Re: PPS and Eval/Documentation issues

[Guest guest]

We have begun looking at the prospect of group evaluations which involve the disciplines who will likely see the patient. This could take place in the am and treatment could begin in the PM.

Cris Lease

Rehab director

Central Washington Hospital

Wenatchee, WA. 98801

PPS and Eval/Documentation issues

1. I would like to know how everyone is approaching the issue of PT/OT/ST

" non-reimbursable " evaluations under PPS. Since the minutes spent on

evaluation cannot be reported as part of the " treatment time " , I was wondering

how our colleagues have handled this situation - how did they

" restructure " / " redefine " their evaluation process? If you're looking for

optimizing the first 5-day assessment period, then you also HAVE to provide

treatment the same day of the evaluation. It seems to me that there is whole

lot to do during the first day- not only for the therapists also for the

patients. Has anyone found a game plan that works?

2. Does anyone have any information about any corresponding changes in the

documentation requirements because of what I mentioned above? I have heard

that several companies are developing some documentation tools that are

interdisciplinary in approach: cuts on repetition, quick and easy to complete,

and, most of all, acceptable to the FI and can stand the scrutiny of MRQs/

Medicare Reviews/ State Survey Processes. How do the Facility Intermediaries

feel about these informally proposed documentation changes?

R. Lazaro, PT, GCS

Stockton, CA

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[Guest guest]

According to MDS 2.0 questions and answers (update ):

" The time it takes to perform an initial evaluation and developing treatment

goals and plan of care CANNOT be counted as minutes of therapy received by

patient. However, reevaluations once a therapy session is underway may be

counted as minutes of therapy received " - If this is the case, evaluations

(regardless of where they were done) cannot be counted as therapy minutes.

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[Guest guest]

My understanding of the " eval " issue is that redundant evaluations are not

credited ... if the discharging facility has already done the eval, etc.,

Medicare will not credit further eval charges. In the cases where no evaluation

has been done (i.e., therapy has not yet started), the eval is counted as part

of the Rehab " minutes " tally.

We must rely on the discharge summaries and inter-facility communications to

avoid duplicity of effort. Is that an unreasonable expectation?

Have I understood this situation incorrectly?

Mark

--

Mark R Eliason, PT

meliason@...

Apple Valley, Minnesota, USA

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[Guest guest]

My understanding is that because the patient is transferring from an acute

(non-exempt) unit to a skilled or rehab (exempt) unit, a new evaluation or

re-evaluation must be done because it is viewed as two separate admissions in

the hospital setting. If we are NOT interpreting that requirement correctly

please let me know. Thanks.

>>> Mark R Eliason 07/29 4:03 PM >>>

My understanding of the " eval " issue is that redundant evaluations are not

credited ... if the discharging facility has already done the eval, etc.,

Medicare will not credit further eval charges. In the cases where no evaluation

has been done (i.e., therapy has not yet started), the eval is counted as part

of the Rehab " minutes " tally.

We must rely on the discharge summaries and inter-facility communications to

avoid duplicity of effort. Is that an unreasonable expectation?

Have I understood this situation incorrectly?

Mark

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[Guest guest]

Medicare regulations require an evaluation by the skilled nursing

facility in order to determine care plan goals, etc. The hospital

evaluation cannot substitute for the initial eval. In a perfect world

however, it would certainly be logical and efficient, especially if the

FIM (or similar tool) were used and both parties were credentialed for

interrater reliablility..

Re: PPS and Eval/Documentation

issues

My understanding is that because the patient is transferring

from an acute (non-exempt) unit to a skilled or rehab (exempt) unit, a

new evaluation or re-evaluation must be done because it is viewed as two

separate admissions in the hospital setting. If we are NOT interpreting

that requirement correctly please let me know. Thanks.

>>> Mark R Eliason 07/29 4:03 PM >>>

My understanding of the " eval " issue is that redundant

evaluations are not

credited ... if the discharging facility has already done the

eval, etc.,

Medicare will not credit further eval charges. In the cases

where no evaluation

has been done (i.e., therapy has not yet started), the eval is

counted as part

of the Rehab " minutes " tally.

We must rely on the discharge summaries and inter-facility

communications to

avoid duplicity of effort. Is that an unreasonable expectation?

Have I understood this situation incorrectly?

Mark

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[Guest guest]

I was under the impression that NO INITIAL evaluation minutes would

count towards your minutes... however, if you do a re-evaluation in

order to reassess and redirect the plan of care, you could include the

" re-eval " time in the minutes on a 14 day MDS. This was from a seminar

by FR & R consulting, Inc. The information came from Administar.

