Physician Documentation Tips

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Physician Documentation Tips

• Lisa Werner Bazemore, MBA, MS, CCC-SLP
• Director of Consulting Services

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Documentation

• Why is documentation so important to medical
  necessity?
• This is a time of defensive documentation
• Just like universal precautions assume any and
  all charts will be audited.
• A reviewer of your medical record will only see
  the ink and paper you send.
• In some cases they are incentivised to deny your
  claims!

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Documentation

• What is your perception of these statements from
  actual medical records?
• The patient has no previous history of suicides.
• The patient refused autopsy.
• Discharge status alive but without my
  permission.
• She stated that she had been constipated most of
  her life until 1989 when she got a divorce.
• Rectal examination revealed a normal-size
  thyroid.
• On the second day the knee was better, and on the
  third day it had completely disappeared.
• The patient has been depressed since she began
  seeing me in 1993.
• Healthy appearing decrepit 69 year old male,
  mentally alert but forgetful.

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Documentation

• When auditors review our charts, all they see is
  what we have documented. They dont know the
  patient and dont know our protocols for patient
  care.

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Physician Documentation

• Purpose
• Establish medical necessity
• Clearly state why the patient needed to occupy an
  inpatient rehabilitation bed
• Indicate why the patient requires an intense
  level of rehabilitation services
• List problems and services that are needed
• Define why patient could not have their needs met
  in a skilled nursing facility
• AND
• Document information required to ensure
  continuity of high quality care

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Physician Documentation

• Physician Buy-In for Medical Necessity
• Physicians should be partnered with for the good
  of the patient and facility so that they
• Understand the importance of medical necessity
  and medical necessity documentation in rehab
• Can identify how medical necessity can be
  assimilated into their current documentation style

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Physician Documentation

• Whats so special about Physical Medicine and
  Rehabilitation?
• Combining into one Plan of Care
• Medical treatments
• Therapy treatments

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Physician Documentation

• Whats so special about Physician documentation?
• CMS stated that if they could identify that the
  stay was reasonable and necessary through the
  pre-admission screening and the post-admission
  evaluation, they would spend less time reviewing
  the rest of the chart.

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The Rule

• Documentation Requirements
• Contractors must consider the documentation in
  the IRF record when determining if admission was
  reasonable and necessary, focusing on
• pre-admission screening
• post-admission physician evaluation
• overall plan of care
• admission orders

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The Rule

• Requirements for the Pre-admission Screening
• CMS believes that a comprehensive pre-admission
  screening process is the key factor in initially
  identifying appropriate candidates for IRF care.
• Pre-admission screening is an evaluation of the
  patients condition and need for rehabilitation
  therapy and medical treatment.
• It is required documentation of the clinical
  evaluation process that forms the basis of the
  admission decision.
• Serves as the primary documentation by the IRF
  clinical staff of the patients status prior to
  admission and of the specific reasons that led
  the IRF clinical staff to conclude that the IRF
  admission would be reasonable and necessary.
• Must be detailed and comprehensive.

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The Rule

• Pre-admission screening should show
• That the patient has the appropriate therapy
  needs for placement in an IRF
• The patient is expected to make measurable
  improvement that will be of practical value in
  terms of improving the patients functional
  capacity or adaptation to impairments.
• That the patients condition is sufficiently
  stable to allow the patient to actively
  participate in an intensive rehabilitation
  program
• The patient is able and willing to participate in
  an intensive rehabilitation program that is
  provided through a coordinated interdisciplinary
  team approach in an inpatient setting.

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The Rule

• Pre-admission screening should show
• An interdisciplinary team approach to care
  requires that treating clinicians interact with
  each other and the patient to define a set of
  coordinated goals for the IRF stay and work
  together in a cooperative manner to deliver the
  services necessary to achieve these goals.
• That the patient requires the intensive services
  of an inpatient rehabilitation setting
• The patient generally requires and is reasonably
  expected to actively participate in at least 3
  hours of therapy per day at least 5 days per week
  and is expected to make measurable improvement
  that will be of practical value to improve their
  functional capacity or adaptation to impairments.

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The Rule

• Scope of pre-admission assessment should include
  
• Patients prior level of function (prior to the
  event or condition that led to the patients need
  for intensive rehabilitation therapy)
• Expected level of improvement
• Expected length of time needed to reach that
  level of improvement
• Evaluation of the patients risk for clinical
  complications
• Conditions that caused the need for
  rehabilitation
• Combination of treatments needed (one of which
  must be PT or OT)
• Expected frequency and duration of treatment in
  the IRF
• Anticipated discharge destination
• Any anticipated post-discharge treatments
• Other information relevant to the care needs of
  the patient

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The Rule

• Pre-admission screening timeline, approval and
  retention
• Individual elements of the pre-admission
  screening may be evaluated by any clinician
  designated by a rehab physician, as long as the
  clinicians are licensed or certified and
  qualified to perform the evaluation within their
  scopes of practice and training.
• Each IRF may determine its own process for
  collecting and compiling the pre-admission
  screening information. The focus of the review of
  the screening will be on its completeness,
  accuracy and the extent to which it supports the
  appropriateness of the admission decision.

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The Rule

• Pre-admission screening timeline, approval and
  retention
• Must be completed within the 48 hours immediately
  preceding the IRF admission.
• If the patient is not admitted within 48 hours of
  the screening, an update conducted in person or
  by telephone no more than 48 hours prior to
  admission is required to document changes in the
  patient's medical and/or functional status.
• Rehabilitation physician must review and document
  his or her concurrence with the findings and
  results of the pre-admission screening prior to
  the IRF admission.

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The Rule

• Pre-admission screening timeline, approval and
  retention
• IRF is responsible for developing a thorough
  pre-admission screening process for patients
  admitted to the IRF from the home or
  community-based environment which includes all
  the required elements described.
• Pre-admission screens cannot be done over the
  telephone however, updates can be done over the
  telephone. Pre-admission screenings can be done
  from faxed patient records.
• Must be retained in the patients record.

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The Rule

• Requirement for a Post-Admission Physician
  Evaluation
• To be completed by a rehabilitation physician
  within 24 hours of admission
• Document the patients status on admission to the
  IRF
• Compare it to that noted in the pre-admission
  screening documentation
• Begin development of the patients expected
  course of treatment that will be completed with
  input from all of the interdisciplinary team
  members in the overall plan of care
• Identify any relevant changes that may have
  occurred since the pre-admission screening
• Provide guidance as to whether or not it is safe
  to initiate the patients therapy program
• Support the medical necessity of the IRF
  admission
• Include a documented history and physical exam,
  as well as a review of the patients prior and
  current medical and functional conditions and
  comorbidities

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The Rule

• Requirement for a Post-Admission Physician
  Evaluation
• It would be useful for the post-admission
  physician evaluation to
• Describe the clinical rehabilitation
  complications for which the patient is at risk
  and the specific plan to avoid them
• Describe the adverse medical conditions that
  might be created due to the patients
  comorbidities and the rigors of the intensive
  rehabilitation program, and the methods that
  might be used to avoid them
• Predict the functional goals to be achieved
  within the medical limitations of the patient

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The Rule

• Requirement for a Post-Admission Physician
  Evaluation
• Serves as a combination medical/functional
  resource for all team members in the care of the
  patient as they prepare to contribute to the
  overall plan of care
• Requires the unique training and experience of
  the rehabilitation physician, as he or she
  performs a hands-on evaluation of the patient
• Does not require the physician to obtain input
  from the interdisciplinary team prior to
  completing, although it would be in the best
  interest of the patient if team member input were
  provided
• The document must be retained in the medical
  record

