Translating thought into word: good documentation enhances care and reduces risk in reimbursement.

Mr. Smith took the last step in his treatment session. The therapist noted in her clinical documentation that he had walked 125 feet, and she later filled in the proper codes for billing. When the Medicare fiscal intermediary (FI) refused to pay for services, she was shocked. How could it be? It was clear that Mr. Smith had made significant progress during the course of treatment.

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But on review of her clinical documentation, something was missing. True, Mr. Smith had ambulated 125 feet with minimum assistance. Missing, for proper reimbursement, was the clinical judgment and rationale that went on in the therapist's mind during that journey. In other words, medical necessity and skilled services rather than progress are the drivers of reimbursement.

The gap between the therapist's thinking and the written word is not an uncommon phenomenon, according to Janette Coleman, district manager and master clinician for Aegis Therapies. "Denials are usually based not upon service rendered, but upon the poor written record of it," she says. "The therapist will tell me what she was working on, but when we look at what actually was written down, it doesn't reflect what she did. I want to see very concisely what the underlying impairments are and what is causing the problem--the thinking behind the treatment."

For example, by simply noting the length of Mr. Smith's journey, the therapist sent a message to the FI that the skilled services of a therapist were not necessary; a CNA could have walked him down the hall. "We need the therapist to use her skilled knowledge to explain why Mr. Smith could only walk 125 feet," says Coleman. "Does he have a problem with his base of support or his heel-to-toe strikes? Is he having difficulty in sequencing the tasks? How was the therapist facilitating Mr. Smith's walk by using her skilled knowledge to help him with these problems? We need some measurements, but we need the analysis, too."

Telling the Story Behind the Story

Anyone watching a therapy session can document that Mrs. Jones did 10 reps of heel slides. "Most therapists want to document the tasks they did in treatment and the outcome," says Bill Goulding, director of outcomes and appeals management for Aegis Therapies. "It often comes down to 'Dear Diary, here's what we did in therapy today.' There's no peek into the therapist's mind, which is really what we're being paid for. Justifying medical necessity and the need for skilled services is the foundation of documentation."

Beyond the list of tasks accomplished, good documentation tells the story of where the resident has been, where he is now, and where he is going. It explains what the tasks mean in terms of what other adjustments must be made, what adaptive equipment might be needed, and what type of other treatment approaches might be added. "That's a different way of documenting," says Goulding. "Without that justification, you risk not receiving appropriate payment, and you don't maintain quality care. You must advocate for the services you provided."

Specifically, documentation should answer questions in four basic areas:

* Resident history. What was the resident's prior level of function, and what has happened recently to change the resident's health status?

* Medical necessity. Why are the services of a therapist required right now to bring the resident's function to a different level? What was the reason behind the treatment?

* Skilled treatment. In what areas is the resident having difficulty, and what are the specific measurements of that difficulty? Why are the skills of a therapist necessary rather than some other paraprofessional within the facility?

* Goals. What are the reasonable, specific goals relating to the areas of difficulty? What progress has been made on the goals, why has that progress been made, and what areas still need work?

The Importance of Incremental Goals

In addition to ensuring payment for services, the goals detailed in documentation affect how long a resident will be on the caseload, and that directly impacts the nursing home's bottom line. Broad goals miss the incremental steps necessary to achieve them. For example, if the resident's strength is diminished, then the goal might be to increase strength by half a grade rather than lift a bag of groceries. If balance is only "fair minus," then the goal might be to increase balance to at least "good." If range of motion is reduced, then the goal might be to increase the range of motion by 10 degrees. "With specific goals we can see when even small, meaningful gains have been achieved, as opposed to a broader goal that only shows progress when larger gains are made," says Coleman.

When goals are too broad, clinicians may discharge a resident because they might feel that those larger gains have not been achieved. "That lack of progress could be because the goal is so broad it will take forever to get there," notes Coleman.

The other side of good documentation is coordination with nursing, particularly for Medicare Part B residents. "What the therapist notes in documentation must be representative of that resident throughout the institution," says Mark Richards, national director of clinical services at Aegis Therapies. "For example, if therapy documents that it takes two people to transfer a resident, that must be reflected in nursing documentation as well. It's important that we're speaking the same language across disciplines."

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A good therapy company can work with nursing to ensure both are on the same page in terms of how to document. "We came into a facility that had been identified by the FI as having significant discrepancies between nursing and therapy documentation," recalls Louanne McCray, Aegis regional sales manager. "We worked with the nursing staff, provided some in-services, and were able to bridge that gap. It was a huge factor in turning around the denials."

Translating thoughts into words on a page is a learning process. "Good documentation is important in controlling exposure to fraud and abuse," says Goulding. "It is the record between the therapist and the resident. In effect, it is our 'clinical ledger.' If there is a dispute, the documentation is the first place to look." Remember the mantra: "If it wasn't written down, it wasn't done."

RELATED ARTICLE: The Good and the Bad (and the Why)

The following demonstrates the difference between good documentation and bad documentation:

BAD DOCUMENTATION under Reason for Referral: "Resident admitted to the facility with orders for physical therapy."

The information here could be discerned by looking at the resident's chart. The therapist has not made a skilled evaluation of the condition of the resident.

GOOD DOCUMENTATION under Reason for Referral: "Resident admitted to the facility after recent fall at home. She is no longer able to safely ambulate; requires physical therapy services to prevent further decline and increase safety."

This statement immediately identifies the change in the resident's condition and the specific reason she may need therapy.

BAD DOCUMENTATION under Short-Term Goals: "Resident will ambulate 150 feet with minimum assist."

This is too broad a statement with no reference to underlying reasons the resident is not currently able to ambulate 150 feet.

GOOD DOCUMENTATION under Short-Term Goals: "Within 2 weeks, resident will increase lower extremity strength by one muscle grade to promote increased independence in ambulation. Within 2 weeks, resident will improve dynamic standing balance to 5 min X 2 with contact guard assist of 1."

These goals give a specific target to aim for based on the underlying reasons for resident's decreased ability to safely ambulate functional distances.