Last January, 2007, CMS issued Transmittal 63 that therapists have:
"Documentation required to indicate objective, measurable beneficiary physical function including, e.g.,
- Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments; or
- Functional assessment scores (and comparison to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or
- Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care."
This Transmittal (which is now permanently incorporated into the Medicare Benefit Policy Manual, Chapter 15, Section 220.2 which describes the regulations for therapy*) also emphasizes that documentation needs to support the complexity of treatment and goal achievement. Complicating factors such as multiple conditions or cognitive disorder must be described in an objective manner and where applicable subjective patient self-reporting.
Documentation must focus on functional outcomes. The standardized or non-standardized assessments must be listed with initial and final results. Findings need to be interpreted in means of performance deficits, and a summary of the results and observations as they relate to the person's functional/occupational performance.
There are many scales and measurements that can be used to meet this mandatory outcome requirement. Many of them are geared to a patient returning to home. Independence or Modified Independence with support are the goals. Many of the people treated by you live in a nursing facility. Your goals should be increased participation in a particular functional task. The Routine Task Inventory (RTI) is such a tool. Record your initial functional performance findings on your evaluation. You will then determine the Allen Cognitive Level and establish your goals. After adapting the environment, and training the caregivers, you can then relate the functional outcomes, weekly or upon discharge, utilizing the RTI for best ability.
The Allen Cognitive Level can also be used in documentation. The initial level assessed from observation and environment would be listed. Your findings (Adapted Placemat, LACLS, and RTI) would follow in Progress Notes as potential best ability. The summary of the course of treatment would reference the best ability and if it is realized or compromised by "can do, will do, may do."
The power of documentation cannot be emphasized enough. It is no longer sufficient to write what the patient is now able to do. The assessment tools you use must be indicated and referenced throughout the course of treatment. The skills required must be documented in addition to the patient's progress. Example: "Skilled cognitive therapy is required to adapt techniques/environment to enable the client to . . ." The tools of measurement must be referenced. Each step progressing to maximum ability must be clearly stated and objectively identified. What is written is not a reflection of your heart or observations, but a reflection of your skills and final outcomes. Your heart drives you. A reviewer must see the reasonable and necessary functional skilled reason for reimbursement.
Outcome goals must not be written in reference to a score. Outcome is not a test score but a function. Any "scoring" must be interpreted. A wrong example of a goal is: "Client will progress from a 3.0 to a 3.6 in dressing."
A functional outcome goal would be written as:
"Client will grasp and don familiar garments presented by caregiver with verbal cues."
The discharge summary is the end of the story. Reference to scores is valuable, but the function achieved is essential. Include both in a brief manner. Documentation is as important as the intervention.
You must include the reliable assessments tools used in your documentation. Before and after functional outcomes must be included to support the course of treatment. (Note from Kim Warchol: If using the LACLS, be sure to document the manual edition being utilized for administration and scoring.)
Upcoming 2008 CMS changes:
- On December 19th, Congress passed a six-month extension of the Medicare B exceptions process (which includes Dementias & Alzheimer's), plus a .5% increase to the Fee Schedule. This will expire on June 30th, 2008. Congress must address the Medicare B items before July 1st, 2008. It is extremely important to contact your Senators and Representatives regarding therapy intervention. AOTA, APTA, ASHA all provide assistance in contacting them. Do not let this fall into the decisions of politicians who do not know what their constituents are dealing with.
- The new Medicare B Therapy Cap will be $1810. For patients who have conditions on the exceptions list, it is possible to go over this amount with justification until June 30th, 2008.
- There is a new code: 96125, "Standard cognitive performance testing of a qualified health care professional." The only example listed by CMS is the RIPA (Ross Information Processing Assessment). While this is listed as "always" therapy (PT, OT, SLP), it is unclear at this time as to how PT & OT might utilize this code. Stay tuned to the DCS Online Community for further developments.
- The Medicare B certification requirement has changed from 30 days to a maximum of 90 days. It is unclear as to how this will affect nursing facilities. DCS recommends that the present process stay in place until you hear from your company or Intermediary.
- CMS will be establishing new guidelines for Medicare A documentation and "therapy student" minutes of treatments in mid-2008.
As always, please send any questions you may have to DCS.
Thank you for finding and intervening in the lives of those who do not realize their best ability!