Eli's Rehab Report

Get your medical definitions, coding and documentation in sync.

Inpatient rehabilitation facilities nationwide adjusted to yet another CMS requirement on Oct. 1. IRFs are now required to report quality measure data on pressure ulcers (PU) and catheter-associated urinary tract infections (CAUTI) as part of the IRF-PAI assessment.

These measures have no impact on payment -- for now -- but putting your facility's best foot forward will prevent unwanted stresses down the road.

Get the Facts Straight for Your Case

"Even though the new quality measures appear to be a minor requirement, it's taken a lot of interdisciplinary communication to ensure everyone is on the same page," says Monica Baggio Tormey, BS, RHIA, CHP, privacy officer and regional director of health information management at New England and Braintree Rehabilitation Hospitals, based in Massachusetts.

For example, ensuring coding staff, physicians, the IRF-PAI coordinator, and nursing staff are all using correct PU staging definitions is critical, Tormey says. Personnel must also "clearly differentiate, document, and stage pressure-related wounds versus other types of wounds."

"Our concurrent coding communication process was leveraged to reconcile any questions about PUs before a patient is discharged to make sure that the documentation exists during the patient stay," Tormey shares.

Watch out: Many IRFs aren't differentiating enough between patients who already have a PU or CAUTI on admission and patients who acquire a PU or CAUTI at the IRF, according to Fran Fowler, FAAHC, principal of Fowler Healthcare Affiliates in Marietta, GA.

That said, rally for better observation and documentation during the preadmission screening. Note warning signs of PUs and CAUTI that will inevitably develop on the IRF stay. "You may have to report them, but you can also explain, 'we're going to be fixing someone else's problem,'" Fowler says.

Good idea: "We have a new requirement to assign present on admission (POA) indicators so real-time communication about high-risk conditions and documentation goes beyond just PUs," says Karen Paquette, RHIT, CCS, regional coding supervisor, also with New England and Braintree Rehabilitation Hospitals.

Ensure Your Coding Lines Up

For pressure ulcers, New England and Braintree Rehabilitation Hospitals are focusing on consistency between clinical and physician documentation to ensure the most accurate ICD-9 codes go into the medical record. Accurate coding will not only back up your quality reporting, but it may also create more efficiency in medical care.

Example: "For CAUTI's, [our] coding staff is heavily relying on infection control specialists to identify UTI's that meet the CDC CAUTI definitions," Paquette shares. Once coding staff confirms a CAUTI, they place a "communication form" in the medical record "so physician and clinical staff are aware of the condition and can address their burden of care related to the CAUTI."

"Like with PUs, the goal is to have the quality measure documentation clearly supported in the medical record by the physician, nursing, and the IDT team," Paquette says. This leads to accurate ICD-9 codes reflecting the quality measures both on the bill and the IRF-PAI form when appropriate.

Sharpen Your Documentation Sword

One cannot stress enough the importance of good documentation. Although the quality indicator is a simple item on the IRF-PAI form, personnel must supply the information appropriately in the chart, Fowler points out.

Heads up, therapists: You can get more involved in documentation, even if you simply note you instructed the patient to change positions every two hours to avoid PUs. And if someone else spots signs of a PU or CAUTI, "be sure to note that someone greater than an aide has assessed it (either therapist or a nurse)," Fowler says.

Finally, take advantage of the team conference to powerhouse your documentation. With an interdisciplinary approach you can collaborate on what every team member has observed and done to prevent and manage PUs and CAUTI. "Often [reviewers] look to that team conference," Fowler notes.