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The pre-admission screen must be reviewed and approved by a rehabilitation physician before admission to an inpatient rehabilitation facility. Once the patient is admitted, a physician must evaluate the pre-admission screening information and verify that the patient’s condition has remained the same. Any changes in the patient’s medical or functional condition must be documented. In an IRF setting, a physician will attend to the patient at least three times per week to assess goals and progress. Beginning October 1, 2018, the post-admission physician evaluation is counted as one of the three required face-to-face rehabilitation physician visits in the first week of the stay. 

The physician’s role is to orchestrate the individualized plan of care and facilitate the interdisciplinary approach through weekly team meetings. Direction for all of this activity begins with the admission assessment documented via the history and physical (H&P). The H&P is a key component of justifying the “reasonable and necessary” criteria for IRF admissions. It substantiates the need for active, ongoing therapeutic intervention by multiple, coordinated therapy disciplines and specialized medical and nursing approaches.

The H&P is now a lengthy document that includes comprehensive information. Much of the information can be gleaned from a proper pre-admission screening assessment and “imported” into the H&P, so to speak. In addition, a well-designed H&P form can guide the process of writing a thorough assessment. It usually begins with the basic data: date and time, referring physician and hospital, primary care physician, informant and a list of what records were reviewed. The next most important pieces of information are the chief complaint and primary diagnosis. These should be written with a coder in mind and in terms of rehabilitation specific impairments and related etiologic diagnosis that will be considered in the 60% rule, when applicable.

The next critical section of the H&P is the History of Present Illness. It begins with a specific onset date of the disease, disorder or injury (or current exacerbation) and tells a story of how this event has impacted the individual’s ability to experience the things that make their life meaningful. It includes a narrative description of current medical issues and status and a list of all active comorbidities impacting the impending rehabilitation program. All of the information that follows (medical/surgical history, review of systems, physical exam, functional assessment, plan of care, etc.) will provide the details, but this area on the H&P presents the “Executive Summary” of what will follow. The History of Present Illness sets the stage for individualizing the plan of care based on the persons’ prior level of functioning and the effects of their current problems.  

Below a quick follow-up and summary of yesterday’s Blog comparing SNF And IRF level care:

In acute rehabilitation provided by an inpatient rehabilitation program, a patient can expect to receive a minimum of three hours of intensive therapy per day, five days per week provided by occupational therapists, physical therapists and speech-language pathology using advanced approaches. Medical care is provided 24 hours a day, seven days a week and a physician will attend to the patient at least three times per week to assess goals and progress. In an IRF, nursing care is provided 24 hours a day, seven days a week by registered nurses as well as Certified Rehabilitation Registered Nurses (CRRNs). The nurse-to-patient ratio is typically one to six or seven patients.  The interdisciplinary team is highly trained group consisting of rehabilitation physicians, internal medicine physicians, nurses, therapists, care managers, dietitians, psychologists and family members who work together to help determine goals and the best individualized treatment approaches the individual. The national average length of time spent at an acute inpatient rehab hospital is 16 days.

In subacute rehabilitation, provided in a skilled nursing facility the patent will receive one or more therapies for an average of one to two hours per day, including physical, occupational, and speech therapy. The therapies are not considered intensive. An attending physician provides a comprehensive initial assessment within 30 days of your admission into a skilled nursing facility. An attending physician, physician assistant, or nurse practitioner is only required to visit once every 30 days. A registered nurse is required to be in the building and on duty for eight hours a day. More often, patients are seen by certified nurse aides. A registered nurse is available in the evening and off hours. The nurse-to-patient ratio is one nurse aide to 20 to 30 patients. In addition to a monthly visit from an attending physician, the patient may be seen by a physician assistant, nurse practitioner, or clinical nurse specialist. Sub-acute teams include physical, occupational, and speech therapists, and a case manager. The national average length of time spent at a skilled nursing facility rehab is 28 days.

I was going to move forward with physician documentation following the decision to admit to an inpatient rehabilitation facility (IRF), but before doing that I think that it’s prudent to explore the other post-acute care settings and their characteristics. When we say that patients cannot safely be treated in less intensive settings, the question is what is, “what is it that those other settings offer and what are their limitations”?

Post-acute care (PAC) includes rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home. In general, post-acute care providers typically include: IRFs, Home Health, Hospice, Long Term Acute Care Hospitals (LTACH), and Skilled Nursing Facilities (SNFs).

Beneficiaries who are generally restricted to their homes and need skilled care (from a nurse, physical, or speech therapist) on a part-time or intermittent basis are eligible to receive certain medical services at home. Home health agency (HHA) personnel visit beneficiaries’ homes to provide services including skilled nursing care, physical, occupational, and speech therapy, medical social work, and home health aide services.

The Medicare hospice benefit covers a broad set of palliative services for beneficiaries who have a life expectancy of six months or less, as determined by their physician. Beneficiaries who elect the Medicare hospice benefit agree to forgo curative treatment for their terminal condition. For conditions unrelated to their terminal illness, Medicare continues to cover items and services outside of hospice. Typically, hospice care is provided in patients’ homes, but hospice services may also be provided in nursing facilities and other inpatient settings. Hospice providers can be freestanding entities or based in hospitals, skilled nursing facilities, or home health agencies. The hospice benefit is designed to provide pain relief, comfort, and emotional and spiritual support to patients with a terminal diagnosis. To provide this type of care, the benefit covers an array of services, such as: skilled nursing services; drugs and biologicals for pain control and symptom management; physical, occupational, and speech therapy;  counseling (dietary, spiritual, family bereavement, and other counseling services), home health aide and homemaker services; short-term inpatient care, inpatient respite care and other services necessary for the palliation and management of the terminal illness.

Patients with chronic critical illness— those who exhibit metabolic, endocrine, physiologic, and immunologic abnormalities that result in profound debilitation and often ongoing respiratory failure—frequently need hospital-level care for relatively extended periods. Nationwide, most chronically critically ill (CCI) patients are treated in acute care hospitals, but some are admitted to long-term care hospitals (LTCHs). These facilities can be freestanding or co-located with other hospitals as hospitals-withinhospitals (HWHs) or satellites. To qualify as an LTCH for Medicare payment, a facility must meet Medicare’s conditions of participation for acute care hospitals and have an average length of stay greater than 25 days for certain Medicare patients. . Under the prospective payment system (PPS), discharges are assigned to case-mix groups containing patients with similar clinical problems who are expected to require similar amounts of resources. Each case-mix group has a national relative weight reflecting the expected costliness of treatment for a patient in that category compared with that for the average LTCH patient.

Beneficiaries who need short-term skilled care (nursing or rehabilitation services) on an inpatient basis following a hospital stay of at least three days are eligible to receive covered services in skilled nursing facilities (SNFs). Medicare covers up to 100 days of SNF care per spell of illness.1 Beginning on day 21 of a SNF stay, a beneficiary is responsible for a daily copayment. In 2019, the copayment is $170.50. In 2018, Medicare estimates program spending was $29 billion for SNF care. Skilled nursing facilities can be hospital-based units or freestanding facilities. Beginning on October 1, 2019, daily payments to SNFs are determined by summing payment rates for six components of care—nursing, physical therapy, occupational therapy, speech– language pathology services, nontherapy ancillary services and supplies, and non–case mix (room and board services).

The differences in post-acute care settings is striking. The characteristics of a patient who is most appropriately treated by a home care agency, hospice or long-term care hospital is quite apparent. The debate around IRF admissions typically arises from the question of skilled nursing with subacute rehabilitation services versus IRF level care with intensive services. Skilled nursing facilities (SNFs) serve as licensed healthcare residences for individuals who require a higher level of medical care than can be provided in an assisted living facility. An inpatient rehab facility offers acute care for those who need a higher level of rehabilitation following traumatic injuries and surgeries such as amputations. Skilled nursing facilities, on the other hand, offer subacute rehabilitation, which are similar but less intensive than the therapies provided at an IRF. In a skilled nursing facility, patients receive one or more therapies for an average of one to two hours per day. The therapies are not considered intensive. In an IRF, patients receive a minimum of three hours per day, five days a week, of intensive physical, occupational, and speech therapy, in addition to medical management and specialized nursing care, coordinated by a team approach.

Making a decision to admit a patient is based on pre-admission screening, but what are the critical pieces of information to focus your attention upon? The first consideration is always going to be the primary impairment, etiologic diagnosis and comorbid conditions. The 60% Rule will be on your mind as well as the interplay between primary impairment and comorbid conditions. Use your outcomes reports to know your compliance percentage and your compliance review period to know where things stand. This will give you context for your decision making. Medicare Administrative Contractors (MACS) use IRF-PPS impairment group codes, etiologic diagnosis and comorbidity codes (ICD-10CM) in their analysis of Presumptive Compliance in addition to a review of medical records to determine compliance percentage. Knowing the rules, is an essential part of your process. For example, and as a reminder, beginning 1, 2017, MACs began to count certain ICD-10 CM codes for patients with traumatic brain injury and hip fracture conditions and cases that contain two or more ICD-10 CM codes from three major multiple trauma lists in specified combinations.

Narrative notes communicate your thinking with regard to a patient’s candidacy for admission. Begin with physiological and safety needs. Describe how the current disease (or exacerbation), disorder or injury has affected the individual from a medical, nursing and functional perspective. Explain resulting impairments and disabilities and why an inpatient rehabilitation program is required for the patient’s safety. Emphasize the complexity of the patient’s problems and that only clinicians skilled in this intensive level of therapy, specialized nursing and physicians specifically trained in rehabilitation medicine can address the patient’s problems safely. I am quite sure that “justifying” your admission decisions is not your favorite thing to do, but it appears to me that when a reviewer begins to examine records, they are approaching the case as if it could have been treated in a lower (less expensive) setting and we want to disprove that theory of the case. Be confident and unequivocal about your opinion that an intensive level of services provides the reasonable and necessary services required for this patient to achieve and maintain a higher level of functioning and quality of life. Relate your decision back to pre-morbid status. What was the patient’s life like before the current problem? In addition to medical/health status, our standards of care also revolve around daily activities, community participation and environment. Describe how the current problem alters the patient’s ability to navigate these domains.

When I was a child, I loved to play with coloring books. I can still remember choosing colors for different objects on the page and filling in the parts of the picture. In those days, the crayons were really wide and when they wore down, you had to peel off the paper. I would wear them down to nubs and if they broke, I just took off all the paper, turned them sideways and colored with them flat on the paper for a different effect. Wonderous was the day when the box of 64 came out with a sharpener!

I was thinking about “coloring in the picture” as a topic for pre-admission screening. Pre-morbid status is captured in a portion of the IRF-PAI, but it is quite brief. There are four items: self-care, indoor mobility, stairs and functional cognition. They are coded on a three-level scale (independent, needed some help, dependent plus unknown and not applicable). There is also an item to indicate devices used. So, in essence, the area of the medical record that actually describes pre-morbid status is the pre-admission screening form. The narrative component of pre-admission screening fills in the picture of how a disease, disorder or injury has affected an individual’s life. Just as in Maslow’s Needs Theory, we first deal with physiological and safety needs, but as we work up the hierarchy, we address emotional, psychological and social needs. Ask yourself, “What makes this person’s life meaningful to them?” and “What abilities are required in order to fulfill that need?”. A rehabilitation program has so many facets: medical management, specialized nursing care and interdisciplinary therapy etc., but in the center of all this activity is a patient who wants to resume a meaningful life and a person who could potentially be treated in a less intensive setting. We are required in our medical documentation to communicate how an admission to an inpatient rehabilitation facility will impact an individual who also happens to be a Medicare beneficiary. Therein lies the rub – lots of rules and without following the rules…a potential for denial of payment.

The Office of the Inspector General (OIG) report was scathing for rehabilitation providers. If facilities continue to document the way they have been documenting, they will get the same result. That is, a vast number of admissions were judged as inappropriate for an inpatient level of treatment. Something has got to change and change is difficult; but as Dr, Phil says, “you can’t change what you don’t acknowledge”.

Changing the way pre-admission screening is done is a really good beginning. Using pre-admission documentation to justify why an admission is reasonable and necessary for a particular patient is a great starting point. Here are five tips that I have gathered from years of medical record auditing:

  1. Use an interdisciplinary approach to design or review your pre-admission screening form
  2. Hire and/or train a skilled clinician as a pre-admission screener (I remember the days when this was done by someone from the marketing department)
  3. The pre-admission screener should collaborate with a coder and examine primary impairment designation as well as comorbid conditions
  4. Support data on the pre-admission screen with narrative documentation as described previously
  5. When making decisions and documenting, keep in mind that you are coloring in the picture of why this individual cannot safely be treated in a less intensive setting.

There is an entire movement in medical documentation known as narrative-based medicine (NBM). The term was coined deliberately to mark its distinction from evidence-based medicine (EBM); in fact, NBM was propagated to counteract the shortcomings of EBM. While I am not advocating this approach in its entirety, there are some salient principles that can be incorporated in pre-admission screening and on-going documentation in the filed of medical rehabilitation. Proponents tell us, “Narratives have always been a vital part of medicine. Stories about patients, the experience of caring for them, and their recovery from illness have always been shared—among physicians as well as among patients and their relatives. With the evolution of “modern” medicine, narratives were increasingly neglected in favor of “facts and findings,” which were regarded as more scientific and objective”.

The development of NBM has to be understood in the context of patient-centered approaches—bringing the patient as a subject back into medicine. An illness narrative tells us not only about a specific medical case, but about the intensive, ultimate, and most authentic reality of life of a person. According to one writer, the illness narrative is not only a description of something pathological; it is the description of the life of the illness in that specific individual human being.

This approach to treatment and documentation may help rehabilitation clinicians justify “reasonable and necessary” care for IRF patients, in preadmission screening and in on-going documentation. It focuses attention on how a disease, disorder or injury has impacted the individual; how it has changed their ability to perform activities that provide quality of life. Further, narrative notes can explain how an inpatient rehabilitation program can benefit the individual (which also leads to an individualized care plan). The key to implementing this approach is learning to accomplish it efficiently. In a nutshell, the formula is: pre-admission functioning (how they were), current medical and functional status (how they are now) and prediction of functional status following IRF care (how they can be). Focus attention on describing the factors that impact the patient during each of those timeframes. For more detailed information, tips and recommendations contact Dr. Pam Smith at This email address is being protected from spambots. You need JavaScript enabled to view it.

According to AARP, “virtually all of us benefit from Medicare, directly or indirectly. Medicare is a lifeline that puts health care in reach of millions of older Americans. But it does much more: By helping older Americans stay healthy and independent, Medicare eases a potential responsibility for younger family members. Before Medicare, almost 1 in 2 older Americans had no health insurance and faced a bleak future if they got seriously ill. Their choices often included wiping out their savings, taking money from their children, seeking welfare or doing without care".

The Medicare trust fund finances health services for beneficiaries of Medicare. The Medicare trust fund comprises two separate funds. The hospital insurance trust fund is financed mainly through payroll taxes on earnings and income taxes on Social Security benefits. The Supplemental Medical Insurance trust fund is financed by general tax revenue and the premiums enrollees pay.

The practice of auditing medical records for compliance with Medicare coverage, payment, coding and billing rules is aimed a protecting the Medicare trust fund and its future viability. CMS developed the Comprehensive Error Rate Testing (CERT) Program to randomly select statistically valid samples of Medicare Fee for Service (FFS) claims and related medical records and perform compliance reviews.

One component of the audit or review is the principle of “reasonable and necessary”. Medical records must justify why it is reasonable and necessary to admit individual patients for the specialized programs provided by inpatient medical rehabilitation.

Why is it reasonable?   Reasonable means sensible, rational, fitting, proper well-grounded, plausible and credible. An admission decision for inpatient rehabilitation is well-grounded when we believe that: 1.) an individual’s impairments and disabilities are complex and require intensive services; 2.) they have the capacity to actively participate in the program; 3.) their prior level of functioning is diminished and they have the potential to improve; 4.) their comorbid conditions in combination with current impairments require medical management and 5.) there is an expected length of time to achieve improvement and an anticipated discharge setting.

Why is it necessary?   Necessary means essential, called for, required and unavoidable. An admission decision for inpatient rehabilitation is requisite when we believe that the ability to meet their most basic needs, physiological and safety needs are threatened by their current condition. Through the admission and program participation, we are helping the patient to avoiding harm.

This discussion brings us back to the pre-admission process. Is the pre-admission screening process narrative as opposed to a check-list? Pre-admission screeners must have clinical skills, but also excellent writing and communication skills. A check-list can be used as a reminder to cover relevant aspects in the narrative, but rich descriptions are key. For more information, contact Dr. Pam Smith at This email address is being protected from spambots. You need JavaScript enabled to view it.  

During a post-audit conference I was told by a physician that when a diagnosis of stroke is identified and documented, that others (auditors) should appreciate what that means. While auditors are clinicians, a diagnosis does not describe the patient's presentation on pre-admission or admission. To establish why a patient requires intensive inpatient services, documentation must include all the relevant conditions associated with the stroke (type of hemiplegia/paresis, dysphagia, aphasia, visual disturbances, impulsivity, etc) and other comorbidities that complicate the patient's current condition (cardiac, respiratory, wound management, pain). When a pre-admission screener and coder work together to capture all relevant conditions, it provides a starting point for other facility clinicians to build upon as evaluations progress. Efficiency, in this case is derived from a team approach to documenting and coding what is observed regarding the patient's disease, disorder or injury and the resulting disabilities. 

