~Documentation for Geriatric Practice

Importance of Documentation

• ***understand current documentation requirements and their impact on reimbursement

• Identify the need for skilled therapy services

  • what we’re doing and why

• Crucial for payment decisions and continuation of therapy services if needed

• Communication with other professionals

Billing Codes: ICD-10 Codes

• ICD-10 refers to the tenth edition of the International Classification of Diseases, which is a medical coding system chiefly designed by the World Health Organization (WHO) to catalog health conditions by categories of similar diseases under which more specific conditions are listed, thus mapping nuanced diseases to broader morbidities

• ICD-10-CM diagnosis codes used in occupational therapy represent a client’s medical and treatment diagnoses; these codes are a uniform method of sharing information regarding a client’s condition and deficits with interdisciplinary team members, other providers, and payers

• Accuracy with coding ICD-10-CM diagnoses is critical to ensuring the correct information is relayed to others involved in a client’s care

ICD-10 Codes

• The US version of ICD-10, created by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), consists of two medical code sets—ICD-10-CM and ICD-10-PCS

• ICD-10-CM (Clinical Modification) – ***Diagnosis Codes*** (used across all healthcare settings and hospitals)

  • The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care in the United States

  • According to WHO, physicians, coders, health information managers, nurses, and other healthcare professionals also use ICD-10-CM to assist them in the storage and retrieval of diagnostic information

  • ICD records are also used in the compilation of national mortality and morbidity statistics

• ICD-10-PCS (Procedure Classification System) – (Codes used to bill for services in inpatient hospital settings only)

  • ICD-10-PCS stands for the International Classification of Diseases, Tenth Revision, Procedure Coding System; as indicated by its name, ICD-10-PCS is a procedural classification system of medical codes

  • It is used in hospital settings to report inpatient procedures

• All health care providers who must comply with the Health Insurance Portability and Accountability Act (HIPAA) must use ICD-10 codes to report patient diagnoses

Medical Diagnosis vs. Treatment Diagnosis

• Medical Diagnosis:

  • the medical condition that has led the client to be referred to skilled occupational therapy services; the ICD-10-CM medical diagnosis code represents the disease or medical condition that is causing the client’s symptoms

  • Often, there is a primary medical diagnosis, as well as comorbidities that might be influencing a client’s occupations

• Treatment Diagnosis:

  • represents the functional limitations or performance deficits impacting the client’s ability to perform desired occupations, resulting from the disease or medical condition identified by the primary medical diagnosis code or comorbidities

OT and Treatment Diagnoses

• Therapists should provide an ICD-10-CM treatment diagnosis to indicate the performance deficits for which the client will receive occupational therapy intervention

  • This diagnosis should be as specific and relevant to the conditions to be treated as possible; therapists must use their clinical judgment to select treatment diagnosis codes that correspond to the client’s condition and most closely reflect the condition for which they are providing intervention (should be as specifc as possible!)

• In general, it is not within the occupational therapy scope of practice for OTs to identify a new medical diagnosis, which is usually provided by the physician; although practice acts tend to be broad and you may not see anything specific, the ability to assign a purely medical diagnosis (without physician input) to clients would need to be authorized for occupational therapists in their state practice acts

  • It’s important to be aware of any state licensure laws related to diagnosis coding

• When selecting diagnosis codes, occupational therapists should choose the ICD-10-CM diagnostic codes that identify the greatest level of specificity possible; this means avoiding “unspecified” codes that indicate general conditions but lack clinical details such as site or laterality

  • e.g., MS: medical diagnosis- given by a physician;

  • e.g., pain in the right upper arm- treatment diagnosis- given by the OTs

    • should include laterality

ICD-10 Codes and Reimbursement

• ***understand current documentation requirements and their impact on reimbursement

• When a claim is submitted to a payer, the first thing the payer sees are the ICD-10-CM diagnosis codes; accuracy with coding both the medical and treatment diagnoses can therefore affect whether the payer reimburses the claim

  • do not use cognitive codes if your patient’s main impairment is physical; this will not be covered/funded (even if they may be having cognitive impairments/need cognitive strategies too)

• Both the medical and treatment diagnosis codes are used to support the medical necessity of the occupational therapy services being delivered

• The codes tell the payer what is going on with the client and why the occupational therapy services billed on the claim were needed

Billing Codes: ICD10 Codes Example

• the diagnosis code lists are derived from ICD-10 diagnosis codes that CMS posts each year so that providers and suppliers utilize the applicable diagnosis codes when submitting medical claims to Medicare

• don’t memorize; they will change in a year (most likely)!

