Re: Re: Inpatient Rehab. 3 hours

[Guest guest]

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come weekends

when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to miss

three hours for the day. We've made the same efforts to work around Xray for

tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

The physiatrist really has to be on board with this and cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit down

with the doc (mabye the director of the unit?) and explain this, and how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes we

have encountered his partners who are covering for him and they are not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't understand

the process. It has to be a team effort. Medicare really emphasizes this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

Ok, but lets say this scenario: The pt. refuses stating she is ill. The

physician has not assessed to determine the impact of the illness on her

participation in therapy. He has opined, and I agree, that it should be the

people that have assessed this condition that decide if it warrants an excuse

from participation in therapy. Should the physician make a visit everytime a

patient has a physical complaint and asks to forgo therapy? I'm not certain why

it would not be sufficient that the whole team document that the patient is

vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss wrote:

The physiatrist really has to be on board with this and cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit down

with the doc (mabye the director of the unit?) and explain this, and how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes we

have encountered his partners who are covering for him and they are not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't understand

the process. It has to be a team effort. Medicare really emphasizes this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

Jim et. al. -

I've been in several meetings of the Florida Society for Rehabilitation

at which representatives of the Medicare intermediary have asked, " Why

should this patient be in an IRF instead of just going to an SNF? "

One major criteria for a facility to be certified as an Inpatient

Rehabilitation Facility is that each patient is under the care of a

rehabilitation doctor. Another criteria is that the patient " ...requires,

receives, and tolerates... " three hours per day of skilled rehab services on

five out of any seven consecutive days. If a retrospective audit of patient

days and minutes shows that the facility has failed to provide this, then

the facility can be decertified, and will cease to be an IRF.

That would cause a loss of a high level rehab facility to the community. It

would also cause the loss of jobs for therapists who really believe in

providing intensive rehab. Of course, since IRFs need rehabilitation

doctors, if the facility loses its certification, the Medical Director

position is no longer necessary, either.

Therefore, in addition to ensuring appropriate skilled professional

services, each therapist and physician in an IRF carries part of the burden

for ensuring the facility's compliance with standards. It's in their

personal interest.

Hope this helps!

Dick Hillyer, PT

W. Hillyer,PT, DPT, MBA, MSM

Hillyer Consulting

Cape Coral, FL

_____

From: PTManager [mailto:PTManager ] On Behalf

Of Jim Arceneaux

Sent: Monday, August 20, 2007 7:18 PM

To: PTManager

Subject: Re: Re: Inpatient Rehab. 3 hours

Ok, but lets say this scenario: The pt. refuses stating she is ill. The

physician has not assessed to determine the impact of the illness on her

participation in therapy. He has opined, and I agree, that it should be the

people that have assessed this condition that decide if it warrants an

excuse from participation in therapy. Should the physician make a visit

everytime a patient has a physical complaint and asks to forgo therapy? I'm

not certain why it would not be sufficient that the whole team document that

the patient is vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss <jweissingalls (DOT) <mailto:jweiss%40ingalls.org> org> wrote:

The physiatrist really has to be on board with this and cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit down

with the doc (mabye the director of the unit?) and explain this, and how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes we

have encountered his partners who are covering for him and they are not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't understand

the process. It has to be a team effort. Medicare really emphasizes this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> kateselsnycap (DOT) <mailto:katesels%40nycap.rr.com> rr.com 8/18/2007 3:06

PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Kateselsnycap (DOT) <mailto:Katesels%40nycap.rr.com> rr.com

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

I would agree. To have the physician be expected to write a hold order every

time a patient is not feeling well enough to participate is overkill and places

an excessive burden on both the physician and staff.

Carol Rehder, PT

Manager, Physical Therapy

Genesis Medical Center

rehder@genesis@...

>>> " Jim Arceneaux " 8/20/2007 6:17 PM >>>

Ok, but lets say this scenario: The pt. refuses stating she is ill. The

physician has not assessed to determine the impact of the illness on her

participation in therapy. He has opined, and I agree, that it should be the

people that have assessed this condition that decide if it warrants an excuse

from participation in therapy. Should the physician make a visit everytime a

patient has a physical complaint and asks to forgo therapy? I'm not certain why

it would not be sufficient that the whole team document that the patient is

vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss wrote:

The physiatrist really has to be on board with this and cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit down

with the doc (mabye the director of the unit?) and explain this, and how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes we

have encountered his partners who are covering for him and they are not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't understand

the process. It has to be a team effort. Medicare really emphasizes this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

I guess my response to this one would be.. yes, it's a burden, but it

still is the responsibility of all involved to document. Let me tell you

first-hand that the denials process is a much bigger burden!!

