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By: Christa Roberts, PT, MPT, RAC-CT and Eleisha Wilkes RN, RAC-CT

The details of proposed rule LSA #18-251 were published on October 4, 2018 by the Indiana Family and Social Services Administration, and introduces plans to revamp the Medicaid program integrity requirements. LSA #18-251 is extensive and impacts the bulk of business facets for Indiana Medicaid providers, including claims filing time limits, medical record retention, provider enrollment, sanctions, audits, and provider appeals.

LSA #18-251 consolidates existing rules, clarifies requirements and adds new program integrity requirements affecting Medicaid providers. Some of the more significant changes are as follows:

  • Currently, providers have up to one year from the date of service to submit an original claim; however, under the proposed rule, providers would have to submit claims for payment within 180 days of the date of service or the claim would be denied (effective January 1, 2019).
  • Providers will be subject to a medical record retention for financial records period of 3 years following submission to Indiana Medicaid (there is currently no record retention policy).
  • The proposed rule consolidates and adds new provider enrollment requirements.
  • Medicaid payment suspension procedures authorized by Federal law are outlined.
  • A new section is added regarding provider exclusions and readmissions (specifically, the rule lists various offenses that could result in an exclusion and sets a duration of up to 3 years for such exclusion).
  • A new section describes prepayment review processes and procedures (previously only available in agency manuals).
  • The proposed rule revises existing Medicaid overpayment provisions to align with changes in Indiana law (adds a 3-year look back period for audits initiated after July 2, 2019, though may be extended to 7 years under certain circumstances).
  • Administrative appeals procedures are consolidated and changed to align with Indiana law.

LSA #18-251 is open for public comment until the public hearing, which is preliminarily scheduled for October 26, 2018. A copy of the proposed rule can be reviewed at: www.in.gov/legislative/iac/20181003-IR-405180251PRA.xml.pdf

 


 

Speak with your doctor to find out how therapy could benefit you!

In today’s climate of scrutiny and burden of justifying therapy services and skilled stays, it is becoming increasingly critical for nursing to take charge in documenting each patients’ skilled needs. Specifically, what should the nurses be documenting in the medical record? How specific is the training for your nursing staff?

Before you answer, remember that the rules of documentation have changed greatly in the past 3 years. Even now, something that is the norm could likely be scrutinized in future audits. Whether you’ve had ADRs and denials for payment, it’s not a matter of if…but when. Those of us that are laser focused on the regs and changing climate of our industry know why things have altered so greatly. However, I have found that keeping to the basics is the best way to explain documentation expectations that are critical for justifying a skilled stay. I have also had my own documentation scrutinized, reviewed my fair share of ADRs and audited countless charts for congruent nursing and therapy documentation. The ideas below are a culmination of questions, mistakes, training and conversations by nurses, administrators and corporations. Try using these proven strategies to improve your skilled nursing documentation to support therapy services, and ultimately support the skilled stay:

The Do’s and Don’ts:

 

 

Justifying a Skilled Stay:

Nurses must ask themselves the following questions (and document the answers) each and every day:

  • Why is this patient here?
  • What is preventing this patient from going home right now? Could this patient go home right now and be safe and independent? Why not?
  • What are you doing that would not or could not happen for this patient at home?
  • Have you noticed this patient improving in any aspect of mobility? Self-care? Communication?
    *Even minor improvements need to be noticed and documented.
  • Why is this patient receiving PT, OT or ST?
  • What would/could happen if this patient was not an inpatient receiving care?
  • What are all of the medical complexities that are impacting this patient’s recovery. Explain the multiple conditions that you are managing. What is making this patient’s recovery take this amount of time?

 

RUG Supportive Documentation: Do they know the Why?

  • Do your nurses know what a RUG level is? Try asking several nurses on your rehab unit if they know what a RUG level is…you may be surprised by how many do not know. Do your nurses understand the importance of ADL coding?  Nurses need to understand the basic reimbursement system for the stay in order to understand the importance of the documentation. Provide a basic PPS inservice to help your staff understand how the MDS, nursing notes and therapy notes combined determine the RUG level. The medical record must make sense—nursing notes and therapy notes must support the coding on the MDS.
  • Do your nurses understand that PLOF is critical for establishing all goals? What was the patient doing prior to the hospitalization? Was he/she completely independent with all self-care and mobility? What about higher level tasks—grocery shopping, driving, cooking, laundry?
  • What does the patient need to be able to safely do prior to returning home? What impairments are preventing the patient from doing these things?
  • Are your nurses documenting their skilled nursing interventions? What if therapy services are denied? Will your nursing documentation prove a skilled nursing level? Provide nursing education regarding specific skilled nursing interventions. Provide sample documentation that reflects skilled nursing interventions.

I hope that these tips and questions help to gauge the level of training and direction for our SNF nurses. Now more than ever, you deserve to be paid for the great care you provide.

HTS is committed to the success of our clients and partners. That is why we provide on-going support and education for our therapists, nurses, and the entire IDT. With the changing expectations for justified skilled stays, make sure you are partnered with a dynamic, progressive therapy provider who will support and enhance your position in our post-acute care market.


Guest Blog

Cassie Murray, OTR, QCP, IASSC CYB 
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This led to her successful career path in occupational therapy.

To contact the author: cmurray@htstherapy.com | 800-486-4449 ext 210 | www.htstherapy.com

Are you making evaluation complexity coding too complex? Don’t make this more difficult than it is! Instead of trying to navigate all of the fancy terminology being used to educate us on how to correctly code complexity, let’s try looking at it plain and simple.

Here are some common problems that have already been discovered and tips for improvement (in plain language):

1. Clinical Decision Making
Clinical reasoning and decision making occurs throughout the evaluation as the clinician decides which questions to ask, what assessment tools and tests to use, identifying goals, deciding what modifications are necessary, etc. Keeping in mind all decisions being made through the course of the evaluation and documenting/justifying those decisions will provide support of the complexity chosen.

2. Patient History
Consider what you need to know about the patient’s medical history to make clinical decisions and develop a skilled POC. Be sure to clearly document all aspects of the patient’s history that you used to determine the plan and goals. Explain specifically how the patient’s medical history is impacting the current POC and your approaches to therapy intervention.

3. Occupational Profile
OT should document detailed description of the occupational profile. Use an Occupational Profile worksheet to assist. If you don’t already have a worksheet, create one for your OTs to help guide the narrative within the documentation. AOTA has provided an occupational profile template. Utilize the available tools from your associations and simply describe the areas within the evaluation.

4. Formal Tests
In order to accurately code the complexity of the evaluation, formal testing must be completed. Make frequently used tests readily available. With the new coding, it is necessary to go ahead and complete at least one formal test on day 1 with the initial evaluation and summarize the results within the POC. This is another component to accurately coding the complexity of the evaluation. Be sure to update the results of the selected tests at re-cert and DC as well.

5. All Criteria Required
Remember that you must code “down” if all criteria for the complexity level is not met. All criteria must be met (and documented) for each complexity level.

Keep in mind that the evaluation is still the same evaluation! Consider that by coding the complexity level, this is really just a way to ensure that we are documenting more thoroughly and justifying our services. I think that often we take for granted the skill and sophistication that we provide. Document your thinking process as you are creating the plan for your patients. No one else is able to do what you do!


Guest Blog

Cassie Murray, OTR, IASSYC CYB 
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This lead to her successful career path in occupational therapy.

To contact the author: cmurray@htstherapy.com | 800-486-4449 ext 210 | www.htstherapy.com