ICD-10 Codes vs. CPT (Current Procedural Terminology) Codes

• For a medical provider to receive reimbursement for medical services, ICD-10-CM codes must be submitted to the payer

• While CPT codes depict the services provided to the patient, ICD-10-CM codes depict the patient’s diagnoses that justify the services rendered as medically necessary

• ICD-10 provides a diagnosis code to describe the medical issues affecting the patient, while CPT codes indicate the treatment, surgery, or other procedures the patient received

CPT Codes for Occupational Therapy

• CPT Codes are owned and copyrighted by the American Medical Association

• CMS and Medicare adopted the use of CPT codes in 1983

• New and revised CPT codes are published each year.

Current Procedural Terminology (CPT) Evaluation Codes for OT: ***3 Levels

• ***identify and distinguish between the 3 levels of evaluation complexity; need to know number of performance deficits impacted, expected time for evaluation and clinical decision making, number of co-morbidities, occupational history

• On January 1, 2017, new codes for OT went into effect

  • 97165: Occupational therapy evaluation, low complexity (straightforward)

  • 97166: Occupational therapy evaluation, moderate complexity (involved)

  • 97167: Occupational therapy evaluation, high complexity (very involved)

  • 97168: Occupational therapy re-evaluation

• Reflect a level of clinical decision-making during the evaluation process

• ***Low Complexity

  • “Identifies 1-3 performance deficits (relating to physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.”

  • Typically, evaluation is 30 minutes spent face-to-face

  • Typically, no comorbidities

• ***Moderate Complexity

  • “Identifies 3-5 performance deficits (relating to physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.”

  • Typically, evaluation is 45 minutes spent face-to-face

  • Expanded chart review

  • Co-morbidities

• ***High Complexity

  • “Identifies 5 or more performance deficits (relating to physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.”

  • Typically, evaluation is 60 minutes spent face-to-face

  • Extensive review of the history of physical, cognitive, or psychosocial

• timing of evaluation is not set in stone- don’t let this be your determining/scoring factor (it’s more as a guide!)

  • score more so off the # of performance deficits + how expanded your chart review is

• insurance would also much rather have you score down; it is much more likely to cover low complexity patients

  • rate as low complexity > (more often) than high complexity

level example

moderate complexity

• ***7~ performance-related deficits BUT she’s 9 weeks out from stroke (she should have already been having therapy)

  • high-complexity patients need more immediate help

    • she lives at home

    • daughter is helping with routine care, but it doesn’t say she isn’t fully able to do her ADLs

• always code down (even though it’s more likely that she’s really high complexity)

***(1) legally blind, (2) short-term memory deficits, decreased ability to complete tasks (3) vacuuming, (4) dusting, (5) doing laundry, (6) knee replacement, (7) trouble coping

Improving Medicare PostAcute Care Transformation (IMPACT) Act of 2014: Quality Reporting Program

• CMS implemented new functional items and related outcome performance measures for post-acute care (PAC) settings

• Intent of cross-setting quality reporting program is to facilitate quality measurement and quality improvement across PAC settings

• GG items promote standardization across PAC settings to evaluate the effects of health care services on patients’ overall health and functional status over time

Value Over Volume in Documentation

• ***identify documentation strategies to facilitate value over volume for OT practice and point of service

• Value is based on outcomes not volume (minutes)

  • i.e., are they becoming more functional? are they becoming more independent? are they able to go home?; NOT did you treat them for 60 minutes?

