Justifying rehab

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JUSTIFYING REHABILITATION SERVICES By defining disability through documentation

Transcript of Justifying rehab

Justifying Rehabilitation Services

By defining disability through documentation

Today, were going to talk about effective documentation that justifies rehab services through the use of a disablement model. 1

Course OverviewWhy?Disablement Model DefinitionNagi ModelRelating model to patient characteristicsJustification statement

2015 Arete Rehabilitation, Inc.

ICF ModelRelating model to patient characteristicsJustification statementProblems & GoalsOutcome Measures

This course will look at why we need to provide well documented justification for our services, then well look at the definition of a disablement model. We will examine two different models and how each model defines disability thru patient characteristics, and finally, you will practice on your own writing a killer justification statement.2

Why?Fraud Prevention System was created 2010Identifies questionable billing patterns in real timeThen reviews documentation for justification 2015 Arete Rehabilitation, Inc.

So, I know you are asking the question, why? Why do I need to be so concerned about the quality of my documentation? Over the years heres some of the comments Ive heard: My documentation is fine. I know what Im doing is necessary. I have too much to do to worry about that. Unfortunately those comments are placing not only those clinicians at risk but the providers that employ them and the patients they are treating. Never more than now has comprehensive documentation that justifies the need for rehab services been so important. Medicare began using the Fraud Prevention System in 2010 that utilized specific clinical algorithms that identify suspicious billing patterns in REAL TIME. Those medical records are then pulled for a clinical review. If your documentation does not justify the level of intervention you are providing then those services will not be reimbursed, placing your patient, your employer, and YOU at risk.3

Disablement Model DefinitionA conceptual explanation of the process and underlying mechanisms by which disease, injury or birth defect impacts a persons ability to function and perform their expected role in society.

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The disablement model is a conceptual framework by which our patients underlying disease process, injury, or birth defect affects their ability to function within their environment and perform their role in society.4

Nagi Disablement ModelDeveloped in the 1960s Constructed as a framework to describe 4 interrelated, yet distinct phenomena distinct to the rehab field.Further refinement in the 1990s added sociocultural factors (i.e., social and physical environment) and personal factors (i.e., lifestyle behaviors and attitudes)

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The Nagi model, developed in the 1960s, identified 4 interrelated, yet distinct processes that link disease to disability. Considered unidimensional, sociocultural factors were added later that take into account a patients social support network, physical environment, behaviors, attitudes, and lifestyle.5

Relating Model to Patient

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Here we see the Nagi model in action. Active pathology or disease process occurs at a cellular level. In this case, a shoulder labral injury. This injury results in the physiologic impairment of decreased strength, that limits function, that is the patients inability to throw at maximal effort, thus creating this patients disability- the inability to be a starting pitcher.6

Justification StatementPatient presents withposterior/superior labral injuryActive Pathology 2015 Arete Rehabilitation, Inc.

Nagi Modelwith resultant decreased strength causingan inability to throw at >75% maximal effort preventing him from participating in his pitching rotation. Physiologic ImpairmentsFunctional LimitationsDisability

So, in this case a justification statement for rehab services would be: The patient presents with a shoulder labral injury (the active pathology), resulting in decreased strength (physiologic impairment), causing an inability to throw at maximal effort (functional limitation), preventing him/her from starting the pitching rotation (disability).7

ICF Disablement ModelThe World Health Organization (WHO) authorized the International Classification of Functioning, Disability and Health (ICF) in 2001. It is accepted by 191 countries as the international standard to describe and measure health and disability.Multidimensional and multidirectional model of human health

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The World Health Organization offered the ICF or International Classification of Functioning, Disability and Health in 2001. It is an in depth view of patient disability through a multi dimensional model of disability that expands on Nagis model by further defining the impact of personal and environmental factors.8

Relating Model to Patient

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Shoulder labral injury

Decreased muscle power and tear of labrumMaximal activity limitation Unable to start in pitching rotation

Lets now look at the same labral injury but through the ICF mode. The shoulder injury is the health condition. The body functions and structures affected are the labral tear and decreased strength, this results in a maximal activity limitation and prevents the patients starting in the pitching rotation. The environmental factor of having an athletic trainer is a positive factor in this patients recovery, however, the personal factor of prior injuries may be a negative factor9

Justification Statement20 y.o. patient with a history of shoulder injury presents withposterior/superior labral injuryHealth Condition 2015 Arete Rehabilitation, Inc.

ICF MODELwith resultant decreased strength causingan inability to throw at >75% maximal effort preventing him from participating in his pitching rotation. Body Functions & StructureActivity LimitationsEnvironmental FactorsPersonal FactorsParticipation LimitationsAn athletic trainer is readily available to assist with rehab transition and prevention of further injury.

