Rehabilitating your rehab.
A three-pronged approach to success under PPS
THOSE OF YOU WHO HAVE WORKED IN LONG TERM CARE FOR any length of time have come to expect periodic changes requiring you to revamp the Operation of your rehabilitation department. The challenge this time: Medicare's prospective payment system.
Although PPS affects the reimbursement of Part A residents only, your program design must incorporate all the groups within your reimbursement case mix, including managed care and Medicaid, while satisfying accreditation requirements and state survey demands as well as the quality needs of the population you serve. The system outlined below is divided into three parts: case management, denial management, and outcomes management. Together, these three elements should cover all the clinical and management requirements necessary for quality and profitability.
You can make the most brilliant strategic and operational decisions in anticipation of PPS, but without someone to implement programs and manage the department, it will be difficult to meet your clinical and management goals. PPS has very specific requirements. To yield the financial and clinical outcomes you want, you need someone who not only knows all the requirements but has the ability to execute them.
Currently, management of your rehab program probably depends on people who are low on the totem pole. The evaluating therapist decides to place someone in a program and determines the intensity of the program. Then the treating therapist ascertains whether progress is being made, and decides when to reduce a program or discharge.
Controlling the flow of patients on and off rehab is crucial to maximizing profitability. Deciding who to put on, the intensity of the program, when to change the intensity, and when to discharge requires the oversight of a skilled individual--a case manager--who can not only participate in the decision-making process but coordinate the care provided by the rehab department. The case manager also determines the most cost-effective programming and then monitors use of services and length of stay.
Any rehab professional can effectively serve as the case manager. In some departments, it might be appropriate for the OT and PT directors to serve jointly. In other departments, there may be a clear leader who would be the obvious choice. The important thing to remember is that someone must be responsible for coordinating the process.
The case manager should oversee the following:
* Determining the appropriate level of rehab programming. Under PPS, the less intensive levels of therapy--low, medium, and high--are generally more profitable than the very high and ultra-high levels. Upon admission, the rehab group must determine which rehab level is most appropriate for the resident based on diagnosis, length of stay, and discharge plans as well as the fiscal realities of RUG III reimbursement rates. The case manager reviews all recommendations and approves the projected rehab intensity level chosen.
* Determining diagnosis and prior level of function to support programmatic decisions. Because HCFA believes that rehab was overutilized during the case mix demonstration project and under the old cost-based reimbursement system, you should be braced for potential Medicare audits. The first step in ensuring audit-free documentation is to establish the resident's prior level of functioning in order to support the rationale for restorative programming. Prior functional status must establish that a person has shown a recent deterioration that warrants rehabilitation.
If prior status was poor, you cannot justify a restorative intervention. For example, if someone is admitted to the facility who hasn't walked in five years, had a 24-hour aide in the home, and was dependent with respect to most ADLs, that person's prior status would not support an intensive rehab program, even though there might still be potential for improvement.
It is also crucial to establish a diagnosis that supports restorative programming. If the diagnosis is medical in nature, such as congestive heart failure or post-pneumonia, rather than rehabilitative, such as stroke or fracture, it is even more important to document your rationale for establishing the program. The case manager should review section "I" (disease diagnoses) of the MDS to make sure the appropriate diagnosis is documented there.
* Ensuring that information entered on the MDS meets the group assignment criteria. Although there is a lot of strategizing you can do to maximize revenues under PPS, there is also a lot of room for error. First you must figure what it takes to meet the qualifiers for the appropriate level. Then you must provide the right number of minutes to meet the qualifiers. Finally, you have to accurately record what you have provided.
For example, if you are projecting a resident to be in the "very high" category, then the MDS must reflect at least 500 minutes of therapy. If OT has provided 225 minutes and PT has provided 270 minutes, the resident got only 495 minutes and you will be 5 minutes short of meeting the qualifier. That five-minute shortfall will leave you in a lower category, and you will collect the lower rates until the next assessment date. The case manager should know the criteria and audit your MDS forms on a regular basis to ensure that you are meeting your time and day target.
* Continuously assessing the resident's progress. After the initial steps are carried out, the case manager must follow the case to make sure that documentation continues to support the rehab category and to make plans for movement through the rehab continuum as the resident improves. Timing of changes should be carefully coordinated with the MDS assessment schedule to take advantage of reimbursement opportunities built into the system. The "low rehab" category should be used when the resident no longer meets restorative criteria but still has the potential to improve.
* Coordinating the decision-making process with nursing. If rehab is no longer able to qualify a resident for Part A, the case manager should talk to nursing to determine whether other criteria could be used to qualify the resident under another skilled category.
* Being a ware of the entire MDS document. Discrepancies within the MDS regarding a resident's functional status can lead to computer-generated denials. You need to corroborate the information provided by your therapists in the sections they fill out with the information provided by nursing. It is not uncommon for nursing to be documenting in the G section that a resident is not walking in the room or the corridor and requires extensive assistance in transfers, while the therapists are documenting that the resident is ambulating 150 feet with supervision. A discrepancy this wide cannot be explained by differences in terminology and rating scales.
The case manager must be aware of what other disciplines are documenting, and must ensure that the MDS is consistent with itself and with the therapy notes. That means reviewing all sections, including B (cognitive patterns), C (communication/hearing patterns), G (physical functioning, particularly the ADLs), and I (disease diagnoses).
Because HCFA auditors plan to aggressively investigate the validity of rehab claims under PPS, it is a good idea to develop a denial management program.
The cases at greatest risk of denial are in-house admissions; residents whose functional status is too high to warrant skilled restorative services, such as those who can ambulate 200 feet with a rolling walker and supervision; residents who have documented mental status deficits that might interfere with high-intensity rehab programming; residents whose documented status in rehab is in direct conflict with other forms of documentation, such as the MDS or nurse's notes; and residents who have had long lengths of stay on rehab.
Your rehab therapist should take the following steps to avoid denial of your rehab claims:
* Choose your residents carefully (especially when considering in-house admissions). In-house admissions should have a completed significant change MDS and supporting documentation in the nurse's notes.
* Document meticulously. One poorly chosen word--such as "confused"--can result in a denial. You also need to establish a prior functional status that supports the need for rehab intervention and proves medical necessity by showing that skilled service is required to attain projected outcomes. Once the program is initiated, you must show meaningful gains in the MDS, corroborated by nursing documentation. If you do not co-sign the notes yourself, you need to be sure that the person co-signing the notes understands the criteria for acceptable documentation and does not cut corners by co-signing notes that fail to meet the rigorous criteria outlined above.
* Perform chart audits (especially if you are not the one co-signing the notes). This will ensure that you have met your documentation criteria and that your documentation is in agreement with other sections of the chart, such as the MDS and nurses' notes, that your therapy attendance records are fully filled out, and that physician orders are in place.
* Discharge weak cases or move them to lower levels on the rehab continuum rather than trying to maintain them in higher RUG categories.
Since OBRA '97, Medicare has supported the philosophy of rehabilitating residents to the highest level of functioning. You have an obligation to measure the success of all the rehab you are providing. Are you rehabilitating your residents to return them to a functional and meaningful life? Are you doing it in a reasonable amount of time? Are you using a reasonable amount of resources to get them there?
You need to show that you are efficient and effective. This can be done with a standardized outcome tool such as the functional independence measure (FIM), or with a less sophisticated tool that documents patients' status at the initiation of the program and compares it with their status at discharge, along with length-of-stay data.
By following these steps, you will maximize profit potential while ensuring quality and compliance.