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Medicare Compliance & Reimbursement

Rehab:

IRFs Can Keep In The Clear With These Strategies

Published on Fri Oct 15, 2004

Putting skill in skilled service notes is the best audit protection.

If inpatient rehab facility managers are still holding their breath for a 75-percent rule reprieve, they could find themselves in a chokehold down the line. Instead, here's what they can do now to maximize their chances for success no matter what the future holds.

Beleaguered inpatient rehab providers are cautiously optimistic that a recent amendment to the 2005 Departments of Labor, Health and Human Services Education Appropriations bill (H.R.5006) will halt the 


75-percent rule. But until Congress nixes the reg, providers must continue to follow strict medical and rehab necessity documentation requirements or face audits and denials from their FIs.

FI probes are rampant across the country, and IRFs are taking the heat for skimpy notes.

"What FIs are finding is that providers weren't even documenting that they were providing skilled therapy," explains consultant Fran Fowler with Fowler Healthcare Affiliates, Inc. in Atlanta. Just writing "walked the patient" (which is not a skilled service) rather than using specifics like "taught the patient gait training" in the chart could trigger a denial.

"Part of the reason for this brevity is that in trying to make notetaking more efficient, they had taken the notes down to the bare minimum," explains Fowler.

But in an audit, brevity isn't going to win IRFs any points. "All they're looking at is the chart," and the right specifics must be there, stresses Fowler.

Remember: IRF patient charts should include notes from four critical sources: the physician, the rehab nurse, the therapist and team meetings. Our experts offer the following documentation advice:

  • Physician notes should show function. To support a patient's placement, the notes must show a "reason for rehab," stresses Angela Phillips, president and CEO of Images & Associates of Amarillo, TX. Ensure the physician has noted in the admitting history and physical not only the patient's medical conditions but why the patient requires inpatient rehab. "Many histories and physicals are medically focused but don't address the patient's functional needs," she notes.

    That's not all. "To further support medical necessity in a rehab unit, auditors would expect to see physician notes three times a week that address rehab issues and talk about the patient's functional progress," says Phillips.

  • Skills and time critical to therapy notes. Notes must show that the patient participated in three hours of therapy a minimum of five times per week. If the patient did not meet these requirements, the note should explain what the issues were that prevented that patient from participating and describe the patient's progress, instructs Phillips.

    Best practice: Use a date and time stamp to show when therapy started and ended, recommends Garry Woessner of Woessner Healthcare Consulting Group in Edina, MN. This applies to all sites of care, he notes.

    Make sure therapy notes support the skilled nature of the treatment you are providing, recommends physical therapy consultant Ellen Strunk with Restore Management Services in Pelham, AL. "For instance, after reading the note, would it be clear to an auditor that only a therapist could have performed the services instead of a restorative CNA or other nursing assistant?" she asks.

    Strunk suggests documenting the manual, visual or verbal cues the therapist gives to the patient to perform the activity correctly. Providers can also relate the therapeutic activity or exercise performed to one of the treatment goals. For instance, a therapist could note that he or she performed "TKEs and bridging...to enhance the patient's ability to stand from a regular height chair," she suggests.

  • Show reassessment in team meeting notes. Make sure that team-meeting notes include specifics on why the patient still needs IRF care. "We recommend that the team assess such specifics as the medical problems that are being addressed and the remaining needs that still require medical care along with a clear description of remaining potential for functional improvement," suggests Phillips.

    Caution: Use team meetings to reassess therapy goals. "Whether the patient is making progress is one of the conditions that CMS uses to evaluate the appropriateness of rehab," says Fowler. When patients fail to progress, explain why, emphasizes Strunk. Failure may be related to an additional or unrelated medical condition such as an acute illness, acute pain or anemia. "Continued treatment can be justified when providers explain what steps they are taking to alleviate the problems and why the patient remains a good rehab candidate," she says.

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