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The Rule

• Requirement for a Post-Admission Physician
  Evaluation
• The conclusion of a post-admission evaluation may
  result in a change from the pre-admission
  conclusion that the patient is appropriate for
  IRF care in such cases, appropriate action
  should be taken.
• The rehabilitation physician must note the
  discrepancy and document any deviations from the
  pre-admission screening
• For example, patient believed to be able to
  tolerate 3 hours per day, but only tolerates 2
  hours on day one due to pain from the ambulance
  trip to the IRF. In this case the reason for the
  temporary change must be noted in the patients
  medical record no need to discharge

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Physician Documentation

• Admission Post-Admission Assessment Format
• Patient Name/History Room
• Date of Admission
• History of Present Illness
• Medical History (Include onset date, chief
  complaint and functional implications)
• Allergies
• Medications (Reconcile home meds, MAR and
  discharge summary meds)
• Past Medical History
• Social History
• Family History
• ROS
• Physical Exam

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Physician Documentation

• Admission Post-Admission Assessment Format
  (continued)
• Assessment/ Plan
• Compare current status with status as notes on
  the pre-admission screening form
• Provide guidance as to whether or not it is safe
  to initiate the patients therapy program
• Impairment (Reason for admission)
• Etiologic diagnosis (Pathophysiologic reason for
  reason for admission)

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Physician Documentation

• Admission Post-Admission Assessment Format
  (continued)
• Medical Necessity The etiologic diagnosis and
  comorbidities listed below require the 24 hour
  availability and frequent intervention of a
  physician with specialized training in
  rehabilitation.
• List of comorbidities interventions
• Describe the clinical rehabilitation
  complications for which the patient is at risk
  and the specific plan to avoid them
• Describe the adverse medical conditions that
  might be created due to the patients
  comorbidities and the rigors of the intensive
  rehabilitation program, and the methods that
  might be used to avoid them

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Physician Documentation

• Admission Post-Admission Assessment Format
  (continued)
• Rehab Necessity (Medical Impact on Function)
• Treatment plan
• Include nursing (24 hr. rehab RN for bowel
  program, therapy carryover, pt edu., skin,)
• Include therapy (Intensive therapy for 3
  hours/day 5 days/week. Interventions PT to
  address, OT to address, etc. OR Refer to
  complete admission orders for interventions)
• Include weekly team conferences to coordinate
  plan of care.
• Rehabilitation Goals
• Prognosis
• Estimated LOS
• Planned Discharge Disposition

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Physician Documentation

• Assessment / Problem List should include
• Rehabilitation diagnosis (primary functional
  limitation, primary impairment and cause)
• Complications and coexisting conditions
• Symptoms that will require treatment
• Chronic medical conditions
• Potential conditions that require preventive
  measures, restrictions and/or precautions
• Functional deficits to be treated by the program

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Physician Documentation

• What is the plan?
• The preliminary plan supports medical necessity
  by describing the treatment for the condition
• Indicates the decision to admit the patient
• Provides evidence of the complexity of the
  interdisciplinary program
• Lists the interventions to be provided by each
  team member
• Implies the skill level required to provide such
  services

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Physician Documentation

• Things to avoid in the assessment and plan
• Do not use the same statement for all patients
  admitted
• Less is not more
• Writing efficiently can help control length
• Limiting the list to medical conditions only
• Forgetting to document what nursing will do
• Forgetting to document what therapy will do
• Comments like
• Medically stable
• No medical issues
• Uneventful course

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Physician Documentation

• Document therapy treatment status, goals and plan
  in the plan
• Examples
• We will initiate comprehensive rehabilitation
  program with physical therapy, occupational
  therapy, recreational therapy, 24 hour
  rehabilitation nursing and physicians. She will
  benefit from this comprehensive rehabilitation
  program to address ADLs and mobility status post
  surgery as she is currently requiring moderate
  assistance for ADLS and mobility.
• Hypertension Will monitor and adjust dosing of
  Norvasc and hydrochlorothiazide due to recent
  uncontrolled pressures.
• Postop anemia Hemoglobin has been stable at 9,
  will continue to monitor and consider adding iron
  supplementation if this continues to be an issue.
  Will hold off for now as patient has constipation
  and iron can be constipating.
• Rehabilitation therapies Goals to manage pain,
  increase ambulation and ADLs to goal of
  independent level and to work on range of motion
  with CPM machine. Assess for equipment needs and
  home safety.

