists in MultipleSettingsBest Practices1

Therapy is Occurring Everywhere!HospitalsOther InpatientFacilitiesOutpatientTherapyIn Home ServicesPart A:Inpatient Units, Acute RehabUnitsPart A:Acute Rehab HospitalsLong-Term Acute HospitalsSkilled Nursing FacilitiesPart B:Freestanding Therapy ClinicsSNFsCORFsHome HealthPart A:Home HealthHospicePart B:Outpatient DepartmentsPart B:Outpatient TherapyConditions of Payment Requirements that must be met beforethe government will pay a claim2

Medicare PaymentDriversMedicare Payment DriversClinicalClinical Condition PLUSCondition Therapy me Health3

Proposed Payment ChangesHH:HHGMSNF:RCS-1Reasonable and Necessary Therapy Services Can only be safely and/oreffectively performed by or underthe supervision of a licensedtherapist Consistent with nature andseverity of patient’s illness andspecific needs Considered specific, safe andeffective treatment underaccepted professional standards4

Documentation to Support Medical NecessityGeneral Guidelines Interventions and goals directly reflect: Specific evaluation findingsSpecific functional deficitsPotential for improvement Goals are objective and measurable Standardized tests and measures are used whenavailable/appropriateAcute Care Hospitals (IP)5

Conditions of Payment - IPPhysician OrderAdmit to IPServicesCertification forLOS 20 daysMedical Necessity Requirements - IP The patient’s condition requiresinpatient hospitalization that isexpected to last at least over 2midnights The patient is receiving aMedicare-specified “inpatientonly” procedure6

Therapy Documentation Requirements - IPNo ing bodyrequirements applyState-specificdocumentation andsupervisionrequirements applyExamples:Plan of care, timelydischarge summaries,no use of inappropriateabbreviations, etc.Inpatient Rehabilitation Facilities(IRF)7

Conditions of Payment IRF60% of patients fallinto specificdiagnosticcategoriesPre-AdmissionScreen (PAS)Post AdmissionPhysician Evaluation(PAPE)Individualized Planof Care (IPOC)InterdisciplinaryTeam ConferencesPhysicianSupervisionOrders forAdmissionRequire interventionfrom multipletherapy disciplinesRequire an intensivetherapy programand meet intensityBe medically stableto benefit from theIRF servicesHave an appropriatelength of stayIRF-PAI (PatientAssessmentInstrument) must bein the recordConditions of Payment: IRF Therapy FocusIndividualizedPlan of nterventionFrom MultipleTherapyDisciplines8

Conditions of Payment: IRF Therapy FocusRequire an IntensiveTherapy Programand Meet IntensityHave an AppropriateLength of StayIRF-PAI (PatientAssessmentInstrument) Must Bein the RecordMedical Necessity Requirements IRFComplexityof nursingservicesTherapyservicesintensityThe IRF stay will onlybe considered to bereasonable andnecessary if, at thetime of admission,documentationsupports all of theseIntensity ofservicesneededNeed yteam approachfor rehab9

Therapy Medical Necessity Focus IRF Interdisciplinary team approachfor rehab Requirements for teamconferences Requirements for teammembers Therapy services intensityTherapy Documentation Requirements IRF Documentation to supportinformation entered on theIRF PAI Documentation to supportthat care is reasonable andnecessary Documentation of mode andminutes provided10

Therapy Documentation Requirements IRF Evaluation orders prior to the evaluationThe full course of intensiverehab, per the plan of care,must be initiated within 36hours from midnight the day ofadmissionFIM scores are completedaccurately for functional tasksrelated to each disciplineTherapy Documentation Requirements IRFDaily notesidentify minutesand modeProgress notessupport progresstowards dischargethat is reasonableand necessaryMissed therapy iswell documented11

Long Term Acute Care Hospitals(LTACH)Conditions of Payment LTACH The regulations thatsupport acute carehospitals apply toLTACHPhysician OrderAdmit to IPServices12

Medical Necessity Requirements LTACH The patient’s condition requiresphysician supervision either on-site oron-call 24 hours per day, 7 days perweek Admission criteria is met from day oneof the stay LOS 25 Days The need for multidisciplinary care tosupport primary and secondarydiagnoses Expected discharge planTherapy Documentation Requirements LTACHNo ing bodyrequirements applyState-specificdocumentation andsupervisionrequirements applyExamples: Plan ofcare, timely dischargesummaries, no use ofinappropriateabbreviations, etc.13

Skilled Nursing Facilities (SNF)Conditions of Payment SNF The patient must have a 3-day qualifying hospital stay OR admission within 30 days of prior discharge A physician order and certification of skilled care is required per time requirementsDiagnosis must relate to the qualifying stayMust require skilled services on a daily basisThese services can only be provided in a SNF on an inpatient basisThe patient must be assigned to a RUG groupCMS MBPM 100-02 Chapter 814

Therapy Medical Necessity Focus SNF Services must be:care provided is skilled directly related to the treatmentplan that is based on the initialevaluation at a level of complexity and thecondition of the patient mustrequire the judgment,knowledge and skills of atherapistTherapy Medical Necessity Focus SNF The services must be:reasonable and necessary provided with the expectationthat the condition will improvein a reasonable and generallypredictable period of time, or necessary for the establishmentof a safe and effectivemaintenance program15