When you decide to admit an individual for inpatient medical rehabilitation, you have done so because an IRF setting is the only safe place to address their needs. That patient cannot safely be treated in a less intensive setting. WHY? 

I'm going to go off the rails here for a moment, but stick with me... Einstein contemplated incredible phenomenon about the universe, but what he communicated to us was E=MC2.  He took unbelievably complex ideas and boiled them down to a pristine theory of relativity. If he can do that for the universe, we can do that for admission decisions! 

Our call to action, based on the latest Office of Inspector General (OIG) reports, is to communicate the complexity of our patients' impairments and resulting disabilities in a way that auditors understand why our patients require intensive services provided by clinicians with unique experience and expertise.

Our IRF-PAI coding and supporting documentation must capture all the relevant conditions that are being addressed by the program. Patients present with a constellation of effects from their disease, disorder or injury and they need to be clearly identified. For example, not all patients that have a stroke require IRF level services, but for those who do need us, there is a very good reason.Their combination of disabilities paired with medical diagnoses and need for specialized nursing care requires a level of service not available in any other setting. The challenge is to communicate this in our documentation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dont' be the Queen of Denials ! (or King as the case may be)

Ranking among the top three reasons for Medicare denying payments are improper documentation (documentation does not support medical necessity) and coding errors. Because of this fact, it seems appropriate to spend some time talking about these issues. My next few blogs will address the rules, but more importantly how to teach people to comply with them.

What is medical nesessity and how do we provide evidence of it?

Simply put, medical necessity is the patient's need for complex nursing care, medical management and intensive therapy. Medical documention ought to specify why patients require these services. Simply stating it is not enough. The claim for this need must be supported. That means, pre-admission screening and admission documentation, in particular (those conditions present at admission) are supported in a comprehensive manner. Each condition needs to appear on a physician problem list, be coded on the IRF-PAI, be described in the the nursing initial assessment and detailed on the therapists initial evaluation. With proper checklists in place, this can actually be done efficiently. What a great beginning this would be. We'll talk about it more as this series of blogs continues.

 

Question: Use of a device is not considered in walking activities?

Answer and Discussion: If a patient uses a device for walking and it is used safely, it does not change the score from independent. If however, use of the device requires set-up, supervision or other types of assistance, such as contact guard for safe ambulation, the score is affected.

Issue: Bladder Management vs Bladder Continence

Discussion: Bladder management in IRF-PAI Version 2.0 was really about the amount of care provided following a bladder accident. Even one accident, during the assessment reference period that resulted in a total clean-up resulted in a score of 1. Bladder continence in Version 3.0 is about the number of days there was involuntary loss of urine during the assessment reference period. This is a different approach for this item (counting number of days). Also, for self-care and motor items, the higher the score the more independent the patient. In bladder and bowel, the lower the score, the more independent the patient. Just be aware. In any case, the pricer software makes the necessary adjustments.

 

Question: How do you score tube feedings?

Answer and Discussion: In IRF-PAI Version 2.0, tube feedings are considered use of an adaptive device. Therefore, it can be scored at levels 6-1 depending on the amount of assistance required to administer feedings. In Version 3.0, tube feeds are not considered as eating a meal. Tube feedings alone, would be score 88 - eating not scored due to medical condition. If tube feedings are supplemental to eating, then score the amount of assistance needed by the patient for eating activities.

This is the new IT HealthTrack blog. It is developed for clinicians who are working in inpatient rehabilitation facilities and who are using the Inpatient Rehabilitation Facility - Patient Assessment Instrument or IRF-PAI. It provides an opportunity to have questions, answers and discussions around scoring and coding issues.We can also examine topics such as: medical necessity, documentation, payment, Medicare regulations and other clinical topics.    

Today's topic is a scoring question. 

Question: Is a tub bench considered an adaptive device for bathing?

Answer and Discussion: No, but let's have some discussion. In IRF-PAI Version 2.0 (including Functional Independence Measure items), a tub bench would be a device for tub transfer, not bathing. A patient may also use devices for bathing, while using a tub bench, such as a hand-held shower or long-handled sponge and then we would score use of devices for bathing. There may also be set-up or clean-up devices; this would also affect scoring. In Version 3.0 (including Minimum Data Set items), there is no scoring for tub transfer, but use of devices would be considered in bathing. However, in Version 3.0, a patient is scored independent with or without a device, so any scoring less than level 6 would have to include set-up or help for bathing activities.

 

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