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How Therapy Can Support Reimbursement and Care Planning

In the COVID-19 pandemic, some states now are seeing a decrease in cases, while others have continued growth, especially in rural and suburban areas. Much of the COVID-19 response is becoming localized to meet these varying caseloads, but one consistent factor nationwide for nursing homes is the continuing need for vigilance and preparedness given how quickly an outbreak can spread among residents and staff. The expectation among public health experts is that all states will see at least a second wave and perhaps multiple waves of cases before a vaccine is available to force a slowdown and potentially eradicate the spread of SARS-CoV-2, the virus that causes COVID-19.


“This pandemic has brought to the forefront the need to have all hands on deck,” says Amy Hobbs, PT, a board-certified clinical specialist in geriatric physical therapy and National Business Leader of Clinical Operations for Accelerated Care Plus in Reno, NV. “Providers must have a strategic and aligned interdisciplinary approach to provide a resident-centered plan of care in spite of all the environmental challenges that come with COVID-19 response.”


An optimal interdisciplinary approach requires that providers put into practice the strong communication and teamwork processes that sometimes fall by the wayside when staff are stressed and stretched thin, says Hobbs. “You want to make sure that each discipline is both documenting their observations and assessments and reaching out to the appropriate nursing staff when they recognize any changes of condition. This applies not only to physical therapy (PT), occupational therapy (OT), and speech-language pathology services (SLP) but also to activities, dietary, social work, and all other team members who are active participants in the resident’s care. With the crush of COVID-19, the onus is on the whole team to make sure quality-of-life and quality-of-care needs are identified on the care plan and provided on the floor.”


Therapy in particular can play a key role in improving care planning—and ensuring accurate reimbursement under the Patient-Driven Payment Model (PDPM), notes Hobbs. “Nurse assessment coordinators (NACs) most commonly look to therapy documentation to provide input for section GG (Functional Abilities and Goals) and section O (Special Treatments, Procedures, and Programs) of the MDS. However, therapy documentation can provide support for other MDS sections as well.”


Therapists and therapy assistants are professional clinicians who have the luxury of time with residents, points out Hobbs. “They generally see the same resident five days a week. In many circumstances, their perspective on that resident is perhaps more complete and seen over a more generous volume of time than nurses get direct access to. That can corroborate many areas of the MDS.”


Here are key areas where NACs can extract needed information from therapy documentation, as well as a few areas that should be monitored to ensure nursing is coordinating appropriately with therapy:


Section B

Therapy documentation can support several items in section B (Hearing, Speech, and Vision), says Hobbs. “For B0200 (Hearing), the steps for assessment in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (page B-3 in chapter 3) specifically guide assessors to ‘consult the resident’s family, direct-care staff, activities personnel, and speech or hearing specialists’ in addition to interviewing and observing the resident and reviewing the medical record.”


Therapy also can provide insights for coding B0600 (Speech Clarity), B0700 (Makes Self Understood), B0800 (Ability to Understand Others), and B1000 (Vision), says Hobbs. “From a vision standpoint, the steps for assessment in the RAI User’s Manual (page B-9 in chapter 3) tell assessors to ‘ask direct-care staff over all shifts if possible about the resident’s usual vision patterns during the 7-day look-back period (e.g., is the resident able to see newsprint, menus, greeting cards?).’ An occupational therapist or physical therapist often will be looking at visual field cuts or limited vision due to a number of different reasons (e.g., glaucoma, cataracts, or stroke), and that type of documentation can help support B1000.”


In addition, residents who are restricted to their rooms during a COVID-19 outbreak may have a reduced ability to be heard and understood, points out Hobbs. “Getting input from therapists can help ensure that the team understands the resident’s needs and wants and can help ensure they are met by the appropriate person.”


Section C

In section C (Cognitive Patterns), the Brief Interview for Mental Status (C0200 – C0500) and the Staff Assessment for Mental Status (C0700 – C1000) are very hot topics because they affect reimbursement under PDPM, as well as care planning, says Hobbs. “For the staff assessment, the steps for assessment in the RAI User’s Manual (page C-20 in chapter 3) state that ‘Observations should be made by staff across all shifts and departments and others with close contact with the resident.’ Therapy documentation can help support the assessment of a resident’s attention, orientation, and ability to register and recall new information. Looking at deeper levels of cognitive performance and executive functioning, physical therapists, occupational therapists, and speech-language pathologists may even be able to identify some deficits that aren’t otherwise revealed in routine day-to-day activity.”


Section D

Section D (Mood) prioritizes the PHQ-9 Resident Mood Interview (D0200 – D0300) over the PHQ-9-OV Staff Assessment of Resident Mood (D0500 – D0600), acknowledges Hobbs. “However, it is not uncommon for therapists to develop an ongoing relationship with the resident that allows them to be more open to expressing feelings of sadness, isolation, disorientation, or depression during a therapy session. Therefore, it’s important for therapists to document that information—and to proactively communicate it to the NAC—to support both MDS coding and care planning.”