Someone please clarify this if it is different... almost ALL of my patients

come from the inpatient side of the hospital and have had therapy

started. If the other interpretation is correct... I could count the eval

minutes almost all of the time.

Thanks

Tina

Indpls, IN

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[Guest guest]

Thank you for that VERY CLEAR clarification.

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[Guest guest]

In a message dated 98-07-29 17:03:20 EDT, Mark Eliason writes:

<< My understanding of the " eval " issue is that redundant evaluations are not

credited ... if the discharging facility has already done the eval, etc.,

Medicare will not credit further eval charges. In the cases where no

evaluation

has been done (i.e., therapy has not yet started), the eval is counted as

part

of the Rehab " minutes " tally.

We must rely on the discharge summaries and inter-facility communications to

avoid duplicity of effort. Is that an unreasonable expectation?>>

PLEASE say it isn't true- I work at an LTAC hospital with a skilled unit, (for

now, anyway.) We have admissions from several different hospitals, LTCs, and

home. One of the most frequent referring hospitals has some therapists that

document patient function so low as to be laughable- someone that I can help

perform a stand pivot transfer with " moderate " assist of one, is documented by

them as requiring Max assist of 3 persons. In this case- it is

unreasonable....

marilyn

Marilyn , PT

Vencor Hospital- Houston Northwest

RSC-AMC '74

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[Guest guest]

Evaluations and Documentation is not JUST a reimbursement issue - remember we

have State Regulations, JCAHO, CARF, and our own Practice Standards to adhere

to - let's not lose sight that we are a profession, we're not making cars!

Ruth Rosenblatt, P.T.

Director of Physical Medicine & Rehabilitation

town University Hospital Medical Center

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[Guest guest]

In a message dated 8/3/98 8:11:11 AM Pacific Daylight Time, Rbrosenb@...

writes:

<< Evaluations and Documentation is not JUST a reimbursement issue - remember

we

have State Regulations, JCAHO, CARF, and our own Practice Standards to adhere

to - let's not lose sight that we are a profession, we're not making cars! >>

This is precisely the point why I brought up this issue. I am sure that every

one of us wants to make sure that we deliver care that is skilled, necessary,

appropriate and ethical.

So I again pose my original question: I'd like to know how our colleagues have

handled the fact that (initial) evaluation minutes are not counted towards

determining the number of therapy treatment minutes. Because of this, one has

to perform treatment on the same day of the evaluation or that day will not be

counted (and if it is a 5 day initial assessment then the patient gets a lower

RUGS classification). One colleague responded by saying that they do the

evaluation in the morning and treatment in the afternoon - which is fine if

you have the patient admitted in the morning - how about those who get

admitted late? (even worse, late on Friday) Has anyone attempted to streamline

the evaluation process and documentation to get a more concise yet complete

evaluation (maybe even interdisciplinary) in a reasonable amount of time to

give more time for treatment? How did the FI respond to this documentation

change?

I look at obtaining the appropriate RUGS classification as a means of

providing the care that the patient appropriately needs. However you look at

it we need to look at these issues as well to be able to deliver the right

care. That's just the reality of it.

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[Guest guest]

In response to the question regarding a " Transfer Form " - I don't know for

sure if this would pass with all the reviewing bodies - I don't think so -

you would have to do a test with your state Medicare intermediary, your state

Medicaid review (if different), and your state P.T. licensing board. The

problem with all this is that it is very often interpreted on the local level.

When you want to facilitate change you sometimes have to put yourself at some

risk. This section and the APTA should certainly make some policy

recommendations to all these review bodies.

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[Guest guest]

Why not evaluate and treat at the same time. When I evaluate as well as the

other therapists on my team, treatment is also occuring: I'm instructing

technique for functional mobility in the usual and ordinary fashion right

along with the eval process. Just as any therapist should do with any

treatment session be it the first, tenth, or thirtieth. Taking the patient

through bed mobility, transfers, and gait/balance activities is both

functional and evaluative.

True, the review of discharge summaries from the hospital and the sitting down

to write the plan of care will not be accountable in therapy minutes. However

by treating while evaluating the PT will be able to see the functional

deficits and quickly obtain the objective measurements of balance, neuro-

muscular imbalances, and anomalies of posture and joint mechanics, etc needed

to set the initial baseline.

Further from what I understand transdisciplinary documentation is perfectly

acceptable. I am not certain, but I'm not sure the HCFA 700 form has ever

been absolutely mandatory, we switched to them only two years ago. I'm sure

someone can set me straight on this last point.