So, in this case a justification statement for rehab services would be: 20 y.o. patient with a history of should injury (personal factors) presents with a shoulder labral injury (the health condition), resulting in decreased strength (body function & structure), causing an inability to throw at maximal effort (activity limitation), preventing him/her from starting the pitching rotation (participation limitation). An athletic trainer is readily available to assist with rehab transition and prevention of further injury (environmental factors). 10

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A nice neat justification package.11

Relating Model to Patient

Decreased ROMDecreased strengthEdemaPainSurgical woundLives alone No family or friends to assistNo prior services

Proximal humeral fracture with ORIF

91 year old female Alert & orientedDrivesShopsPt goal is to go home

Activity LimitationsUnable to dressUnable to washUnable to get OOBDecreased ROMDecreased strengthUnable to self - feedParticipation LimitationsUnable to go homeUnable to feed her catUnable to drive to store

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Lets look at some patient examples that you are more likely to encounter in the SNF setting. A patient is admitted with a ORIF s/p a proximal humeral fracture. So, her health condition is a proximal fracture with ORIF, the body structure and function affected are: decreased ROM, decreased strength, edema, pain, and a surgical incision. The activity limitations she is experiencing are: the inability to wash, dress, get OOB, and feed herself. The environmental factors that affect her recovery are: living alone without family or friends available to assist and no history of prior services. The personal factors contributing to her rehab course is the fact that she is an active 91 y.o. alert and oriented female who wants to go home and previously was driving and shopping independently. This new health condition then results in her participation limitations which are: inability to go home alone, feed her cat, and drive to the store. 12

Justification Statement

Health ConditionBody Functions and StructureActivity LimitationEnvironmental FactorsPersonal FactorsParticipation Limitations

Patient is an alert and oriented 91 year widowed female who lives alone, with no available outside assistance or history of prior services. She is s/p proximal humeral fx with ORIF with resultant decreased ROM, decreased strength, edema, pain and surgical wound. This has caused an inability to wash, dress, get OOB or feed herself which is preventing her from returning home alone where she needs be independent in self care, feed her cat, and drive to the store. 2015 Arete Rehabilitation, Inc.

So, lets put this information into a justification statement for rehab intervention. (Read statement). This is a clear statement of what this patient must accomplish in rehab to go home and justifies our services. However, this then needs to be reflected in our problem statements, goals, and use of outcome measure. 13

Problems & GoalsProblem StatementsUnable to dressUnable to washUnable to get OOBDecreased ROMDecreased strengthUnable to self - feed

Short Term GoalsLong Term GoalsReturn home with servicesIndependent with self-careIndependent feeding cat

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Your problem statements are the patients activity limitation, your long term goals address the participation limitations, and the short term goals are the path to get you from start to finish.14

Outcome Measures

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The Boston University AM-PAC is a valid and reliable measure of a patients status. It is currently in use across the country and since 2004 is one of the measures that CMS recommends we use to measure level of disability and progress. It is a six question assessment in the areas of ADLs, Basic mobility with and without stairs, and applied cognition. This outcome measure also is directly correlated to the Med B g codes- which takes the guess work of the g-codes. 15

Relating Model to Patient

EdemaPoor perfusionShortness of breathMuscle wastingLives with wife 3 rd floor walk up Doesnt leave house

COPD

77 year old male Alert & orientedLikes to watch TVAppears depressedActivity LimitationsUnable to stand >1 minUnable to walk >5Unable to get OOBDecreased strengthDecreased gait velocityDecreased balanceParticipation LimitationsUnable to ambulate to and from bathroomUnable to stand to get dressed

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Now were going to take a look at a chronic condition and how to relate these patient characteristics to a justification statement. We have a 77 year old male who was just admitted from the acute after a COPD exacerbation. He has significant organ level impairment which results in significant activity limitations that prevent him from ambulating to the bathroom. This is complicated by apparent depression and that fact that he lives in a 3rd floor walk up with no elevator. 16

Justification Statement 77 year old alert & oriented, depressed appearing male who lives with his wife in a 3rd floor walk up. He presents after hospitalization for a COPD exacerbation and resultant edema, muscle wasting, impaired perfusion, and shortness of breath. He is unable to stand for >1 min, unable to get OOB, unable to ambulate >5, demonstrates decreased gait velocity, and decreased strength. These limitations prevent him from ambulating to the bathroom and standing long enough to get dressed. 2015 Arete Rehabilitation, Inc.

Health ConditionBody Functions and StructureActivity LimitationEnvironmental FactorsPersonal FactorsParticipation Limitations

An example of a justification statement is: READ Statement.17

Problems & GoalsProblemsUnable to stand >1 minUnable to walk >5Unable to get OOBDecreased strengthDecreased gait velocityDecreased balance

Short Term Goals

Long Term GoalsReturn home with servicesStanding time >2 min to get dressed and use bathroomMod I ambulation to and from bathroom with sufficient gait speed to prevent incontinence. 2015 Arete Rehabilitation, Inc.

