Learning Outcomes
After this course, participants will be able to:
Identify at least two strategies for how therapy documentation creates a clinical picture of the client and justifies reimbursement.
List at least three requirements for documentation to possibly include: screens; evaluation/plan of care; reason for referral; the prior level of function; goals; progress reporting and discharge summary.
Outline at least three complex skills to support the necessity of your treatment plans.
Identify at least two examples of appropriate documentation.
Introduction
We all have a baseline knowledge of this topic and you may hear information repeated in this presentation that you already know - that is intentional. I want us to be all on the same page moving forward. I will present a lot of examples of documentation throughout this course so that, by the end, you will have things that you can incorporate in your documentation in your practice setting.
There are two quotes that apply to today's course: "There's not enough documentation" and, "There's too much documentation." These are messages that I get all the time in my clinical practice. I am being told that I need to document this very complete picture of this client. I am also told that we need to be very brief and succinct in our documentation. While at times it feels like we just can't win with these competing messages about documentation, there is a way to roll out your documentation so that it becomes very second nature. You can include what you need to in your documentation and have documentation that is very appropriate and thorough.
Today, I'm going to be talking about all disciplines. Sometimes I get feedback on my presentations that say I should only be giving physical therapy examples. I included multidisciplinary examples today because as physical therapists, we need to know what all of our coworkers are doing in their documentation. We need to follow up on that documentation so that we can work together as a multidisciplinary team and create a cohesive plan of care for our clients. I want us to work truly as part of a multidisciplinary team, and not in a physical therapy (PT) silo.
Performing the Rehab Screen
We are going to be talking about a lot of payer rules today, including a lot of rules established by CMS. I know many of you do not work in long-term care settings, but I am going to talk about CMS regulations and reimbursement rules today because a lot of other payers follow the lead that CMS takes in regard to reimbursement.
Purpose of the Rehab Screen
What's the purpose of the screen? There are several:
Therapists attempt to identify clients’ needs and possible rehab potential
A screen may not result in a therapy evaluation
Does not require a physician order
Provides additional documentation on finding to support medical necessity
Through this rehab screen, we attempt to identify our client's needs and possible rehab potential. If there are no needs or potential, then we just simply write "screen only" on the screen. However, if we complete the screen and realize that this client does need a PT evaluation, then we request the orders and initiate that valuation process.
A screen does not require a physician's order. There are a lot of benefits to completing that rehab screen. It is used to support and provide the evaluation with documentation. If you're screening a client and determine the need for an evaluation, that screening form or whichever way it takes form in your particular practice setting, is going to provide additional documentation on the evaluation findings and then help to strengthen the claim for your clinical reasoning skills.
Importance of Screening
Screens are important for our clients for a lot of different reasons. If we focus on routinely screening our clients for physical and cognitive impairments, in addition to psychosocial and other issues, then we typically see significant improvements in our client's function. If we see impairments, it is important to then refer appropriately to trained rehab professionals. We see lower direct and indirect healthcare costs and increase psychological health-related quality of life.
Best Practice
It's important to keep in mind that a screen is not an evaluation. The screen is meant to determine if an evaluation is required. An evaluation is not a guarantee of establishing goals and a plan of care. A lot of times we have to perform an evaluation service to determine if further rehab potential can be established or the current needs or goals of the client may be accomplished with only the single eval and treat visit. Now, ask yourself as a therapist, are you using clinical reasoning skills to determine if the client is not at their prior level of function or is demonstrating the potential for rehab goals?
These clinical reasoning skills are thoughts that require the trained skill of a licensed healthcare professional of you, the therapist. Your thoughts need to be different. They need to be unique. If your thoughts are the same as anyone else, then it's not skilled or rehab-based. For example, if you say this client needs a wheelchair, you, the CNA, activities staff, that client's roommate, and their family can all have the same conclusion. However, if you expand on this thought into developing a seating and positioning program, then you've demonstrated the medical necessity of rehab services to initiate the evaluation and begin that plan of care. The key to successful screening is the ability to identify the subtle changes, and then know what programs you have available in your practice setting that could benefit that particular client.