Therapy Medical Necessity Focus SNF The services must be: considered under acceptedstandards of medical practice reasonable and necessary forthe patientreasonable and necessaryTherapy Documentation Requirements SNFA physicianorder toEvaluate andTreat isrequired priorto the firsttreatmentInitial evaluation and plan ofcare need to be completedincluding:DiagnosisDocumentationneeds to supportreasonable andnecessaryrequirements andskilledLong Term Goals (LTG)Interventions,frequency andduration16

Therapy Documentation Requirements SNFMinutes recorded to theMDS need to be supportedby documentation as skilledminutesModes of therapy need tobe recorded and supportedas per requirementsMinutes need to berecorded as “actual”minutes, not roundedHome Health (HH)17

Conditions of Payment - HH Be confined to the home Required for Medicare, not for Medicaid, varies by plan forMedicare Advantage, commercial payors Defined as:a) needing assistance to leave the home, or medicallycontraindicated to leave the home ANDb) normally unable to leave, and doing so requires asignificant effortConditions of Payment - HH Be confined to the home Under the care of the physician Physician certifies the need for home health and the plan ofcare Physician orders obtained for any changes to the plan of care A face-to-face visit 90 days before or 30 days after admission(Medicare & Medicaid) Physician recertifies the need for home health and the plan ofcare every 60 days18

Conditions of Payment - HH Be confined to the home Under the care of a physician Require intermittent skilled nursing or PT/SLPservices or continuing OT servicesConditions of Payment - HH Be confined to the home Under the care of a physician Require intermittent skilled nursing or PT/SLPservices or continuing OT services Therapy reassessments at least every 30 days tojustify the need for continued services19

Conditions of Payment - HH Be confined to the home Under the care of a physician Require intermittent skilled nursing or PT/SLPservices or continuing OT services Timely submission of OASIS assessmentTherapy Medical Necessity Focus - HH The skills of a therapist are necessary Restorative The patient’s condition will improve materially in a reasonableand generally predictable period of time, as evidenced byobjective successive measurements. Maintenance Establish or update a maintenance program Carry out a maintenance program if the patient’s conditionwarrants the skills of a therapist to do so20

Each Visit NoteTherapy Documentation Requirements - HHThe history and physical exam pertinent to the day’s visit,including the response or changes in behavior to previouslyadministered skilled servicesThe skilled services applied on the current visitThe patient/caregiver’s immediate response to the skilledservices providedThe plan for the next visit based on the rationale of priorresults.Therapy ReassessmentsTherapy Documentation Requirements - HHPerformed by a licensed therapist (not assistant)Functionally reassess the patient and comparethe resultant measurement to prior assessmentmeasurements.Document measurement results along with thetherapist’s determination of the effectiveness oftherapy, or lack thereof.21

Part B Therapy in Home HealthAgency has a Part Bprovider numberPatient no longermeets criteria for HHservices (Dischargedfrom Home Health)Patient continues torequired skilledtherapy22

Outpatient/Part B (OP)Conditions of Payment - OP Services required are based on individual needs Services are under a Plan of Care Patient must be under the care of a physician or NPPThese conditions are considered to be met when thephysician or NPP certifies the outpatient plan of care23

Medical Necessity Focus OPPatient specific is a KEY focus Services must meet accepted standards of practice Services must be specific and effective for the patient’scondition The services as documented support that the skills of aqualified therapist are necessary The documentation supports the clinician’s assessmentwith changes based on their clinical judgmentDocumentation Requirements OPNo physician’sorder is requiredInitial Evaluationand Plan of CareCertification of thePlan of Care-takersplace of orderMust be signed assoon as possibleor within 30 daysof the evaluationDelayedCertification isallowed24

Functional Reporting CodesDocumentation Requirements - OPG CodesC ModifiersRequired to be used on the initialevaluation, every progress update,recertification and dischargeDocumentation Requirements OPProgress update onor before every 10thvisitDaily documentationto support codesbilled each sessionRecertification perplan of care or perpatient needDischarge Summary25

Documentation Requirements OPThere is no longer a “therapycap” for Medicare patientsUse of the KX Modifier StillRequired Applied when the patient hasexceeded the old cap amount and thetreatment is still medically necessaryHospice (HOS)26

Conditions of Payment - HOS Beneficiary election of hospice benefit – NOE Certification of terminal illness – CTI Plan of care established and periodically reviewed and updated by the IDGFace-to-face at 3rd benefit period and eachsubsequent benefit periodMedical Necessity Focus - HOSServices inaccordance withthe plan of careHospice servicesare reasonable andnecessary formanagement of theterminal condition andrelated illness27

Documentation Requirements - HOSNo Medicare-specificdocumentationrequirementsTherapy provided toaddress the terminalillness and relatedconditionsGoals and interventionsfocused on symptommanagement ormaintenance offunctional abilitiesDocumentation Requirements - HOSPart B Therapy ProvidedOutside the Hospice Benefit Clear documentation that the servicesprovided are NOT related to the terminalillness and related conditions28