The problems come directly from the activity limitations, the Long term goals come directly from the participation limitations and the short term goals are the path in which the patient follows to return home. 18

Outcome MeasuresAM-PAC Basic Mobility 2015 Arete Rehabilitation, Inc.

The Basic Mobility AM-PAC has two versions, one that includes stairs and one that does not. This is the version with stairs since this patient must climb three flights to get home. 19

Relating Model to Patient

AgitationWeight lossStage III wound buttocksLong term care patientFamily very involvedDementia Unit

Dementia

87 year old female Alert Disoriented Family wants to take patient out to eatActivity LimitationsUnable to tolerate dietPoor p.o. eats < 10%Refuses to be fed

Participation LimitationsWeight lossNon healing woundNutrition risk

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On to Dementia and a dysphagia problem. Here we have a typical patient in or near the end stage of dementia experiencing a weight loss. READ SLIDE20

Justification Statement 87 year old alert, but disoriented long term care female resident who resides on the dementia unit referred to speech due to weight loss, agitation and a stage III decubitus secondary to a dementia diagnosis. As a result she presents with an inability to tolerate current diet texture, exhibits poor p.o., and refusal to eat which has caused further weight loss, non-healing of the stage III wound and significant nutritional risk.

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Health ConditionBody Functions and StructureActivity LimitationEnvironmental FactorsPersonal FactorsParticipation Limitations

Read Justification statement21

Problems & GoalsProblemsUnable to tolerate (current diet texture)Poor p.o. eats =30 days. 2015 Arete Rehabilitation, Inc.

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Outcome Measures 2015 Arete Rehabilitation, Inc.

AM-PAC Mobility without Stairs

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The END 2015 Arete Rehabilitation, Inc.

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

AM-PAC Inpatient Daily Activity Short Form Conversion Table

Boston University AM-PAC 6 Clicks Daily Activity Inpatient Short Form Score Conversion Table*

AM-PAC Raw Score

AM-PAC Scale Score

Scale Score Standard Error

CMS 0-100% score CMS G-Code

Modifier

6 17.07 3.74 100.00% CN

7 20.13 3.68 92.44% CM

8 22.86 3.43 85.69% CM

9 25.33 3.17 79.59% CL

10 27.31 2.96 74.70% CL

11 29.04 2.79 70.42% CL

12 30.60 2.68 66.57% CL

13 32.03 2.62 63.03% CL

14 33.39 2.61 59.67% CK

15 34.69 2.65 56.46% CK

16 35.96 2.71 53.32% CK

17 37.26 2.82 50.11% CK

18 38.66 2.97 46.65% CK

19 40.22 3.20 42.80% CK

20 42.03 3.55 38.32% CJ

21 44.27 4.08 32.79% CJ

22 47.10 4.81 25.80% CJ

23 51.12 5.88 15.86% CI

24 57.54 7.36 0.00% CH

*Use this form to convert AM-PAC Daily Activity Inpatient Raw Scores

AM-PAC Inpatient Daily Activity Short Form Scoring Example

1. Add the number values associated with the response to each item. For example, items totals yield a

Raw Score of 9. 2. Match the raw score to the t-Scale scores (t-Scale score = 25.33, S.E. = 3.17). 3. Find the associated CMS % (CMS % = 79.59%). 4. Locate the correct CMS Functional Modifier Code, or G Code (G-code = CL)

NOTE: Each AM-PAC Short Form has a separate conversion table. Make sure that you use the correct conversion table when calculating scores.

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

AM-PAC Inpatient Daily Activity Short Form

Boston University AM-PAC 6 Clicks Daily Activity Inpatient Short Form

Please check the box that reflects your (the patients) best answer to each question.

How much help from another person does the patient currently need Total A lot A Little None

1. Putting on and taking off regular lower body clothing? 1 2 3 4

2. Bathing (including washing, rinsing, drying)? 1 2 3 4

3. Toileting, which includes using toilet, bedpan or urinal? 1 2 3 4

4. Putting on and taking off regular upper body clothing?

1 2 3 4

5. Taking care of personal grooming such as brushing teeth?

1 2 3 4

6. Eating meals? 1 2 3 4

Raw Score: CMS 0-100% Score:

Standardized Score: CMS Modifier:

Note: Use the AM-PAC Daily Activity Inpatient Short Form Conversion Table to convert raw scores.