• Impact:

  • If value or improved outcomes are not achieved, there may be no reimbursement for OT service

    • note should be concise: “__ is the functional outcome of this session” NOT “we did 10 reps of sit-to-stands, 3x”

• Need to highlight the value of the scope of OT in documentation

• Goal: provide the right care to clients, in the right amount, when they need it, to show documented outcomes in the following 6 areas:

  • Activities of Daily Living

  • Instrumental Activities of Daily Living

  • Behavioral & Psychosocial Skills

  • Falls Prevention

  • Vision

  • Functional Cognition

IMPACT Act: Requires 5 Sets of Quality Data

• ***identify documentation strategies to facilitate value over volume for OT practice and point of service

1. Physical and Cognitive Function and Changes in Function

2. Skin Integrity (onset and worsening of pressure ulcers)

3. Medication reconciliation (i.e., formal process in healthcare to ensure patients receive the correct medications, preventing errors during transitions of care)

4. Incidence of major falls

5. Discharge planning from one post-acute setting to another (including home setting):

   1. Timely transfer of health information to the next care setting

   2. Patient preference

IMPACT Act: Resource Use Quality Measures

• ***identify documentation strategies to facilitate value over volume for OT practice and point of service

1. Total Medicare spending per beneficiary

2. Whether the patient was discharged to the community

   1. insurance wants people to go home

3. All-cause risk-adjusted preventable hospital readmission rates

   1. huge issue if someone, e.g., falls

Functional Assessment in Post-Acute Care (PAC) Settings

GG Coding

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

• Section GG is a standardized assessment utilized by the Centers for Medicare and Medicaid Services (CMS) in post-acute care settings

• The assessment measures a patient’s need for assistance with self-care and mobility while also documenting the patient’s prior level of function

• Post-Acute Care settings consist of Long-Term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), and Home Health (HH)

• The IMPACT Act of 2014 required CMS to develop a set of standardized outcome measures in post-acute care; before Section GG’s implementation, CMS said that they were essentially comparing apples to oranges versus apples to apples (thus, preventing comparison or consistency)

• CMS wanted a universal language to track how patients improve/decline as they move through the post-acute care continuum; this data helps CMS evaluate the services a patient receives and how it relates to functional improvements

GG Coding: Important for Goal Setting

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

• ***demonstrate the ability to formulate goals

score the person’s usual performance; guidelines for coding

• using the 6-pt scale, code the patient’s or resident’s usual performance (not their best or worst performance) for each activity

• if helper assistance is required because the patient’s or resident’s performance is unsafe or poor quality, score according to the amount and type of assistance provided

• remember, activities may be completed with or without assistive devices, and patients or residents should perform activities as independently as possible, as long as they are safe

Section GG Scoring

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

• 6-Independent

  • Person completes the activity by themselves with no assistance from a helper

• 5-Setup or Cleanup Assistance

  • Helper SETS UP or CLEANS UP; person completes activity

  • Helper assists only before or following the activity (the helper can walk away and leave the person unsupervised to complete the task)

• 4-Supervision or Touching Assistance

  • Helper provides VERBAL CUES or TOUCHING/STEADYING and/or CONTACT GUARD ASSISTANCE as the person completes the activity

  • Assistance may be provided throughout the activity or intermittently

• 3-Partial/Moderate Assistance

  • Helper may lift, hold, or support the trunk or limbs but provides LESS THEN HALF of the effort

• 2-Substantial/Maximal Assistance

  • Helper may lifts or holds the trunk or limbs and provides MORE THAN HALF the effort

• 1-Dependent

  • Helper does ALL of the effort

  • Person does none of the effort to complete the activity

  • Or, the assistance of 2 or more helpers is required for the person to complete the activity

GG0100: Prior Functioning Everyday Activities

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

The assessment of a patient’s or resident’s prior functional status is key to realizing a patient’s or resident’s potential for improvement, stability, or decline

• insurance only wants to restore someone to their prior level of function (don’t want to pay them to become any better than they need to be/exceed in outcomes)

GG0110: Prior Device Use

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

This item collects data on a patient’s or resident’s usual ability with everyday activities prior to the current illness, exacerbation, or injury

• e.g., be able to independently use a wheelchair (if that’s what they were doing before)

GG0130: Assessment and Coding

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

assess the patient’s or resident’s performance based on direct observation as well as reports from the patient or resident, clinicians, care staff, and/or family

GG Coding Tip

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

• Use of an assistive device to complete the activity should not affect coding

  • e.g., use of a walker independently can still be coded as a 6

• Activities should be performed as independently as possible, provided they are safe, for improved QOL and well-being

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

Code 05, Setup or clean-up assistance

• had to be set up with a strap, but after that, doesn’t need any supervision

patient needed help opening a creamer from a nursing aide

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

Code 05, Setup or clean-up assistance

patient needed a walker to get up out of bed, but did it alone without any nursing assistant coming into the room

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

Code 06, Independent

• use of tools doesn’t affect scoring

• ***be able to identify qualifier for and describe “GG Scores” (i.e., what does setup or cleanup assistance count as, what is partial/moderate assistance, what is dependent, etc.)