Section E

For section E (Behavior), NACs should review therapy documentation to look for missed visits, suggests Hobbs. “If a resident refused the PT, OT, or SLP session for a day during the look-back period, it should be captured in E0800 (Rejection of Care—Presence and Frequency) if it meets the coding criteria.” Note: Missed therapy sessions could also be important in the context of providing a daily skilled service to meet a Medicare Part A skilled level of care. For details, see section 30.6, Daily Skilled Services Defined, in chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” of the Medicare Benefit Policy Manual.


Sections G and GG

“NACs have an opportunity to look at therapy progress notes that are done weekly and sometimes daily to corroborate what is being reported by direct-care nursing staff and what is being observed by family members for usual performance of the activities of daily living in section GG,” says Hobbs.


“However, sometimes there is a language barrier between nursing and rehabilitation in terms of how the two disciplines look at and assess function (i.e., the same activities are measured using different scales and different language to reflect performance),” she notes. “For example, therapy documentation may address how much assist is needed while nursing looks at the level of independence. Section GG has created a common language that will eventually help ensure nursing and therapy assess on the same scale, but it’s a potential tripping point as long as both section GG and section G (Functional Status) remain on the MDS.”


Section H

In section H (Bladder and Bowel), therapists often can provide insight into a resident’s continence picture for H0300 (Urinary Continence), says Hobbs. “Working with the residents in therapy sessions, therapists are aware of residents who have frequency or urgency issues but don’t make it to the bathroom.”


Section I

“Obviously, therapy evaluations contain a lot of information about medical necessity that relates to the skilled services that the physical therapist, occupational therapist, or speech-language pathologist is providing,” says Hobbs. “However, it is more important than ever under PDPM to ensure that the diagnoses in section I (Active Diagnoses) are linked to the underlying impairment that therapy is treating—and that that impairment is addressed with goals that support section Q (Participation in Assessment and Goal Setting) and the discharge disposition. This should all interconnect in the therapy documentation and be reflected back in the nursing documentation as well.”


Section J

In section J (Health Conditions), the Pain Assessment Interview (J0300 – J0600) sometimes can give an incomplete picture of the resident’s pain, says Hobbs. “If, for example, the nurse does the interview when the resident is in bed and has had their pain medication, they may not indicate that they have had any pain. However, if a therapist comes in even 15 minutes later and starts a therapy session targeting a painful joint, that resident may experience sharp phasic pain that breaks through the pain medication, and they will report to the therapist, ‘Yes, my knee hurts, and it is a moderate level.’ Therapy documentation should be reviewed to get the bigger picture of that breakthrough pain that the movement of therapy will sometimes evoke so that it can be addressed on the care plan.”


Another key item is J1100 (Shortness of Breath (Dyspnea)), says Hobbs. “Therapists often will document shortness of breath on exertion and quantify that with the symptoms the resident is demonstrating, as well as their vital signs corresponding pulse oximetry levels.”


Section K

In section K (Swallowing/Nutritional Status), K0100 (Swallowing Disorders) has always been relevant for care planning, but it may not have always been well-documented, says Hobbs. “Now that it impacts payment under PDPM, CMS likely will take the opportunity to look more acutely at the changes in documentation patterns pre-PDPM and post-PDPM. Having an SLP assessment to corroborate swallowing disorders will be helpful if swallowing disorders are noted in K0100.”


Section M

In section M (Skin Conditions), sometimes there is discord between nursing and therapy in wound staging for M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage), says Hobbs. “For example, one assessor may perceive a pressure ulcer to be a Stage 2 partial thickness loss of dermis, while another assessor perceives it to be a Stage 3 full thickness tissue loss. Doing a co-assessment together, especially when therapy is involved in providing supplemental care for the pressure ulcer, can help the two assessors gain alignment in validating which components of the integumentary system they are seeing and what the appropriate staging is. That type of dialogue and collaboration can help you avoid a potential sticking point in your documentation.”


With COVID-19, M0100 (Determination of Pressure Ulcer/Injury Risk) also comes into play, adds Hobbs. “Residents may be more sedentary from being restricted to their rooms during outbreaks. Consequently, they may be at greater risk for developing pressure ulcers,” notes Hobbs. “Input from therapists and other team members can help make sure you have a mobility system in place to prevent pressure ulcers from developing even when your facility is on heightened COVID-19 restrictions.”


Section Q

For section Q, therapy and nursing need to be aligned on item Q0300A (Resident’s Overall Goals Established During Assessment Process), says Hobbs. “You want to make sure that the conversation that is had with nursing is also the same conversation that is being had in therapy. If the resident is not consistent in what they are targeting for their discharge goal, you need to get everyone on the same page so that all care collaborators are aligned in helping the resident meet their discharge expectation.”

Note: Look out for more information coming soon on a new certificate course from AAPACN, “Collaboration in Skilled Nursing Facilities: A Certificate of Skills in Medicare, MDS, and PDPM for Therapy Professionals,” developed for the entire therapy team by the MDS experts at AANAC and the clinical therapy experts at Aegis Therapies.

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