Carey, PT

Dir. of Rehab

Beverly Healthcare

Winston-Salem, NC

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[Guest guest]

If a " Transfer Report " was created and completed by the Acute therapist, which

indicates:

1. functional ratings at time of transfer,

2. indicates where the patient is being transferred from and to,

3. indicates where the mobility reassessment can be found after transfer to TSU

(i.e., on the MDS form),

4. and also lists revised goals,

could the Skilled PT then initiate treatment immediately, after referring to the

acute PT's transfer information for the MDS form, because the Acute therapist

did it immediately prior to transfer as part of her final transfer or discharge

documentation note? (Assuming that it is done within a reasonable time frame

i.e., within 24 hrs of actual transfer and no significant alteration in medical

status has occurred)?

>>> 08/03 9:43 AM >>>

Evaluations and Documentation is not JUST a reimbursement issue - remember we

have State Regulations, JCAHO, CARF, and our own Practice Standards to adhere

to - let's not lose sight that we are a profession, we're not making cars!

Ruth Rosenblatt, P.T.

Director of Physical Medicine & Rehabilitation

town University Hospital Medical Center

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[Guest guest]

 Just a reminder to the list to check on the SOURCE DOCUMENTS when

discussing regulations - especially Medicare. The final rule for this

thread is:

Medicare Program: Prospective Payment System and

Consolidated Billing for SNF: Final Rule. 42 CFR Parts 409, et al. Pages

26252 - 26316. Published May 12, 1998.

You can find it at the Federal Register or from our site at:

<http://www.thefocusgroup.net/news.htm#HCFA

Downloads>

If you need Adobe Acrobat to view this, you can download Acrobat Reader

from

<www.adobe.com>

R. Kovacek, MSA, PT

KovacekManagementServices, Inc.

The FOCUS Group, Inc.

20225 Danbury Lane

Harper Woods, MI 48225

Fax

Email Pkovacek@...

<http://www.theFOCUSgroup.net>

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[Guest guest]

,

You wrote:

> Further from what I understand transdisciplinary documentation is perfectly

> acceptable. I am not certain, but I'm not sure the HCFA 700 form has ever

> been absolutely mandatory, we switched to them only two years ago. I'm sure

> someone can set me straight on this last point.

>

I believe the requirements for use of the 700/701 forms is up to the discretion

of your fiscal intermediary (FI) ... some require them, some require other

documentation. We've found them to be useful as a " first defense " when

additional documentation is requested. (BTW, I have seen some contract

companies use the 700 as their *sole* evaluation documentation, which I don't

like and is not the intended purpose of the 700. What do others think?)

> Why not evaluate and treat at the same time. ...

> ... Just as any therapist should do with any

> treatment session be it the first, tenth, or thirtieth.

>

I would certainly agree with your point. It is very difficult to separate

evaluation and treatment, and in many cases using an " Eval " charge is simply a

billing issue designed to " load " an extra charge for the time/cost of opening

and documenting a new case. In this age of limited visits and constant

scrutiny, evaluation and education is (or should be) thoroughly integrated

within each moment of each session.

However, having said that, what about " therapy extenders " , including PTAs??

If integrated/ongoing evaluation is preferred or even necessary, how does the

non-evaluative role of the PTA fit-in?

--

Mark R Eliason, PT

meliason@...

Apple Valley, Minnesota, USA

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[Guest guest]

Re: Initial PT Eval When Payor Refuses to Allow Payment

It is my understanding that acquiring and recording the baseline information

which

we call an " evaluation " is a basic standard of participation in Medicare, JCAHO,

and CARF. Further, in some states in which I have been licensed, it is required

also. Although APTA is a voluntary participation organization, its standards

also

require the process and the document.

Therefore, a physical therapist practicing properly does not have the latitude

to

NOT prepare an initial baseline document, regardless of whether the examination

and

testing is a separate visit.

The issue before us is actually one of economics: Payors have decided to reduce

their expenditures, and are refusing to pay for evaluations. They are

attempting

to control " demand " which has traditionally been controlled by the clinician and

patient. They cannot simply tell the public, " We are short of money, so we're

rationing your access to services. " because the public would revolt. Therefore,

payors have told their staffs to stop the flow of dollars, and blame it on

providers' documentation, techniques, expenses, or anything available.

A receiving provider must prepare an evaluation. Otherwise we are only

order-following technicians.

W. Hillyer, MBA, MSM, PT

Hillyer Associates, Inc.