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Physician Documentation

• Link medical and therapy issues to show how they
  interrelate
• A 72-year old female, previously modified
  independent, following cerebellar infarct now has
  decreased balance and coordination. She is now
  unable to return to prior level of function.
  Needs inpatient rehab, physical, occupational and
  speech therapies for decreased function and
  cognition. Rehab physician management is needed
  therapy plan of care, management of pain control
  with non-narcotic use, management of chest pain
  and monitoring for complications following
  stroke. Rehab nursing to work on bowel and
  bladder training, transfers, education.
• Physical therapy to work towards improvement of
  bed mobility, transfer training,
  balance/coordination with gait to a modified
  independent level
• Rehab nursing to support therapy goals, return to
  modified independent with bowel/bladder, educate
  on prevention of stroke
• Occupational therapy Speech therapy

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The Rule

• Requirement for Evaluating the Appropriateness of
  IRF Admission / Inpatient Rehabilitation Facility
  Medical Necessity Criteria
• Must reasonably be expected to actively
  participate in, and benefit significantly from,
  the intensive rehab therapy program.
• This occurs when the patients condition and
  functional status are such that
• The patient can reasonably be expected to make
  measurable improvement (that will be of practical
  value to improve the patients functional
  capacity or adaptation to impairments) as a
  result of the rehabilitation treatment and
• such improvement can be expected to be made
  within a prescribed period of time.

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The Rule

• Requirement for Evaluating the Appropriateness of
  IRF Admission / Inpatient Rehabilitation Facility
  Medical Necessity Criteria
• The patient requires physician supervision by a
  rehabilitation physician (defined as a licensed
  physician with specialized training and
  experience in inpatient rehabilitation).
• The information in the patients IRF medical
  record must document a reasonable expectation
  that at the time of admission to the IRF, the
  patients medical management and rehabilitation
  needs require an inpatient stay and close
  physician involvement.
• Means that the rehab physician must conduct
  face-to-face visits with the patient at least 3
  days per week throughout the patients stay in
  the IRF to
• Assess the patient both medically and
  functionally (with an emphasis on the important
  interactions between the patients medical and
  functional goals and progress), as well as
• Modify the course of treatment as needed to
  maximize the patients capacity to benefit from
  the rehabilitation process.

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The Rule

• Requirement for Evaluating the Appropriateness of
  IRF Admission / Inpatient Rehabilitation Facility
  Medical Necessity Criteria
• Candidates for IRF admission should be assessed
  to ascertain the presence of risk factors
  requiring a level of physician supervision
  similar to the physician involvement generally
  expected in an acute inpatient environment, as
  compared with other settings of care (proposed
  rule).
• Per CMS, during the past 25 years, it was often
  assumed that close medical supervision was
  demonstrated by frequent changes in orders due to
  a patients fluctuating medical status.
  Currently, however, patients medical conditions
  can be more effectively managed so that they are
  less likely to fluctuate and interfere with the
  rigorous program of therapies provided in an IRF.
• All IRFs may increase the frequency of the
  physician visits as they believe best serves
  their patient populations.

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Physician Documentation Progress Notes

• Proving medical necessity during the stay
• Close medical supervision means patient requires
  medical care daily
• Evidenced through physician visits and progress
  notes
• Do each of these visits demonstrate active
  intervention by the physicians on the medical and
  rehabilitation needs of the patient?
• Are there changes in orders for the
  rehabilitation intervention?

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Physician Documentation Progress Note

• Daily Progress Note
• Subjective
• Objective
• Assessment / Plan
• Medical issues being followed closely
• Issues that 24 hours rehabilitation nursing is
  following
• Rehab progress since last note
• Justification for continued stay
• Continue current care and rehab or adjustment to
  plan of care

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Physician Documentation Progress Note

• Saying it
• Document progress with rehabilitation programs
• Document changes in plan of care
• Document barriers to attaining goals
• Document collaborative efforts of team and other
  consulting physicians

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Physician Documentation Progress Note

• Remember to include
• Medication changes document why changed
• Lab results document decisions made based on
  lab results
• Ordering additional tests/labs document reason
  why ordered, discuss risks, advantages, hasten
  rehab participation and discharge
• Document interaction with other professionals
• Document patients functional gains as discussed
  with patient

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Physician Documentation Progress Note

• Documentation about therapy treatment status,
  goals and plan in the same document as the
  medical treatment plan
• Examples
• Therapy progress is delayed due to new onset
  cognitive issues, I will order a speech therapy
  consult
• Pain is limiting progress in all disciplines so
  we will increase the patients pain medications
  to include . . .
• Missed 1 hour of therapy due to nausea and
  vomiting, will add Phenergan PRN for reoccurrence

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Physician Documentation Progress Note

• Link medical and therapy issues to show how they
  interrelate
• Example
• Hypertension remains uncontrolled despite
  adjustment in Norvasc. This has resulted in
  fatigue and discomfort that have caused the
  patient progress slowly with PT and OT. Will
  consult cardiology to assist with control of
  hypertension and remove this barrier to intensive
  therapy participation.
• Missed 1 hour of therapy due to nausea and
  vomiting per PT, will add Phenergan PRN for
  reoccurrence and monitor participation in
  intensive rehab via conversations with therapy.

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Physician Documentation Discharge Summary

• Components of the Discharge Summary
• Medical issues that required an acute level of
  care
• Patient is a 63 year old male with a history of
  
• While on the unit we managed these complicated
  issues
• Brief history of rehab stay
• Functional improvement
• Ambulation - The patient was () on admission with
  gait at () feet with/without assistive device.
  The patient was () at discharge with gait at ()
  feet with/without assistive device.
• Discharge diagnosis and comorbidities
• Discharge follow-up
• Discharge medications
• Discharge labs
• Discharge therapy with outpatient/home health
  care/no therapy needed 

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Essential to providing high-quality care in IRFs
  since comprehensive planning of the patients
  course of treatment early on leads to a more
  coordinated delivery of services to the patient.
  Such coordinated care is a critical aspect of the
  care provided in IRFs.
• Requires that an individualized overall plan of
  care be developed for each IRF admission by a
  rehabilitation physician with input from the
  interdisciplinary team by the end of the fourth
  day following the patients admission to the IRF.
• Must support the determination that the IRF
  admission is reasonable and necessary.
• Must be maintained in the medical record.

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Synthesized by a rehabilitation physician from
• Pre-admission screening
• Post-admission physician evaluation
• Information garnered from the assessments of all
  therapy disciplines
• Information from the assessments of other
  pertinent clinicians

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Purpose is to support a documented overall plan
  of care. The overall plan of care must detail
• Estimated length of stay
• Patients medical prognosis
• Anticipated functional outcomes
• Anticipated discharge destination from the IRF
• Anticipated interventions that support the
  medical necessity of the admission
• Based on patients impairments, functional
  status, complicating conditions, and any other
  contributing factors. Should include these
  details about the PT, OT, SLP, P/O therapies
  expected
• Intensity ( of hours/day)
• Frequency ( of days/week)
• Duration (total of days during IRF stay)

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Individual clinicians will contribute, but it is
  the sole responsibility of a rehabilitation
  physician to integrate the information that is
  required in the overall plan of care and to
  document it in the patients medical record.
• If the overall plan of care differs from the
  actual length of stay and/or expected intensity,
  frequency and duration, then the reasons for the
  discrepancies must be documented in detail in the
  patients medical record.
• Good practice to conduct the first
  interdisciplinary team meeting within 4 days of
  admission to develop the overall individualized
  plan of care. It is the IRFs choice to develop
  the internal process.

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Questions?

• Lisa Werner Bazemore, MBA, MS, CCC-SLP
• lbazemore_at_erehabdata.com
• 202-588-1766