Code 02, Substantial/maximal assistance

• able to get arm into the shirt independently (but with lots of effort), but the rest of the task of upper body dressing needed assistance (more than 50%, making it NOT partial/moderate assistance)

GG 0170 Mobility CARE Items

REIMBURSEMENT FOR OT SERVICES

• ***understand current documentation requirements and their impact on reimbursement

increased GG scores + increased independence

==> improved outcomes

==>==> reimbursement

Forms of Documentation

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

• Initial Evaluation/Plan of Care

• Daily Intervention/Treatment/Session (Contact Note)

• Progress Note:

  • Written usually monthly, as determined by the facility

  • Summary of the intervention process and documents progress

  • Includes recommendations for continuation of services

• Discharge Summary

  • to the home, subacute care, etc.

Objective Measures & Assessment Tools

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

• Need to use objective assessment tools

  • for documenting change/progress

• Measures for Varied Settings

Documentation of Standardized Assessments

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

Summary should include:

• Test/screen that was administered (put the name of the assessment used)

• Purpose/objective of the tool

• State results (e.g., scored 17/30, indicating moderate cognitive impairment)

• Indicate areas of strength & areas that posed a challenge

• Recommendations

Occupational Therapy Initial Evaluation Report: SOAP Format

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

• extremely common in mental health practices

• a bit more standardized in acute settings (check-off digital system > handwriting note)

• SOAP

  • S: Subjective- information provided by the client or caregiver

  • O: Objective- factual information, e.g., status of therapy goals, accuracy level, cueing level, etc.

  • A: Assessment- clinical impressions and interpretation of the subjective and objective information

  • P: Plan- what are the recommended next steps for the treatment and plan for the next session?

Plan of Care (initial evaluation)

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

Must include:

• Diagnoses

• Long-term treatment goals

• Type and amount of treatment

• Frequency (amount of time in a week that a person should get therapy)

• Duration (how many weeks)

  • e.g., 2x/week (frequency) x 4 weeks (duration)

What does POC (Plan of Care) include?

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

• Rehabilitation/Treatment Diagnosis

  • (MS weakness, Lack of coordination, Need for personal care assistance)

• Identify specific interventions to be used to treat the patient’s needs (thinking CPT codes)

  • (i.e., therapeutic exercise, functional training, manual therapy techniques, adaptive devices/equipment needs, modalities)

• Establish anticipated goals, expected outcomes, and any predicted level of improvement

• Short-term goals (optional) or Long-term goals

• Determine the intensity, frequency, and duration of care

• Anticipated discharge plans

Medicare Documentation Requirements

• ***identify current Medicare requirements for documentation

• Evaluation/Reevaluations

• Plan of Care

• Therapy Goals

• Progress Notes/Reports

• Treatment notes for each treatment day

Documentation Pitfalls

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

• Goals are not client-centered or measurable

• Use of abbreviations that are not acceptable medical abbreviations

• Intervention activities are not used as functional outcomes

  • e.g., “patient is able to throw a ball into a bucket” is NOT a functional outcome

• Duplication of services

  • Need to demonstrate coordination of care

    • OT notes shouldn’t look identical to PT notes (e.g., both doing bed transfers); insurance will not pay for this!

• No documentation of change

Goal Writing: COAST Method

• ***demonstrate the ability to formulate goals

• ***identify current Medicare requirements for documentation

• C – Client will perform

• O – Occupation

• A – Assist Level

• S – Specific Condition (ensures goal is measurable)

• T – Timeline

• Example of Short-term Goal:

  • Client will prepare a simple meal with contact guard assist in standing using a walker within 2 weeks

    • C: prepare a simple meal

    • O: prepare a simple meal

    • A: with contact guard assist

    • S: in standing using a walker

    • T: within 2 weeks

    • upgrade goal:

      • decrease assistance (independently)

      • be more specific with the description of a “simple meal”

        • < “hot meal”

    • downgrade goal:

      • increase assistance (min or mod)

