MDS Alert
Know These Ins and Outs of Therapy Service Documentation
Hint: Medicare Part A has different requirements than Medicare Part B. Rehabilitation and/or therapy services are a major aspect of many residents’ stays in nursing facilities. Make sure you’re capturing rehabilitation information correctly to document each resident’s medical situation accurately, as well as to secure the reimbursement your facility earned. Providing and documenting therapy is crucial for residents’ medical records, but it’s also important to know what surveyors are looking for, in terms of compliance. Define What Counts as Therapy There are myriad therapy services that may constitute a facility’s rehab provisions, including physical therapy, occupational therapy, speech-language pathology, respiratory therapy, and rehabilitative services for mental illness or intellectual disability. It’s important that you document in Section O (Special Treatments, Procedures, and Programs) of the Minimum Data Set (MDS) only the therapies described by the Resident Assessment Instrument (RAI) Manual. Remember, restorative and rehabilitative services differ, and knowing the different and documenting care appropriately is important. The RAI Manual explains the difference, on page O-20: “… therapy services can include the actual performance of a maintenance program in those instances where the skills of a qualified therapist are needed to accomplish this safely and effectively. However, when the performance of a maintenance program does not require the skills of a therapist because it could be accomplished safely and effectively by the patient or with the assistance of non-therapists (including unskilled caregivers), such services are not considered therapy services in this context.” In situations where facilities prefer to have licensed professionals perform repetitive exercises and other maintenance treatments or supervise aides assisting residents with these maintenance services, even if a qualified therapist’s involvement isn’t medically necessary, don’t include the services in item O0400 (Minutes). In this scenario, “the specific interventions would be considered restorative nursing care when performed by nurses or aides. Services provided by therapists, licensed or not, that are not specifically listed in this manual or on the MDS item set shall not be coded as therapy in Item 0400. These services should be documented in the resident’s medical record,” the RAI Manual says (emphasis original). Services provided in this situation would instead be categorized as nursing interventions. Note Who Orders, Provides Services First thing’s first: Medicare Part A residents who receive therapy need a written order from a physician, and qualified personnel must provide the services. Residents who are Part B beneficiaries receiving therapy do not require an order, but a physician’s order may substitute for a plan of care. Additionally, orders written by therapists are not recognized by Part B unless a physician or nonphysician practitioner signs and dates the plan of care. “Qualified personnel” are appropriately licensed or certified per their state, which, of course, can vary. Regardless, qualified personnel must meet the specific licensure/ certification requirements as required by their state and have the training, competency, and skills to serve residents appropriately. Although federal and state regulations sometimes differ, always look to the higher degree of supervision, says Linda Elizaitis, RN, RAC-CT, BS, president and founder of CMS Compliance Group in Melville, New York. For example, only physical therapists can supervise physical therapy assistants, and only occupational therapists can supervise occupational therapy assistants. Additionally, speech language pathology (SLP) services may be provided only by a licensed speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant who’s licensed/certified by the state. See Example of Citation Elizaitis notes that the citations relevant to the provision of these rehabilitation services — F825 Provide/ Obtain Specialized Rehab Services and F826 Rehab Services- Physician Order/Qualified Person, respectively — are not very highly cited by surveyors. However, it’s still important to double-check that orders are in place for therapy. Surveyors have cited facilities with these Ftags when they see and observe a resident with contractures, she says. One example she provides: Surveyors observed, on their initial tour of a facility, two residents with contractures, and saw them again multiple times throughout the survey without any devices to help prevent or resolve the contractures in place. Although the facility had physician’s orders for both of the respective residents to have splints, the Restorative Aide didn’t have them on her list of splints, and neither resident had contractures addressed in their care plans.
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