Eli's Rehab Report

Work together to get documentation in synch.

Therapy use continues to garner scrutiny in home health. And it's the documentation that can sink your claims. Take the time to adjust the way you approach therapy situations to improve patient care and avoid putting your reimbursement in jeopardy.

"There is a functional domain disconnect between what the nurse selects on the OASIS and the therapy notes," says occupational therapist Karen Vance with BKD in Springfield, Mo. "The OASIS is supposed to be discipline-neutral, but people aren't taking the time to synch things up."

Tip: Taking the time to check therapy documentation against the OASIS items which indicate the patient's ability to participate in activities of daily living can help secure your reimbursement. OASIS items that can earn functional domain points include:

• M1810 -- Current Ability to Dress Upper Body;
• M1820 -- Current Ability to Dress Lower Body;
• M1830 -- Bathing;
• M1840 -- Toilet Transferring;
• M1850 -- Transferring; and
• M1860 -- Ambulation/Locomotion.

Use All Five Days

The biggest mental road block to synching up the data from the OASIS and the therapy documentation is that clinicians don't understand the five-day window they have to complete the OASIS at start of care (SOC) says Cindy Krafft, PT, MS, COS-C, senior clinical consultant with Fazzi Associates in Peoria, Ill.

Because the OASIS requires a single signature, it can seem as though one person must do all of the documentation in one two-hour visit, Krafft says. As a result, clinicians often feel like they must lock down the OASIS assessment as quickly as possible.

Take your time: "The system is built with the five-day timeframe to give you time to revisit and discuss with other people who have seen the patient," Krafft says.

Problem: By not taking advantage of the five-day timeframe, "we have overwhelmingly told the Centers for Medicare & Medicaid Services that we can do the SOC in one day," Krafft says. But this speedy turn-around may be masking inaccurate assessments.

Work Together

One person is responsible for completing the OASIS but that has never made her all-knowing, Krafft says. The five-day timeframe for completing a SOC OASIS should give you time to discuss the patient's condition with other staff who have been in the home.

Often the physical therapist is in the home during the five-day timeframe and thinks she has nothing to do with the OASIS, Krafft says. This same lack of involvement can occur when one nurse does the admission over a weekend and another nurse goes out to see the patient on Monday. "Does she look at the OASIS to see if there's something that needs to be discussed? No," says Krafft.

One way to encourage interdisciplinary cooperation is through case conferences, Vance says. Following OASIS guidelines and the timeframe, gather together the people who have laid eyes on the patient, she says. The nurse can then take all of this input into account to get a broader picture of the patient's condition.

This doesn't mean that the nurse just changes her notes and moves on, Vance says. "Nurses may not understand the language of the functional domains the way the therapists do," she says. The case conference can help get everyone speaking the same language.

In the case conference venue, therapists can explain to the nurse exactly what it looks like when they are talking about "minimum assistance."

Try this: Role playing can help drive home exactly what's going on with a particular patient, Vance says. With the nurse acting as the patient, the therapist can demonstrate what minimal assistance looks like.

Interdisciplinary gatherings can also help therapists to better grasp the OASIS. "Therapists need to understand that even if they don't complete the OASIS, they need to be aware of what is being reported," Krafft says.

Documentation tip: Therapists should include OASIS concepts in their documentation, Krafft says. Things like whether the patient needs intermittent or consistent assistance in bathing, and when the patient is experiencing pain interfering with activities, will help support the need for skilled care.

Refine Your Observation Techniques

One old problem still dogs good therapy documentation, Vance says -- the nurse or therapist gathering the functional domain data during the assessment is asking questions rather than observing. Seeing the patient perform the activity is always best.

But even actually observing the activities being performed doesn't guarantee an accurate assessment, Vance says. When activities of daily living are measured or assessed in isolation, you don't get a true representation of your patient's abilities.

For example: Suppose your patient has COPD. The therapist may assess her dressing ability on one visit and it seems fine, Vance says. The therapist assesses the bathing or ambulation on another visit and finds that fine as well. This can result in a patient's ability being scored too high from the beginning, she warns.

Your patient doesn't just perform one task a day, Vance says. The question is really, "How is this patient doing after she has performed all of these ADLs?"

Try this: Take the opportunity to assess your patient at different times in the day, Vance says. If you don't take the time to observe accurately from the start, in the end your patient won't appear to show the improvement he achieved.