Therapy's role under PDGM (Part 2)

Care coordination, effective documentation must measure up under new payment model

EDITOR’S NOTE: Our summer series of blog posts on the future of therapy under PDGM continues today, with a look at the importance of care coordination and documentation. Look for these posts each Monday.

Care coordination and effective documentation will be the wheels carrying therapy forward under Medicare’s new payment model, when reimbursement no longer hinges on therapy volume.

If home health agencies get it right, therapy has the potential to be something of a Cinderella story under the Patient-Driven Groupings Model (PDGM), according to Home Health Solutions Owner and President J’non Griffin.

All the elements of the classic tale are in place; once highly favored, therapy may be temporarily considered of far less value under changed circumstances, but its true value will be revealed in the end through a transformation process.

“Therapy is an integral part of home care, and that isn’t going to change,” said J’non Griffin, Home Health Solutions President and Owner. “But in this Cinderella story, the transformation is going to have to be in the way we use therapy as an essential and valuable component of the assessment and care planning processes.

“We're going to need to transition away from unnecessary utilization to drive reimbursement and rely on therapy as part of a thorough and effective overall care coordination process to improve patient outcomes."

Is therapy necessary?

Therapy still has a crucial role to play in the comprehensive assessment at Start of Care, when a thorough and objective evaluation can determine where and how skilled therapy services may improve the patient’s condition or prevent further decline.

But home care providers have not always been effective in documenting the relationship between the patient’s functional impairment and need for therapy services, or in clearly demonstrating at each visit exactly how therapy is addressing those needs, J'non said. Results from Targeted Probe and Educate (TPE) reviews conducted by Medicare administrative contractors reveal home care agencies frequently fail to establish the medical need for skilled therapy services, or provide any documentation showing an initial therapy evaluation has occurred. Many times therapy visit notes do not tie into the overall Plan of Care, and fail to indicate how the skilled service being provided on that visit is expected to help meet identified goals.

“The need for gait training or therapeutic exercise may be obvious to everyone who is caring for that patient but without the proper documentation establishing the need, and without specifically showing how the therapy provided will fit into the Plan of Care, it is not considered medically necessary,” J’non said.

“And agencies are not going to be able to afford to provide any unnecessary skilled therapy services under PDGM.”

Care coordination One of the important new factors determining reimbursement under PDGM will be a patient's level of functional impairment, determined in particular by certain M items from the OASIS assessment. In an ideal situation, therapy and skilled nursing will work together to make those important assessments and decide how to best address the patient's specific needs for better outcomes, J'non said. But there is room for improvement at many home health agencies in care coordination efforts. Direct contradictions within the patient’s medical record continue to be a problem, calling into question whether disciplines are effectively communicating about patients and contributing as a team to the care and services provided.

For example, J’non said a nurse may indicate the patient is bed bound while the therapist identifies the patient as ambulatory, or some of the GG items coded on OASIS may not align with the therapy evaluation in the medical record.

“Agencies are going to need to strive for more consistency,” J’non said. “It’s more important than ever to clean up these issues.”

Documentation Effective documentation will be the key to establishing medical necessity for therapy visits under PDGM , J’non said.

“There must be clear evidence in the documentation that therapy is supporting the Plan of Care, and that each visit is an integral step toward achieving the home care episode’s individualized and patient-centered goals,” she said.

She offered the following tips for establishing the medical necessity of skilled therapy services.

5 Documentation Tips

1. Comprehensive, measurable and evidence-based tests should be used at the Start of Care to determine specific needs and set measurable goals. Documentation should show which tests were used.

2. Cite those test results to clearly state the patient needs which have been identified. All services provided must be clearly tied to those needs.

3. Base the Plan of Care on the needs identified. Include the skilled services addressing those needs on the Plan of Care for the physician to approve.

4. Be specific. Clearly state how specific services are expected to improve the patient’s condition or prevent decline.

5. Notes for visits should show each time how the specific therapeutic exercises which are performed during that visit are specifically tied into the Plan of Care. What will they achieve?

Need more documentation help?

Want more documentation tips? Check out our Review Choice 101 digital guide, a collection of 101 documentation tips to help your agency pass reviewer scrutiny. It’s sold in our online store, The Solutions Shop, for $99.