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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.

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