Tips for Success
If you are in a practice setting that works very closely with nursing, effective communication between nursing and therapy is key. Both nursing and therapy documentation should support the skilled service that each of these disciplines is providing. Nursing therapy needs to be meeting and communicating regularly to discuss your client's plan of care so that each discipline can support the work needed to assist the client in their recovery. Regular meetings with restorative nursing staff, if that is in your practice setting, or at least some type of communication process between the two can help to ensure that our clients don't further decline and that they are improving in function, or at least maintaining that function. You want to utilize a referral form for your nursing staff that's simple to use. Therapy may need to provide education about the best way to use this form so it's completed correctly with useful information that can then lead to a screen for that client. In addition, we need supportive documentation in the medical record to justify service delivery. We will talk more about this later in the course.
Thinking more about providing education, you want to make sure that members of the multidisciplinary team ensure that everyone knows the programs and the deficits that therapy can address. We know that we provide a lot of great programs. We can provide programs with seating and positioning on incontinence management, lymphedema, et cetera. We just have to be our own cheerleaders and really let our community know about these services and how to use those services. Finally, you want to obtain information from a lot of different sources. Sources for me in long-term care might be looking at the quarterly care plan list, rounds, or incident or accident reports. Ultimately, we will use the screen to build a thorough plan of care.
Screening Chart Review
As we screen, we need to complete a chart review, including reviewing sections:
Nurse’s notes
MD notes
CNA flow sheets
Restorative nursing notes
Previous therapy notes and discharge summary
All disciplines should see a change in function or performance or behavior. They need to document what they see as this becomes supporting documentation for the screen as well as the second therapy evaluation.
Role of Nursing in Screens
In order for rehab to identify declining functional components in a timely manner, we have to have accurate nursing documentation. That nursing documentation really does form the basis for identifying the actual onset date of the client's changing conditions. If we have multiple entries, those entries help to establish that skilled nursing observation, assessment, and monitoring are ongoing. That is key for CMS rules and regulations when it comes to documentation.
It also establishes that there is a pattern or chain of circumstances with that particular client which warrant a closer look. Through these skilled observations of CNAs or nurses, these subtle changes in your client's performance are identified, which then signals the need for a screen by rehab. Identifying change in these areas needs to be documented and should generate a referral to therapy for screening that client.
Examples of Nursing Documentation to Support Screens
Let me give you some examples of actual nursing documentation that support a rehab screen. I've taken this verbiage from the medical records that I have reviewed. If you're not seeing supportive nursing documentation in the medical record, then you may need to educate the nursing staff in your community about the importance of this documentation.
Client noted with increased left leaning over the side of the wheelchair every evening after meals.
Client noted with knees buckling daily when CNA staff ambulate patient to the toilet.
Client complains of increased shoulder pain during dressing.
This note indicates that client is now having pain that's limiting their function.
Client noted with excessive chewing prior to swallowing during meals.
Client no longer propels self to meals.
Client with unsteady gait during walk to dine restorative nursing program.
Client with increased confusion regarding recognition of family members or previously familiar objects in environment.
Client noted with decreased ability to control saliva throughout the day for several days.
This would trigger a screen for speech-language pathology (SLP) and you as a physical therapist can initiate the referral for the SLP screen even after reading notes in their chart.
Client with decreased task attention; no longer able to watch movies during activities.
Client with recurrent respiratory infections.
Observe Clients!
You as a therapist can also identify those subtle changes in clients that would warrant a rehab screen. How many times during the day do you walk back and forth to the nursing unit? Or say to the dining room, or even if you're in an outpatient setting, perhaps you walk back and forth to the waiting area and back. You're probably doing this pretty frequently throughout the day, and then you go throughout your day, file your documentation, complete your evaluation, and do whatever it is you do during the day.
When you are walking throughout your practice setting, do you have blinders on or are you observing and watching for what your clients need? Observe clients who have:
Had a fall
Abnormal posture
Poor head, neck, or trunk control
Contractures
Problems with edema
Decreased safety awareness
Decreased transfer ability
Decreased ability to re-position self
Poor supported sitting balance
Poor skin integrity
Pressure injuries
Difficulty eating or swallowing
Decreased participation in ADL
Complaints of pain
Decreased ability to self-propel wheelchair
Difficulty breathing
Decreased socialization due to poor position
Difficulty maneuvering wheelchair in environment
Difficulty using motorized wheelchair or scooter
Are they sitting and slumping in their wheelchair? Are they having problems with swelling? Are they now not as aware of safety as they used to be? What about pressure injuries? Are they starting to have difficulty maintaining good skin hygiene? Are they able to correct their poor posture when they get into that slumped posture? Are they starting to complain of pain? Are they having difficulty breathing? And of course, right now during the pandemic, we have a lot of clients that are post-COVID that are having residual effects from being deconditioned from having COVID.
We're looking for things like that as we walk throughout our communities. What about decreased socialization due to poor positioning? Are they no longer able to use that motorized wheelchair scooter that they used to zip through your community with?
Screening/Data Collection
After you've identified a client that needs a rehab screen, remember that a screen has to provide a very brief hands-off client review, which may consist of that medical record review, client observation, as well as communication with nursing. The data collection or screening process uses a multidisciplinary approach to look at clients who may need therapeutic intervention from PT, OT, or SLP. That data collection process is a mechanism for gathering information regarding a client's past and current functional level and their medical status.
It does not require a physician's order, and it is a process that is completed without physical contact by you, the therapist. If you do this screen and determine that more thorough testing is desired, then you would get a physician's order for an eval and the eval would then take place. In a long-term care setting, the data collection or screening form should to the best of your ability be completed within 24 hours of admission or referral from nursing. If a referral is received over the weekend, then the screen should be conducted on the next business date. Now, note, there are exceptions to this rule and therapists should discuss these as well as any other facility-specific policies with their manager. We all know that our communities all operate just a little differently. In your community, you may have a more community-specific policy.
Screens can be completed on the following occasions:
New Admits/Re-Admits
Referrals from Nursing
Facility “problem” lists
MDS Quality Measure Reports
Significant Change List
Care Plan Schedule (Quarterly)
This includes when patients are admitted, readmitted, or if they're referred from nursing. Also, if they appear on a problem list, such as a falls list, contracture list, wound list, et cetera. It can be completed as a part of the MDS quality measure reports, or if there's any kind of significant change list in your community. If there's a care plan schedule where you screen residents for falls quarterly or whatever your particular community decides patients are screened then. Note that the form should be completed in its entirety.
Remember, no recommendations should be made from the screen other than an eval. You cannot make a referral that a client needs a wheelchair from a screen. Depending on your community's protocol, that screen form should be maintained either in the client's medical record or in a notebook in the therapy department that's available for review upon request. It should be easily available for all the clinicians in your department.
Creating the Evaluation and Plan of Care Part 1 (Medical vs. Treatment Diagnosis and Reason for Referral)
Once it’s been established that yes, your client is appropriate for therapy evaluation, where do you start with creating the therapy plan of care? We're going to talk about some of those integral pieces of the evaluation, and then ultimately the plan of care.
We'll start by talking about medical versus treatment diagnosis, and then the reason for referral. Here’s a little background about the evaluation and plan of care. If you've been a therapist for a long time, I'm sure that you are a pro at this, but the evaluation and plan of care establish that baseline data, including what your client looks like at the initial evaluation. It captures those initial objective measurements.
It identifies functional loss and the need for skilled therapy related to things like self-care dependence, such as how much assistance does your client requires and mobility dependence, specifically whether or not the client's mobility has changed. It really captures their safety dependence or complications. What does their safety awareness look like? It looks at their cognition and if there is a decline in cognition. It indicates the projected outcome and path to facilitate outcome achievement. These are of course your short-term goals and long-term goals and we're going to talk about writing goals in the next section.
Evaluation
Your evaluation has to paint the picture of the client and clearly show how the client's problems and deficits translate into functional loss and the need for skilled therapy. The reviewer has never seen the patient. For the most part, everyone reading your documentation hasn't seen your client. The documentation has to demonstrate the services were medically necessary and skilled. In this step, the therapist asked, “Where are we?” and then determined the client's current functional levels and areas of impairment.
The initial eval begins with an interview of your client, which is a crucial component of the evaluation and prerequisite to establishing the practical and meaningful plan of care for your client. The interview follows a complete review of the medical record and focuses on the perspective of the client, the caregiver, or both. The interview establishes what activities the client can perform and how often these activities are actually being performed and if the client or caregiver is satisfied or dissatisfied with his or her performance. A successful interview uncovers the client's perceived problems, their physical or cognitive disabilities, their relevant medical history, and available family and community support. Then that interview identifies areas in which the client is doing well or poorly and screens activities that are not relevant for that particular client.
Here are some guidelines to consider when you're completing the evaluation. It has to be completed upon physician orders prior to the initiation of treatment. It has to include objective measurable data, demonstrating the client's prior level of function, current impairments, and establish a baseline of function. It has to demonstrate the client's need for skilled therapy based on the diagnosis, prior level of function, impairments, and prognosis, which might include positive prognostic indicators. Finally, it has to demonstrate an expectation that the client is going to be able to make some progress with their established goals. Additionally, that evaluation should include an individualized therapy plan, which includes those goals, both short and long-term goals, and the discharge disposition.
We want to include modalities that are acceptable under medical standards to address the client's problem that is noted in the evaluation data. The evaluation has to be signed and dated by the physician and maintained in the rehab section of the client’s medical record. The evaluation should be completed and address all areas of functional performance. Finally, if treatment is provided on the day of evaluation, is important that we complete a daily note, which is included with the evaluation. We will talk a bit more about those daily notes in a bit.
In addition to the elements that we've already discussed, we have to be certain that the evaluation includes the discharge plan if this is known. Oftentimes, the discharge location is still up in the air at the time of initial evaluation. If this is the case, then it should be added to the documentation as it becomes known in the progress report, the updated plan of care, or the daily encounter note. The evaluation should include a consent for treatment. It has to indicate somewhere that the client has been advised of the treatment plan and consents to the treatment under the plan.
It should include a review of medications that might impact therapy. Medications, as we all know, can have side effects that can impact performance and progress in therapy. These should be indicated in that plan of care. The evaluation should also include an onset date, which is the date of the onset of symptoms that resulted in the current need for therapy. We don't need a date that's two years ago, we need a date that hones in on when the deficits of that client are being treated in therapy at that moment. When did those deficits begin? It might be the date the client was admitted to the hospital, the date nursing communicated a decline of function, or the date the therapist conducted the screen, for example. Last but not least the evaluation must be signed and dated by the therapist.
Plan of Care (POC)
Regardless of the payer, all clients evaluated and treated by rehab need a plan of care, which is part of the evaluation. That plan of care shows us where we are, which is their current function, and where we want to go, or the patient-centered functional goals that we're going to write for our clients. The plan of care also includes CPT codes, which are the path we're going to travel to make that progress with our clients, and how long it will take, which is our frequency and duration.
As a result of this evaluation, an individualized treatment plan is developed and documented for each client. These goals and intervention strategies are developed considering the skills that will be required in that client's discharge environment. The treatment goals and interventions are revised according to the client's progress on that plan of care. Again, the plan of care is part of the eval. It indicates our outcomes, our interventions, and how long it's going to take. Every payer requires a plan of care. The required components may be a little different, but if we follow CMS's instructions on what should be included in the plan of care, we should be okay for other payers as well.
By CMS, of course, I mean Medicare. The required contents of the plan of care at a minimum, include:
Type of therapy (PT, OT, or ST)
Treatment diagnosis
Long term goal (final outcome)
Interventions/CPT codes
Frequency/duration
Dated signature of therapist
Make sure you include the type of therapy, the treatment diagnosis, and long-term goals, or the final outcome of the plan of care. Also include interventions, CPT codes, frequency and duration, and the dated signature of the therapist, which establishes that plan. Documenting things like “see eval” rather than providing supportive documentation for the treatment provided is not appropriate in that medical record.
Evaluation Codes for Physical Therapy (PT)
Let's take a brief moment to talk about evaluation codes. I didn't feel like I could do this course without at least briefly mentioning PT and OT complexity codes. We're still getting a lot of questions about therapists justifying their complexity codes. As a reminder, there are three levels of evaluation codes: low complexity, moderate complexity and high complexity evals. There's one single code for re-evaluation.
Evaluation:
97161 Low Complexity Evaluation
97162 Moderate Complexity Evaluation
9716 High Complexity Evaluation
Re-evaluation Code:
97164
Evaluation Codes for Occupational Therapy (OT)
For OT, there are also codes for low complexity, moderate complexity, high complexity, and then there's a re-eval code.
Evaluation
97165 Low Complexity Evaluation
97166 Moderate Complexity Evaluation
97167 High Complexity Evaluation
Re‐evaluation
97168
Decision Making
For PTs, let's look at the components of clinical decision-making for those PT codes. Remember that all elements of an evaluation and clinical decision-making process have to be included in that evaluation. These codes have four components of complexity and severity including history, examination, clinical presentation, and clinical decision making.
All four components should be taken into consideration in making the decision as to which code you're going to choose for that client. The first is client history, including their medical and functional history. That's why that client interview is so important. It includes relevant co-morbidities and personal factors. Next is examination, which requires the use of some type of standardized test. The last two components are clinical presentation of the client and clinical decision-making, including the use of the standardized client assessment instrument, or measurable assessment of functional outcomes which is our long-term or short-term goals. It will be your judgment based on all of this information that will make the decision about which code you’re going to select for your client.
To re-emphasize the point, all four of these components must be considered when making that code selection. I'm not going to go through all these components in a lot of detail because I have such limited time, but I want to encourage you that if you are still confused about how to make these decisions, there are a lot of trainings out there that can help you feel confident with your code selection.
Very quickly let's talk about clinical decision-making for OTs. To determine the level of occupational profile that has to be completed, you have to consider the presenting problems, the reason for referral, and the client's goals. Although a client may have multiple diagnoses and be very complex, if they are stable and they want one small targeted issue addressed by OT intervention, then this component should be coded as low complexity.
Next, the client's history, both medical and therapy, is reviewed and considered to identify aspects such as the prior level of function and presenting diagnosis as causing the client to seek OT services. Then the OT should consider all the information gathered in the history, the occupational profile, and the data from all of this assessment to determine the priority of occupational performance deficits that are going to be addressed with that client. Ideally, the OT is using standardized assessments to identify a deficit and decide with the client if the deficit is to be addressed. The eval has to clearly document the deficit and how it impacts function for that client. The third component, performance deficits, results in activity limitations or participation restrictions that are connected to the deficits in OT. It's really important that the OT evaluation not only show the deficit but also how it affects participation in activities.
Let me give you an example. A client displays a range of motion deficit that affects the ability to dress oneself. The fourth component is the level of clinical decision-making. What skills must the clinician use? How difficult is the work of the clinician? What aspects of the client affect the decision-making intensity? The best practice in OT requires clinical reasonings to occur throughout the evaluation process. This includes decisions about questions to ask, in the occupational profile and history, the choice of assessments and tests used to measure performance for that particular client, and in identifying goals and outcomes for that client. Once again, I'm going to encourage you that if you still have a lot of questions about this, there are a lot of different trainings out there that can help you make sure that you're clear with these concepts.
Common Mistakes to Avoid
Before we move on, I wanted to mention a few common mistakes that I see when therapists are creating the evaluation and plan of care that we haven't touched on yet today. First, that initial eval lacks pertinent medical or therapy history that could impact that plan of care. As you all know, co-morbidities can significantly affect the client's progress, even though they may not be the primary reason for the therapy referral.
Part of telling the story is to identify and include any co-morbidity that may affect performance in the evaluation documentation. For example, the client is referred because of her arthritis pain, but macular degeneration is also impacting her activities of daily living. We have to identify how these comorbidities can impact the plan of care. This goes along with what we just stated. In addition to her painful arthritis, this client has significant vision loss due to macular degeneration, which affects her ability to safely perform household activities, like cooking meals for her family. That would be for a higher-level client.
The intervention identified in the plan of care does not have the level of complexity that requires the skills of a therapy practitioner. I see this often as an error that therapists make. Your documentation has to differentiate specialized skills from non-skilled services. That practitioner needs to really identify what they're doing to assist the client to achieve this functional performance outcome.
Another mistake that I see is therapists not documenting a medically necessary therapy statement in a clear way that makes that very neat correlation between skilled intervention and the client's outcomes. For example, skilled therapy is necessary to design and fabricate a hand splint to enable the client to write legibly while protecting joints. That's an example of that clear correlation.
Another mistake is that these outcome measures are written without an adequate baseline function to measure change. I see this all the time. For example, when you're reading documentation, they identified that there is some type of feeding goal in the progress note, but there's no evaluation of eating or swallowing skills to know where the treatment is starting. Use the baseline of current performance as that first objective measure in developing your goals in the plan of care.
Documentation Bloopers
I wanted to provide some levity throughout this course and I am going to give you some examples of documentation bloopers that I have found as I've gone through documentation. Of course, these are all anonymous and this is not to make fun of the therapist. I know I have my own fair share of documentation bloopers out there. This is just so we can all see how sometimes we get in a rush and are hurrying and we omit words, or we omit thoughts and they become actual documentation bloopers.
“She is numb from her toes down.”
“On the second day, the knee was better, and on the third day it disappeared!”
“Skin: somewhat pale but present.”
“The skin was moist and dry.”
“Occasional, constant, infrequent headaches.”
You can see that therapists are quickly documenting and omitting words.
