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Physical Therapy Goals


The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

How to Minimize Income


I have never been inside an agency that has too much cash on hand but if you happen to be one who would like to earn a little less money, I can help. Follow the steps outlined below to minimize your income and prevent the problem of not knowing what to do with all your extra money.

  1. Do not invest in ICD-9 or OASIS training for your staff. They can read the internet just like everyone else.
  2. Make sure that every patient in your agency is scheduled to be seen by a nurse once a week for nine weeks. It doesn’t matter how many or how few visits are needed to provide good care. What’s important is that it is easy to follow a 1w9 pattern.
  3. Do not waste your time putting in processes to manage therapy. You only stand to make money if therapy is tightly managed and missed visits are made up as quickly as possible.
  4. Make frequent use of the hospital. Not only will you lose money by providing extra care to patients discharged from the hospital but your patients might just be safer there if you are planning on implementing any of these measures.
  5. Do not provide any management training for your nurses. Simply expect that because they are ideal clinicians that they will know how to manage a business and staff.
  6. Finally, hire your staff indiscriminately. Anyone with an R and an N behind their name can do OASIS. If you are bound and determined to keep extra cash to a minimum, treat the nurses as though they are disposable and easily replaceable. Certainly that is the case if you are not looking for loyal, qualified employees.

Anyone who tries any of these strategies, please post a comment so we can evaluate their effectiveness.

Don’t Talk to the Hand


I was reviewing clinical records recently for an excellent client. Well, most of the time they are excellent. But like every other client, past, present and future, they got a little careless when it came to coordination of care. A better name for care coordination I think might be simply talking to each other.

The particular chart I looked at was almost perfect. I was just getting ready to put it back on the shelf but had two questions. First, within the admission paperwork, there was mention of an area of redness on the heel of this patient. All subsequent notes noted that there was a wound on a finger. I thought it was sloppy charting. The second question concerned the patient being started on Lortab the week before discharge. Why?

So, before I called it quits for the day, I asked about the patient. As it turned out, the patient was scheduled for discharge and I had the opportunity to go with the nurse to see the patient. He was sitting up on arrival, fully dressed. I hated to inconvenience him but I asked if I could remove his sneakers and socks anyway. I managed to get the right foot exposed first and there was nothing to write home about. Just because I had come this far, I next turned to the left foot. With the help of an aide, I managed to take the snap shot below.

6

Upon further investigation, I learned that the admitting nurse was only doing the visit as a favor to the agency. She documented the foot problem but didn’t report it. The aide saw the wound but assumed the nurse was aware. The LPN read about the wound on the finger but nothing written about the foot so she assumed it was a careless mistake like I did. The patient was cranky and frankly, didn’t like anyone removing his shoes and socks.

It would be easy if one person was to blame. But too many people knew about this wound. And everyone assumed that everyone else knew, too. It was a system failure with ominous results. However, this same failure to communicate exists in every client’s office at one time or another.

So could we all just please talk to each other?

Tuesday Musings


As promised, here are the answers to Monday’s quiz.  See the previous post below this one if you missed out on the quiz.  In fact, stop reading now and answer the quiz if you haven’t already done so.

The first response was that therapy should be provided under the management of a physical therapist.  This makes perfect sense to me.  And in agencies large enough to have a separate therapy department, I highly recommend a director of therapy.  However, it is clearly stated in the Conditions of Participation for Home Health and most state minimum standards that all care in an agency is provided under the direction of the Director of Nurses.  This is very challenging for many nurses, including myself.  How do we manage therapy if we don’t know exactly what it is that they do?  Looking at the larger picture, is it so much different than a CEO of a major airline managing pilots and mechanics when he or she has never flown or repaired a plane?  In order to manage therapy as nurses, we must cultivate trusted sources and work with therapists who do not feel threatened when we question their work.  We learn a lot this way!

The next response has to do with visit frequencies.  Certainly therapy plans of care that include 7 or 14 visits are financially lucrative and there is nothing at all wrong with keeping payment criteria in mind when determining frequencies.  In fact, it is important to be aware of these numbers in an agency that wants to do well financially.  However, the ultimate frequency that the patient receives should be the one that best reflects the patient needs.  Always.  If a patient needs 13 visits, then that’s what the patient should receive. (However, show me a patient who requires 13 PT visits and I bet I can find a need for a few OT visits in the clinical documentation!)

The third answer involving wound care was correct.  It is within the scope of practice for physical therapists to perform wound care.  In fact, physical therapists can do certain things that nurses cannot such as sharps debridement in most states.  This can work to an agency’s advantage two ways.  First in wound care patients receiving physical therapy, duplicate visits can be eliminated by having the therapist assess and perform wound care on days when PT is ordered.  Secondly, consider a PT wound care program if you are not suffering from a lack of physical therapists.  Choose one or two interested therapists and invest in advanced wound care training for them.   If your agency decides to take advantage of either of these advantages of therapists performing wound care, be sure that you specify that physical therapy should be doing wound care on the plan of care.

The last answer about OASIS was also incorrect.  Many agencies choose to have the nursing staff perform all OASIS assessments.  This may be a sound strategy especially when physical therapists are in short supply.  However, in an agency where a large number of patients are admitted for physical therapy only, consider training the therapists to perform the OASIS assessment.  This eliminates the need for using a nurse to do an assessment and then write a care plan based upon the PT’s assessment.

If you have any questions about the answers to yesterday’s quiz, please post them below in the ‘responses’ box or email us at haydelconsulting@bellsouth.com.

Home Health Physical Therapy


Update:  The Louisiana DHH clarified on Friday afternoon that even though they expect orders and goals to be included on the care plan, it is recognized that this is not always possible.  In these instances, a separate verbal order containing all of the physical therapy goals and orders is satisfactory.  We apologize for any confusion.  Please feel free to comment below or email us at haydelconsulting@bellsouth.net if you have any questions.

It is common for agencies to order a Physical Therapy evaluation on home health admission and wait until the paperwork has been submitted to the office to write orders for frequency, treatment modalities and goals.  These orders have traditionally been sent to the physician as a separate verbal order.  Well, most of the time:)

During a recent client survey, a state surveyor informed us that CMS now expects the orders for frequency, modalities and goals to be on the 485.  Because this was contrary to the advice we have traditionally offered to our clients, we called the Louisiana Department of Health and Hospitals.  Louisiana DHH also informed us that CMS expected all orders and goals for physical therapy to be included on the 485 and failure to do so will appear as thought the agency simply didn’t complete the care plan.

So there you have it.  Managing Physical Therapy has always been a challenge in Home Health.  We would like to hear your views on these changes.  Is this how your agency already does therapy?  Will changing to this process improve or impede coordination of care in your agency?  Or is this change so insignificant that it can be integrated into your current process without much trouble.

To leave a comment, click on the link below.  To resond privately, email us at Haydelconsulting@bellsouth.net

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