Town & Country Physical Therapy, Inc.

P.O. Box 467 Millsboro, DE 19966

Fax

rwhpt@...

admin@...

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[Guest guest]

Well said, . The goal to set in this situation is to make your evaluation

as efficient as possible. Using the acute care d/c eval as a guide, a therapist

should be able to select which tests and measures are required to verify the

accuracy of that evaluation at the same time as treatment is being provided to

advance a patient's function. Subtracting some portion of your treatment time to

represent the time spent doing the evaluation allows you to meet standards of

practice, provide ethical care and bill for treatment provided.

>>> " W. Hillyer " 08/06/98 05:49am >>>

Re: Initial PT Eval When Payor Refuses to Allow Payment

It is my understanding that acquiring and recording the baseline information

which

we call an " evaluation " is a basic standard of participation in Medicare, JCAHO,

and CARF. Further, in some states in which I have been licensed, it is required

also. Although APTA is a voluntary participation organization, its standards

also

require the process and the document.

Therefore, a physical therapist practicing properly does not have the latitude

to

NOT prepare an initial baseline document, regardless of whether the examination

and

testing is a separate visit.

The issue before us is actually one of economics: Payors have decided to reduce

their expenditures, and are refusing to pay for evaluations. They are

attempting

to control " demand " which has traditionally been controlled by the clinician and

patient. They cannot simply tell the public, " We are short of money, so we're

rationing your access to services. " because the public would revolt. Therefore,

payors have told their staffs to stop the flow of dollars, and blame it on

providers' documentation, techniques, expenses, or anything available.

A receiving provider must prepare an evaluation. Otherwise we are only

order-following technicians.

W. Hillyer, MBA, MSM, PT

Hillyer Associates, Inc.

Town & Country Physical Therapy, Inc.

P.O. Box 467 Millsboro, DE 19966

Fax

rwhpt@...

admin@...

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[Guest guest]

Mark,

Good question:

" what about " therapy extenders " , including PTAs??

If integrated/ongoing evaluation is preferred or even necessary, how does the

non-evaluative role of the PTA fit-in? "

Reminds me of a situation which arose in my clinic last year. Because of time

constraints PTAs and COTAs were asked to help the therapists catch up on the

quarterly screens. Higher-ups instructed the therapists in our clinic to stop

that practice; the therapists were told that was an evaluative procedure and

could not be performed by the assistants. A copy of a letter from the state's

PT licensing board supported the higher-ups in this opinion. After digging

out the practice acts for both disciplines I found language referring to PTAs

and COTAs (along with a list of techniques assistants could perform under

supervision) which stated " and assisting the PT/OT with an evaluative

procedure; such as accruing information, taking measurements, etc.

Therefore I modified the assistants role in the screen by allowing them to

collect the basic data for the form (name, diagnoses, dates of admit. etc) as

well as nursing and/or care plan notes indicative of significant changes, ROM

measurements of residents with known contractures, and then leaving the rest

for the therapist to decide to eval or not to eval. The crux of a procedure

identified as evaluative is the INTERPRETATION of the available data, Dr's

referral and accompanying diagnoses. Then from the INTERPRETATION the

determination of the most appropriate treatment plan, frequency and duration,

and finally expected functional outcomes.

So to answer more directly, I plan for the role of the assistant to remain

the same. I expect the supervising therapist to make it his/her business to

know the skill level of his/her assistant, to be clear with the assistant

which treatment techniques to employ, to be sure the assistant understands the

expected rate of progress, and for the assistant to provide regular progress

updates to the therapist and to refer back for re-eval when the resident is

not progressing as planned. I have had the pleasure of working with several

fine PTAs who are quite capable of " assisting with assessment " during their

treatment sessions within their training and skill level.

And on occassion they even point out something I missed...( did I say that?)

Carey, PT

Director of Rehab

Winston Salem, NC

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[Guest guest]

At 10:32 PM 8/6/98 -0400, you wrote:

>Mark,

>

>Good question:

>

> " what about " therapy extenders " , including PTAs??

>If integrated/ongoing evaluation is preferred or even necessary, how does the

>non-evaluative role of the PTA fit-in? "

>

>Reminds me of a situation which arose in my clinic last year. Because of

time

>constraints PTAs and COTAs were asked to help the therapists catch up on the

>quarterly screens. Higher-ups instructed the therapists in our clinic to

stop

>that practice; the therapists were told that was an evaluative procedure and

>could not be performed by the assistants. A copy of a letter from the

state's

>PT licensing board supported the higher-ups in this opinion. After digging

>out the practice acts for both disciplines I found language referring to PTAs

>and COTAs (along with a list of techniques assistants could perform under

>supervision) which stated " and assisting the PT/OT with an evaluative

>procedure; such as accruing information, taking measurements, etc.