At the very least, the physician needs to document in his/her note that

the patient missed therapy for whatever reason -- even if there is no

hold order and even if the MD didn't physically assess the pt on this.

That would indicate communication with the therapy staff. Aren't your

physicians seeing the patients daily anyway? There needs to be 24-hr

availability of a physician for a pt to be on inpt rehab anyway, so they

should at least be able to document!

This is also not meant to address pt refusals -- I am talking about

those cases where there is actually a medical reason that the pt cannot

participate (low BP, blood sugar levels, awaiting results of x-rays to

r/o fractures, etc etc). We emphasize to our patients from day one that

they are expected to come to all of their therapy sessions, and general

malaise, etc is not enough to not come down. We tell them that if they

don't feel like coming, we will be making up the session later in the

day, so if it is just a matter of pt refusals, this may help reduce

that. This way they know they can't just " get out " of it, because we'll

get them in later anyway.

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL 60426

>>> rehder@... 8/21/2007 8:36 AM >>>

I would agree. To have the physician be expected to write a hold order

every time a patient is not feeling well enough to participate is

overkill and places an excessive burden on both the physician and

staff.

Carol Rehder, PT

Manager, Physical Therapy

Genesis Medical Center

rehder@genesis@...

>>> " Jim Arceneaux " 8/20/2007 6:17 PM >>>

Ok, but lets say this scenario: The pt. refuses stating she is ill.

The physician has not assessed to determine the impact of the illness on

her participation in therapy. He has opined, and I agree, that it

should be the people that have assessed this condition that decide if it

warrants an excuse from participation in therapy. Should the physician

make a visit everytime a patient has a physical complaint and asks to

forgo therapy? I'm not certain why it would not be sufficient that the

whole team document that the patient is vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss wrote:

The physiatrist really has to be on board with this and

cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit

down

with the doc (mabye the director of the unit?) and explain this, and

how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes

we

have encountered his partners who are covering for him and they are

not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't

understand

the process. It has to be a team effort. Medicare really emphasizes

this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work

around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

Availability 24 hours is one thing, but to expect the physician to have to

document or write an order for when a pt. has a case of loose bowels is another.

There is no requirement that the physician see the patient every day.

Jim Arceneaux, LOTR

Weiss wrote:

I guess my response to this one would be.. yes, it's a burden, but it

still is the responsibility of all involved to document. Let me tell you

first-hand that the denials process is a much bigger burden!!

At the very least, the physician needs to document in his/her note that

the patient missed therapy for whatever reason -- even if there is no

hold order and even if the MD didn't physically assess the pt on this.

That would indicate communication with the therapy staff. Aren't your

physicians seeing the patients daily anyway? There needs to be 24-hr

availability of a physician for a pt to be on inpt rehab anyway, so they

should at least be able to document!

This is also not meant to address pt refusals -- I am talking about

those cases where there is actually a medical reason that the pt cannot

participate (low BP, blood sugar levels, awaiting results of x-rays to

r/o fractures, etc etc). We emphasize to our patients from day one that

they are expected to come to all of their therapy sessions, and general

malaise, etc is not enough to not come down. We tell them that if they

don't feel like coming, we will be making up the session later in the

day, so if it is just a matter of pt refusals, this may help reduce

that. This way they know they can't just " get out " of it, because we'll

get them in later anyway.

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL 60426

>>> rehder@... 8/21/2007 8:36 AM >>>

I would agree. To have the physician be expected to write a hold order

every time a patient is not feeling well enough to participate is

overkill and places an excessive burden on both the physician and

staff.

Carol Rehder, PT

Manager, Physical Therapy

Genesis Medical Center

rehder@genesis@...

>>> " Jim Arceneaux " 8/20/2007 6:17 PM >>>

Ok, but lets say this scenario: The pt. refuses stating she is ill.

The physician has not assessed to determine the impact of the illness on

her participation in therapy. He has opined, and I agree, that it

should be the people that have assessed this condition that decide if it

warrants an excuse from participation in therapy. Should the physician

make a visit everytime a patient has a physical complaint and asks to

forgo therapy? I'm not certain why it would not be sufficient that the

whole team document that the patient is vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss wrote:

The physiatrist really has to be on board with this and

cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit

down

with the doc (mabye the director of the unit?) and explain this, and

how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes

we

have encountered his partners who are covering for him and they are

not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't

understand

the process. It has to be a team effort. Medicare really emphasizes

this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work

around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.

[Guest guest]

This discussion is becoming quite an argument, I feel. Don't forget,

neither myself or the others came up with these rules -- I feel they are

unreasonable as well, so don't shoot the messengers. That said -- I

will reiterate that while the MD may not have to write hold orders for

every little thing, they should still be documenting it in their notes,

and why a patient missed 3 hours that day! And, I won't say that those

orders need to be written, but in the best case scenario, they would be.

