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Restorative Nursing Payment and Documentation Issues: Keys to Success

Restorative nursing can impact fee-for-service Medicare Part A payment in the Behavioral Symptoms and Cognitive Performance category and the Reduced Physical Function category of the nursing component in the Patient-Driven Payment Model (PDPM), says Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA. “More often, restorative nursing affects Medicaid payments in case-mix states via PDPM, RUG-IV, or RUG-III.”

The daily payment impact per resident typically isn’t huge, explains Maher. “For example, the difference between PDE2 (two or more restorative programs at least six days a week) and PDE1 (one or no restorative programs at least six days a week) in Los Angeles County is roughly $14 a day under PDPM. The difference can be more significant in case-mix states. However, for both Medicare and Medicaid, the cumulative payment impact can be fairly substantial for providers depending on how many residents are on restorative programs.”

Understanding the following payment and documentation issues can help the lead restorative nurse ensure accurate payment:

Learn what counts as a restorative program for payment

“Under PDPM, as well as under RUG-based case-mix systems that may be used with the Optional State Assessment (OSA) effective Oct. 1, 2023, the resident must receive two restorative programs to affect the case-mix end splits,” points out Maher. Key points include the following:

* Two restorative programs that can count toward payment aren’t in O0500. “Often, providers aren’t aware that H0200C (Current Toileting Program or Trial) for urinary continence and/or H0500 (Bowel Toileting Program) will trigger as a restorative program if the resident has at least four days of a systematic bowel and/or bladder toileting program during the seven-day look-back period,” says Maher. “That’s different from O0500. Restorative programs captured in O0500 must be provided 15 or more minutes a day for at least six days in the seven-day look-back period, according to the draft RAI User’s Manual (pages 6-46 – 6-47).”

* Three “sets” of restorative programs count as one restorative program for payment. “It doesn’t matter whether only one individual program is provided or both programs in the set are provided to the resident,” says Maher. “Chapter 6 of the draft RAI User’s Manual explains that each set of these programs is grouped together and only counts as one of the two required restorative programs for payment purposes. The three sets are: H0200C and H0500; O0500A (Range of Motion (Passive)) and O0500B (Range of Motion (Active)); and O0500D (Bed Mobility) and O0500F (Walking).”

Maher offers the following examples:

  • A resident is on a bed mobility restorative program and a walking restorative program six days during the seven-day look-back period. Those two programs together only count as one program for payment, so this resident doesn’t have the two restorative programs needed to affect payment.
  • A resident is on a bed mobility restorative program and a transfer training restorative program (O0500E) six days during the seven-day look-back period. Those two programs each count as separate programs for payment, so this resident has the two restorative programs needed to affect payment.
  • A resident is on a bed mobility restorative program, a walking restorative program, and a transfer training restorative program six days during the seven-day look-back period. Although bed mobility and walking together only count as one program for payment, this resident has the two restorative programs needed to affect payment because they are also doing transfer training.
  • A resident is on an active range of motion restorative program and a bed mobility restorative program six days during the seven-day look-back period. These programs aren’t being provided with their specific set partners (passive range of motion and walking, respectively), so they each count as a separate program for payment. This resident has the two restorative programs needed to affect payment.

* All restorative programs have to be treated as unique even if they count as one program for payment. “Each program needs to be written up and care planned separately, the interventions should be delivered separately, the minutes for each program have to be documented separately, and the programs should be evaluated individually,” says Maher. “In addition, the restorative nursing assistants (RNAs) or certified nursing assistants (CNAs) who provide the program have to be trained in the activity for that resident and the interventions.”

Being grouped together for payment doesn’t erase how unique some of these paired programs are, explains Maher. “For example, while passive range of motion and active range of motion together only count as one restorative program for payment, they are in fact very different programs. Passive range of motion would be for a resident who cannot physically move that limb themselves. The RNA, the CNA, or the restorative nurse would be required to move the joint through the range of motion. In active range of motion, the resident could do the exercise themselves with cueing or with active assistance if they need help to complete the movement. So, it makes sense that they must be provided and documented separately.”

Note: O0500A – O0500J is part of the Optional State Assessment (OSA) that some states will implement effective Oct. 1, 2023 for Medicaid case-mix payments. Providers should check with their state survey agency (contact information is listed in Appendix B, found here) or a state provider association to learn whether they will need to implement the OSA.

Learn the role of the physician order

The RAI User’s Manual doesn’t require restorative nursing programs to have a physician order to be coded in O0500, says Maher. “So, the lead restorative nurse may initiate a restorative nursing program or, alternatively, request a therapy evaluation when they see a resident decline.”

The one exception in the RAI User’s Manual to the “no physician order needed” rule for coding O0500 involves the use of continuous passive motion (CPM) devices in a restorative nursing program. One of the additional criteria for CPM devices is a physician order, according to the draft manual (page O-51). “In addition, some states may require a physician order for restorative nursing programs, so you need to be aware of state regulations,” explains Maher.

It’s also important to know that, while providers often don’t use it, a restorative program can serve as a Medicare Part A resident’s daily skilled nursing service if the resident qualifies for a skilled level of care, says Maher. “Those level-of-care requirements include that the resident must need skilled services that are ordered by a physician.” Note: For more information, see sections 30, Skilled Nursing Facility Level of Care—General, and 30.6, Daily Skilled Services Defined, in chapter 8 of the Medicare Benefit Policy Manual.