      • increase timeline

      • in a seated position

  • Client will complete lower body dressing with minimal assistance using assistive devices within 1 week

    • C: will complete lower body dressing

    • O: lower body dressing

    • A: with minimal assistance

    • S: using assistive devices

    • T: within 1 week

Document Long-term Goals

• ***demonstrate the ability to formulate goals

• ***identify current Medicare requirements for documentation

• To be included in Plan of Care

• should match your short-term goal

  • STG: upper body dressing

  • STG: lower body dressing

  • STG: clothes acquisition

• Examples:

  • LTG: Client will complete all dressing tasks independently by discharge

  • LTG: Client will perform yardwork independently while adhering to energy conservation strategies upon discharge

Daily Treatment Encounter Session Note

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

The daily note must contain:

• Date of Service

• Treatment rendered/ all services provided

• How much time was spent on each service

  • e.g., 15 mins for therapeutic exercise

  • e.g., 10 mins for ADL training

• Any changes made to treatment from the last visit

• Any observations of the patient made during treatment

  • i.e., response to treatment, or changes noted during the session

• example of how to start off

  • “Seen for 45 minutes OT session today … Tx included … or documented under each code …….”

Progress Note

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• ***identify current Medicare requirements for documentation

• An evaluation of the patient’s progress

• Professional judgement about the medical necessity of continued care

• Goal status

• Any treatment modifications

• De-emphasize treatment media

  • do not say the day-to-day exercise treatments

  • look at the big picture functional status/goals

• SOAP format

D/C Summary

• ***identify key documents required in clinical practice for older adults

• ***understand current documentation requirements and their impact on reimbursement

• The course of treatment

• Discharge notification

• Objective summary of patient status referencing the condition at the start of treatment

• Equipment needs/status of their equipment (if you are recommending they purchase something)

• Patient/Caregiver education & training

• Recommendations/Follow-up

Progress Note Example of Medical Justification for Continued Skilled Services

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

• ***identify current Medicare requirements for documentation

What is considered “NOT Reasonable and Necessary”

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

Unskilled services

• General exercises to promote fitness/ flexibility

  • e.g., don’t document “using the arm bike”- even if it is useful to do as a warmup before your actual intervention

• Activities to provide diversion or general motivation

• Services not included in the plan of care or provided by staff that are not properly supervised or qualified

Considerations

• ***understand current documentation requirements and their impact on reimbursement

• Cognitive factors

• Chronic vs. new injury/ illness

• PLOF (prior level of function)

• Assessing objective measurable gains for OT

  • Change in the level of assistance

  • Changes in types of functional activities

  • Modification of assistive devices

  • Noted decreased pain levels and changes in the ability to perform tasks because of decreased pain

Non-skilled Terminology – Terms to Avoid

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

• Ambulate

  • a very “PT term”

  • “functional transfer”, “functional mobility” is better for OTs

• Discuss

• Encourage

  • sounds like you had to push the person to do something

• Help

• Little Change

• Maintain

• Monitor

• No changes

• Observe

• Watch

  • just watching? what are you really doing?

  • “cueing” better

• Supervised

Skilled Terminology

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

why do they need a skilled therapist?

• Adapt

• Assess

• Analyze

• Continues to progress because …

• Continues to require …… because

• Design

• Fabricate

• Facilitate

• Instruct

• Modify

• Correction of techniques

• Trained

Practice Writing Contact Note: SOAP Format

S: Patient has reported having increased LBP (low back pain)

O: Patient is able to perform all their UE therapy exercises; standing reaching activities; retrieve/return items from kitchen cabinets; cross midline using good safety techniques; do toilet transfer with supervision; hygiene tasks with minimal assistance; clothing management with minimal assistance; handwashing with cues

A: Missing; but could~ be that patient needs cues to achieve upright posture

P: Missing; should be “continue with OT sessions 1x/week to increase standing tolerance to increase engagement with functional tasks”

Progress Report: What Is Missing?

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable

• not organized as a SOAP note- bad; make it more organized

• does not have professional judgment for continued medical care

  • what improvements do you want them to make in therapy?

• treatment modifications could be fine-tuned a bit

• exclude part about 2lb hand weight; insurance doesn’t care and it’s not functional

Medical Justification Example

• ***be able to critique documentation samples to ensure medical justification, measurable, and reimbursable