I cannot predict what each FI would do in an audit, so it's best to

cover yourself as well as you can.

Also, I guess I would finish by saying that you can't kill yourself

trying to be responsible for what the MD writes. Just make sure the

therapists are documenting the interdisciplinary communication. But you

need to educate the docs on what needs to be there. I suppose we are

lucky in our facility in that our MD's office is on the rehab unit, and

at least one of them is always around. When they aren't here in the

evening, the pt isn't getting therapy anyway.

Jen Weiss, PT

>>> jimpalestine@... 8/22/2007 6:31 PM >>>

Availability 24 hours is one thing, but to expect the physician to have

to document or write an order for when a pt. has a case of loose bowels

is another. There is no requirement that the physician see the patient

every day.

Jim Arceneaux, LOTR

Weiss wrote:

I guess my response to this one would be.. yes, it's a

burden, but it

still is the responsibility of all involved to document. Let me tell

you

first-hand that the denials process is a much bigger burden!!

At the very least, the physician needs to document in his/her note

that

the patient missed therapy for whatever reason -- even if there is no

hold order and even if the MD didn't physically assess the pt on this.

That would indicate communication with the therapy staff. Aren't your

physicians seeing the patients daily anyway? There needs to be 24-hr

availability of a physician for a pt to be on inpt rehab anyway, so

they

should at least be able to document!

This is also not meant to address pt refusals -- I am talking about

those cases where there is actually a medical reason that the pt

cannot

participate (low BP, blood sugar levels, awaiting results of x-rays to

r/o fractures, etc etc). We emphasize to our patients from day one

that

they are expected to come to all of their therapy sessions, and

general

malaise, etc is not enough to not come down. We tell them that if they

don't feel like coming, we will be making up the session later in the

day, so if it is just a matter of pt refusals, this may help reduce

that. This way they know they can't just " get out " of it, because

we'll

get them in later anyway.

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL 60426

>>> rehder@... 8/21/2007 8:36 AM >>>

I would agree. To have the physician be expected to write a hold order

every time a patient is not feeling well enough to participate is

overkill and places an excessive burden on both the physician and

staff.

Carol Rehder, PT

Manager, Physical Therapy

Genesis Medical Center

rehder@genesis@...

>>> " Jim Arceneaux " 8/20/2007 6:17 PM >>>

Ok, but lets say this scenario: The pt. refuses stating she is ill.

The physician has not assessed to determine the impact of the illness

on

her participation in therapy. He has opined, and I agree, that it

should be the people that have assessed this condition that decide if

it

warrants an excuse from participation in therapy. Should the physician

make a visit everytime a patient has a physical complaint and asks to

forgo therapy? I'm not certain why it would not be sufficient that the

whole team document that the patient is vomitting for example.

Jim Arceneaux, LOTR

Palestine Regional Rehabilitation Hospital

Weiss wrote:

The physiatrist really has to be on board with this and

cannot be

resistant to writing hold orders. We have been audited and are going

through the process of denials right now, and our medical director is

acutely aware of the importance of this. Someone might need to sit

down

with the doc (mabye the director of the unit?) and explain this, and

how

this can affect reimbursement, etc, and it is really not an option.

Obviously the MD shouldn't be writing hold orders inappropriately, but

if the pt cannot participate due to a (temporary) medical condition or

has a stat test ordered, it has to be in there. No options! Sometimes

we

have encountered his partners who are covering for him and they are

not

as aware, and we simply explain the situation and often tell them what

they should be documenting in their notes, because they don't

understand

the process. It has to be a team effort. Medicare really emphasizes

this

as well, so if the MD and the therapy team are not in sync, there will

be problems if you are audited.

Good luck!

Weiss, PT

Inpatient Rehab Coordinator

Ingalls Memorial Hospital

Harvey, IL

>>> katesels@... 8/18/2007 3:06 PM >>>

Ditto.

Our doc is resistive to writing any hold and it puts us in a jam come

weekends when we make up our time and with limited PT and OT staff.

Katesel Strimbeck PT, MS

Glenmont, NY

Katesels@...

Re: Inpatient Rehab. 3 hours

Well put.

Our understanding also is that dialysis is not a sufficient reason to

miss three hours for the day. We've made the same efforts to work

around

Xray for tests, as well as dialysis, with difficulty but it's doable.

Dan Gaskell

Carilion Clinic

Roanoke, VA

---------------------------------

Building a website is a piece of cake.

Yahoo! Small Business gives you all the tools to get online.