Starting the Countdown
Auditors at LW Consulting, Inc. (LWCI) review thousands of skilled nursing facility (SNF) records every year and yet negative trends continue to be identified in documentation. Looking ahead to 2023, after several years of experience working with the Patient Driven Payment Model (PDPM), therapy issues contribute to these negative trends in documentation. It is astonishing to see the inconsistencies in therapy documentation related to content, skill, demonstration of medical necessity, and accurate coding and billing practices. There are steps that can be taken to improve accuracy in therapy documentation and comply with regulation.
What can be done to improve therapy documentation in your facility? One of the first integral steps to take is to have external audits completed as part of a comprehensive compliance plan. LWCI partners with many providers to complete audits, discuss findings, educate staff, and strategize and implement operational improvement plans.
Over the next several weeks in this Blog Series, top risks in therapy documentation will be highlighted as LWCI reflects on the main risk areas identified in 2022 audits to proactively prepare for 2023.
What are some of the top risk areas noted this past year in therapy documentation?
For this series, let’s start the countdown ten through eight:
# 10 – An Incomprehensive Prior Level of Function (PLOF).
Why is PLOF important? A therapist cannot truly devise a relevant discharge plan if he or she does not capture a strong understanding of the resident’s prior level of functioning. Clearly documenting a resident’s prior level of function regarding mobility, ADLs, cognitive status, communication, etc. on the evaluation is key to goal development and the entire discharge plan. The PLOF should be comprehensive and unique to each resident and should correlate to the goals. Rehab potential should be realistic related to the PLOF. The PLOF should support the discharge plan. Demonstration of knowledge of the resident’s prior level of functioning and their capabilities prior to injury or illness is key to proper discharge planning. When the PLOF is not comprehensive, related to the goals, or correlated to an attainable discharge plan, it can pose risk. The PLOF for each discipline should relate to the goals for each discipline. Often, we see the PLOF in the PT evaluation copied into the OT and SLP evaluations which is not discipline specific or best practice. When reviewing audits in the year 2022, therapy documentation of prior level of function lacked specificity, detail, and discipline specific information.
# 9 – Modes of Therapy are not supported.
A problem is identified when the billing service logs, and the daily notes do not match regarding modes of therapy. Individual minutes should be supported as individual minutes and clearly record the one-to-one care the resident received. When utilizing group therapy, it should be clear from the documentation as to why the resident would benefit from group therapy. Group therapy must be included on the initial plan of treatment, and it should be evident that the focus of the group relates to each resident’s outlined goals. Documentation should clearly indicate group therapy was provided, the rationale in which it was provided, and the goals should be clinically appropriate for a particular resident to benefit from group treatment. From audits completed in 2022, an issue raising concern was the coding of group minutes when the resident was clinically not appropriate for group treatment. Documentation presents the resident required one-to-one care based on his/her clinical presentation, goals, or cognitive status; yet group treatment was billed. The documentation does not support group treatment in this scenario.
A similar issue arises when considering the provision and billing for concurrent treatment. Merely having concurrent [or group minutes] on a billing service log without supportive documentation in the narrative does not support therapy minutes reported on a Minimum Data Set (MDS). Concurrent therapy must support the definition of concurrent in the Resident Assessment Instrument (RAI) Manual as follows: “concurrent therapy is the treatment of two residents at the same time regardless of payor source when the residents are not performing the same or similar activities, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A.”
The documentation should indicate concurrent treatment was provided to two residents at the same time, indicate a rationale, and be feasible to ensure line-of-sight supervision requirements of another resident can be appropriately provided.
In terms of co-treatment, the biggest identified risk was when documentation of co-treatment did not support the need for two skilled professionals. In other words, documentation did not clearly demonstrate the need for each discipline’s unique skill. According to the RAI Manual regarding Medicare A residents “the decision to co-treat should be made on a case-by-case basis and the need for co-treatment should be well documented for each patient. Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited.” Without proper documentation to match the billing per mode of therapy, compliance with regulation and accurate reimbursement is at risk.
# 8 – Current Procedural Terminology (CPT) codes that are not supported based on the narrative documentation.
For example, the therapist bills therapeutic exercise; however, the daily note supports the therapist truly performed tasks that should be coded under therapeutic activities. Mismatched narratives and CPT billing really becomes even more of a risk with Medicare B residents. For Medicare B residents, varying CPT codes result in different reimbursement based on the physician fee schedule. The lesson here: what is coded on the billing service log should match the description of the task based on the narrative of the daily note. Audits conducted this past year demonstrated inconsistencies with narrative documentation and the billed CPT code including but not limited to initial vs. subsequent orthotic codes, manual therapy vs. therapeutic activities, ADL training vs. therapeutic activities, therapeutic exercise vs. therapeutic activities. Other billing and coding discrepancies were identified, but these examples were some of the most common.
Without a proper operational system in place including the use of an audit process, facilities may not even be aware of their top risk areas.
Tune into Part 2 of this blog series where LWCI shares insight into the next top three risk areas focusing on diagnosis coding, standardized assessments and frequency and duration inconsistencies identified in 2022 LWCI audits.