>Therefore I modified the assistants role in the screen by allowing them to

>collect the basic data for the form (name, diagnoses, dates of admit. etc) as

>well as nursing and/or care plan notes indicative of significant changes, ROM

>measurements of residents with known contractures, and then leaving the rest

>for the therapist to decide to eval or not to eval. The crux of a

procedure

>identified as evaluative is the INTERPRETATION of the available data, Dr's

>referral and accompanying diagnoses. Then from the INTERPRETATION the

>determination of the most appropriate treatment plan, frequency and duration,

>and finally expected functional outcomes.

>

>So to answer more directly, I plan for the role of the assistant to remain

>the same. I expect the supervising therapist to make it his/her business to

>know the skill level of his/her assistant, to be clear with the assistant

>which treatment techniques to employ, to be sure the assistant understands

the

>expected rate of progress, and for the assistant to provide regular progress

>updates to the therapist and to refer back for re-eval when the resident is

>not progressing as planned. I have had the pleasure of working with several

>fine PTAs who are quite capable of " assisting with assessment " during their

>treatment sessions within their training and skill level.

>

>And on occassion they even point out something I missed...( did I say that?)

>

> Carey, PT

>Director of Rehab

>Winston Salem, NC

>

>Again, not to beat a dead horse, but what you can do will ultimately

depend on what your particular state's practice act allows the PT, PTA and

aide to do. What you are doing may not be legal in other states. In NY, for

example, PTA's may not do any testing. That includes taking ROM

measurements. I believe that basic data collection is ok, at least in NY. I

think that therapists, legally and ethically, need to check with their own

state boards about what is permissable in their states with respect to the

use of assistive personnel.

- Laurie

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[Guest guest]

I work for a Rehab Agency in Missouri and we recently implemeted an

interdisciplinary screen for our long-term care facilities. The screen is

designed with yes/no questions based on changes in the resident's functional

status from the previous quarter. Any discipline (therapist or assistant)

can complete the screen for all three disciplines, as they are simply

obtaining this information fro the medical record, conversation with nursing

staff, review of incident reports, etc. The only decision made from this

screen is whether or not an eval is indicated (not the what treatment is

needed). That is what is determined during the skilled evaluation. We had

had to educate all of our staff in what things trigger the need for an eval

and feel that assistants are able to make those decisions. The evaluating

therapist still has the final decision on whether or not skilled therapy is

indicated.

I'm curious to hear if others utilize assistants to screen. I look forward to

your input.

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[Guest guest]

We use ass't regularly to perform screens, and ours is a yes/no format, but

discipline specific. would you be able to share yours?

Caren Betz PT,GCS

Facil Rehab Dir

Hays Nrsg Ctr

San Marcos, TX 78666

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[Guest guest]

We also use an interdisciplinary screening in our SNF. The process is very

similar to what

your system seems to be. Assistants, both OT and PT, are included.

Objective data from the

previous few months regarding function as well as resident and nursing

subjective input is placed on the screen tool. The screen tool has three

options: Eval is indicated (when obvious change in function is

present), No need for treatment (when no apparent change in status is

evident), and Recommend

further screening by speech, PT or OT (when the individual doing the screen

is unsure). The therapist will then use this tool and write on the chart

screen document. Hope this helps.

Jeff

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> From: Kaerlita@...

> To: ptmanager@...

> Subject: Re: PPS and Eval/Documentation issues

> Date: Sunday, August 09, 1998 4:55 PM

>

> I work for a Rehab Agency in Missouri and we recently implemeted an

> interdisciplinary screen for our long-term care facilities. The screen

is

> designed with yes/no questions based on changes in the resident's

functional

> status from the previous quarter. Any discipline (therapist or

assistant)

> can complete the screen for all three disciplines, as they are simply

> obtaining this information fro the medical record, conversation with

nursing

> staff, review of incident reports, etc. The only decision made from this

> screen is whether or not an eval is indicated (not the what treatment is

> needed). That is what is determined during the skilled evaluation. We

had

> had to educate all of our staff in what things trigger the need for an

eval

> and feel that assistants are able to make those decisions. The

evaluating

> therapist still has the final decision on whether or not skilled therapy

is

> indicated.

>

> I'm curious to hear if others utilize assistants to screen. I look

forward to

> your input.

>

>

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