Medical Necessity" is "THE" hot topic these days in our industry as a result of the increase in pre-payment and post-payment audits being conducted by Medicare and third party payers. Headlined in most Healthcare Journals, newsletters and Online is the following tag line -Medical Necessity will continue to Dominate Documentation Audits.
The stakes are continuing to be raised on provider compliance and implications for therapy providers increase the risks of practice in an era of fraud and abuse scrutiny.
Medical Necessity has become a key phrase that auditors are quoting when reviewing medical records and is one of the top reasons for claim denials. Ensuring that your documentation supports the medical necessity of the service you are providing and billing for is crucial for providers.
Daily and weekly progress notes have become a primary focus area when conducting internal audits. Here are some tangible suggestions to increase your Documentation Integrity!
Daily Documentation is required to reflect the skilled services being provided. Daily documentation should include:
a. Objective measures of the current level of assistance required for functional tasks.
b. A description of the skilled services provided.
- Example: Non-skilled documentation: Observed patient brushing his teeth after set up with verbal cues. The skilled component necessary or the importance of instruction has been omitted in the previous sentence. Skilled terminology: The occupational therapist provided verbal cues to instruct the patient in a compensatory strategy for using one hand to sequence squeezing the toothpaste onto the toothbrush, running the water and brushing the teeth with the appropriate end of the toothbrush. These specific instructions provided to the patient were important to the patient learning the task.
c. Assessment of the patient's response to the services.
d. Progress towards the treatment goals.
e. Documentation of any treatment variations with the associated rationale.
f. Accurate documentation of treatment time in minutes, to be recorded on the MDS.
Weekly Progress Summary should include:
- Document the current level of assistance required for functional tasks and compare it to the previous week's status to evaluate the patient's progress.
- Determine if progress towards goals has occurred.
- If progress towards goals has not occurred, document the possible reasons contributing to the lack of progress. The goals should be revised or the patient should be evaluated for possible discontinuation of therapy services. Determine if a functional maintenance program would be indicated.
d. Document the need for continued services by a skilled therapist verses the use of restorative nursing.
- Non-skilled services include: observing or monitoring, general practice techniques, and reviewing previously learned material.
- Skilled services include: educating the patient, assessing mobility skills, evaluating the effectiveness of, instructing the patient in a progressive exercise program, or modifying the treatment program.
e. Document evidence of carryover of the skills learned in therapy to the functional tasks.
- Examples: Physical therapy has been working on weight shifting in the parallel bars to allow a patient to take a step, this task is then carried over to the resident's ability to weight shift and take a step with a standard walker. An occupational therapist may work on overhead reaching exercises with the carryover seen when the patient can reach into the cupboard to get a glass of water without assistance.
f. Identify the expectation for further progress.
g. Identify the resident's risk factors that may be eliminated by receiving the therapy services.
- Examples: The resident is at a high risk to fall due to balance deficits, the resident is at high risk for aspiration due to delayed swallowing response, or the resident is at high risk for burns due to problems spilling while attempting to drink from a cup.
h. Justify the frequency, duration and intensity of the treatment.
- Example: The resident would benefit from one more week of treatment at five times per week to provide reinforcement and carryover of the functional tasks. The program will continue with a progression of the exercise program, modifications to the functional maintenance program and completion of staff education with the functional maintenance program.