Catch restorative issues before the ARD in case-mix states

“In case-mix states, reviewing all Medicaid residents about a month before their next assessment reference date (ARD) is a good strategy,” says Maher. “If you talk to the CNAs and the charge nurses on the unit, you can determine if the resident has shown any functional decline. Then if they are showing some functional decline, you can put the appropriate restorative programs in place to get the resident back to baseline as much as possible before the ARD. You don’t want to wait until the resident triggers a quality measure (QM) for decline before you start to help them improve so that they can stay at their highest practicable level of functioning. And, you can get paid for those programs as well.”

Ensure that staff document restorative minutes accurately

When RNAs or CNAs document restorative nursing minutes, they should document the actual minutes provided, says Maher. “And, those minutes shouldn’t always equal 15 minutes for each treatment or the same number of minutes per treatment for every resident.”

Maher offers the following example to illustrate: A resident is on a walk-to-dine program for all three meals each day. At breakfast time, the RNA takes the resident in their wheelchair to the door of the dining room and locks the wheelchair. The resident stands up, and the RNA walks them into the dining room to sit in their chair at their table. After the resident eats their meal, the RNA walks them back to their wheelchair and then takes them back to their room.

“To document this program to show at least 15 minutes of restorative programming in a 24-hour period (i.e., to capture a day of restorative services) that can be coded in O0500 (Walking), the RNA should count the minutes it took to walk the resident from their wheelchair to their dining chair and back from their dining chair to their wheelchair at breakfast,” explains Maher. “And, since the resident is on a walk-to-dine program for all three meals, the RNA would do the same at lunch and dinner.”

In this type of scenario, it’s common to see documentation that shows five minutes at breakfast, another five minutes at lunch, and another five minutes at dinner for every resident on a walk-to-dine program, says Maher. “However, all residents totaling 15 minutes each day doesn’t make clinical sense, especially for any type of walking program. A single resident may walk at different rates at different times of the day. For example, the resident may take five minutes at breakfast, but six minutes at lunch and seven minutes at dinner. In addition, it may take another resident twice as long to walk the same distance as this resident. For example, they may take 10 minutes at breakfast, 10 minutes at lunch, and 11 minutes at dinner.”

Just like therapy treatments should not always equal 15 minutes, neither should restorative treatments, stresses Maher. “Your team should have the practice of looking at their watch or a stopwatch to time the treatments and documenting in the medical record the actual minutes that they provide treatment to the resident for each restorative program. If there are at least 15 total minutes when you count all the treatments during the 24-hour day for that particular restorative program, then you can code it as a day in O0500. However, restorative minutes that do not meet the coding criteria are still beneficial to the resident—and they are documented in the medical record to show the efforts of your team.”

Create a mechanism for determining when restorative should end

In some facilities, greater than 50 percent of long-stay residents are on a restorative nursing program, points out Carol Hill, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “That typically isn’t sustainable. The restorative team often doesn’t have enough staff to carry out all the programs according to the coding criteria in the RAI User’s Manual when that many residents in the building are on restorative.”

This type of situation most often develops when a resident is discharged from skilled therapy services and put on one or more restorative nursing programs—and there is no real mechanism for evaluating how long restorative should continue, explains Hill. “The restorative nurse may not feel comfortable making that judgment, believing that it is beyond a nursing scope of practice, especially for such issues as range-of-motion concerns.”

Better coordination with therapy may help the lead restorative nurse create that mechanism for evaluating whether the resident can be discharged from restorative services, suggests Hill. “Usually when therapy turns a resident over to restorative nursing, they provide a functional maintenance program (FMP) to guide the resident’s restorative programs. However, the FMP often has an open-ended time frame. Having a conversation with therapy can assist you to set a timeline for re-evaluation.”

For example, the lead restorative nurse may decide to do the resident’s restorative programs for six weeks, explains Hill. “Then, the lead restorative nurse can collaborate with nursing at the end of six weeks to determine on a case-by-case basis: Is restorative still needed? Is the resident okay to perform this independently? Can they do it with the assistance of nursing on the floor? Or, do we need to refer them back to therapy?”

Be careful about documenting ‘periodic’ evaluation quarterly

The RAI User’s Manual (page O-48 in the draft) indicates that the lead restorative nurse should conduct evaluations as follows:

Measurable objective and interventions must be documented in the care plan and in the medical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident’s medical record.  

Evidence of periodic evaluation by the licensed nurse must be present in the resident’s medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established.

Some providers interpret periodic evaluation as being a quarterly requirement for long-stay residents, but there are potential concerns that must be navigated:

  • State requirements. “Some states want to see monthly monitoring, as well as a quarterly evaluation, for long-stay residents who are receiving restorative nursing services,” points out Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC, chief nursing officer at Pathway Health in Lake Elmo, MN. “For example, the state of Illinois requires a monthly review of all care plan goals plus a quarterly review that looks at the resident’s progress, participation, and response to each restorative program that they are on.”
  • The potential for missing key changes in resident function. Monthly evaluations are the safest option because it’s easier to pick up changes in the resident’s functional status, suggests Hill. “If you only have quarterly evaluations, a resident could have a decline several months in the making before you recognize it.”

Another option is to train RNAs or other staff to identify functional changes and report them to the lead restorative nurse, says LaGrange. “This will help you identify when you need to document an assessment in between quarterly evaluations.”

Identify where the resident is headed in periodic evaluations

While not a requirement, a progress note that documents the lead restorative nurse’s periodic evaluation should include, as a best practice, both a summary of the resident’s performance in the restorative program and a clear path forward that is supported by that performance, recommends Hill. “In your progress note, you should be able to provide an evidence-based decision on whether you will continue the program, discontinue the program (e.g., following discussions with therapy or nursing), or refer the resident back to therapy. For example, if you decide a therapy referral is needed, your progress note should support your decision—and the therapy pick-up—by documenting the resident’s functional deficits or declines.”

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