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

AM-PAC Inpatient Basic Mobility Short Form Score Conversion Table

Boston University AM-PAC 6 Clicks

Basic Mobility Inpatient Short Form Score Conversion Table*

AM-PAC Raw Score

AM-PAC t-Scale Score

Scale Score Standard Error

CMS 0-100% score CMS G Code

Modifier

6 23.55 4.57 100.00% CN

7 26.42 4.33 92.36% CM

8 28.58 4.04 86.62% CM

9 30.55 3.69 81.38% CM

10 32.29 3.42 76.75% CL

11 33.86 3.22 72.57% CL

12 35.33 3.08 68.66% CL

13 36.74 2.99 64.91% CL

14 38.10 2.95 61.29% CL

15 39.45 2.93 57.70% CK

16 40.78 2.95 54.16% CK

17 42.13 3.03 50.57% CK

18 43.63 3.20 46.58% CK

19 45.44 3.55 41.77% CK

20 47.67 4.06 35.83% CJ

21 50.25 4.69 28.97% CJ

22 53.28 5.43 20.91% CJ

23 56.93 6.22 11.20% CI

24 61.14 6.94 0.00% CH

*Use this form to convert AM-PAC Basic Mobility Inpatient Raw Scores. AM-PAC Inpatient Basic Mobility Short Form Scoring Example

1. Add the number values associated with the response to each item. For example, items totals yield a Raw Score of 21.

2. Match the raw score to the t-Scale scores (t-Scale score = 50.25, SE = 4.69). 3. Find the associated CMS % (CMS % = 28.97%). 4. Locate the correct CMS Functional Modifier Code, or G Code (G code = CJ)

NOTE: Each AM-PAC Short Form has a separate conversion table. Make sure that you use the correct conversion table.

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

AM-PAC Inpatient Basic Mobility Short Form

Boston University AM-PAC 6 Clicks Basic Mobility Inpatient Short Form

Please check the box that reflects your (the patients) best answer to each question.

How much difficulty does the patient currently have

Unable A Lot A Little None

1. Turning over in bed (including adjusting bedclothes, sheets and

blankets)?

1 2 3 4

2. Sitting down on and standing up from a chair with arms (e.g.,

wheelchair, bedside commode, etc.)

1 2 3 4

3. Moving from lying on back to sitting on the side of the bed?

1 2 3 4

How much help from another person does the patient currently need Total A Lot A Little None

4. Moving to and from a bed to a chair (including a wheelchair)?

1 2 3 4

5. Need to walk in hospital room?

1 2 3 4

6. Climbing 3-5 steps with a railing?

1 2 3 4

Raw Score: CMS 0-100% Score:

Standardized Score: CMS Modifier:

Note: Use the AM-PAC Basic Mobility Inpatient Short Form Conversion Table to convert raw scores.

Swallowing

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

Boston University AM-PAC Basic Mobility Inpatient Short Form Score Conversion Table* (Without Stair Climbing)

Boston University AM-PAC Basic Mobility Inpatient Short Form Score Conversion Table*

(Without Stair Climbing)

AM-PAC Raw Score

AM-PAC t-Scale Score

Scale Score Standard Error

CMS 0-100% score CMS G Code

Modifier

5 23.59 4.58 100.00% CN

6 26.48 4.35 92.18% CM

7 28.66 4.07 86.29% CM

8 30.65 3.73 80.91% CM

9 32.44 3.48 76.07% CL

10 34.07 3.31 71.66% CL

11 35.66 3.24 67.36% CL

12 37.26 3.26 63.03% CL

13 38.96 3.41 58.44% CK

14 40.85 3.69 53.33% CK

15 43.03 4.11 47.43% CK

16 45.54 4.65 40.64% CK

17 48.47 5.25 32.72% CJ

18 51.97 5.91 23.26% CJ

19 56.04 6.58 12.25% CI

20 60.57 7.18 0.00% CH

NOTE: Each AM-PAC Short Form has a separate conversion table. Make sure that you use the correct conversion table.

AM-PAC Short Form Manual (v. 9) 2015, Trustees of Boston University, under license to CREcare, LLC. All rights reserved.

Boston University AM-PAC Basic Mobility Inpatient Short Form (Without Stair Climbing)

Boston University AM-PAC Basic Mobility Inpatient Short Form

(Without Stair Climbing)

Please check the box that reflects your (the patients) best answer to each question.

How much difficulty does the patient currently have

Unable A Lot A Little None

1. Turning over in bed (including adjusting bedclothes, sheets and

blankets)?

1 2 3 4

2. Sitting down on and standing up from a chair with arms (e.g.,

wheelchair, bedside commode, etc.)

1 2 3 4

3. Moving from lying on back to sitting on the side of the bed?

1 2 3 4

How much help from another person does the patient currently need Total A Lot A Little None

4. Moving to and from a bed to a chair (including a wheelchair)?

1 2 3 4

5. Need to walk in hospital room?

1 2 3 4

Raw Score: CMS 0-100% Score:

Standardized Score: CMS Modifier: