Coding Compliance Late Effects of a CVA Part II of II

There are many occasions where weakness, dysphasia, aphasia are shown throughout the assessment, but unless documented as such we cannot conclude that these are complications of the CVA.  In SmartScribe the musculoskeletal section is often used by agencies to show late effects of a CVA.  There is a box marked hemiplegia, so please check that box and below that box it must be noted this is due to or related to CVA.  If you are using your own documentation please include in the narrative which diagnosis are related or due to the CVA.
As an additional note if the late effects of a CVA or hemiplegia is used we will note code separately abnormality of gate or muscle weakness these are inherent to hemiplegia.  Also, please specify whether the hemiplegia is on the dominant or non-dominant side so that we may use the best code for you.

In conclusion, in dealing with diabetic complications and late effects of a CVA please use the phrases “related to” or “due to” where appropriate so that we may use the most accurate codes as possible.

Coding Compliance Diabetic Complications – CVA Part I of II

Coding Compliance Diabetic Complication – Late Effects of a CVA Part I

Many times we see a diagnosis of diabetes and throughout the assessment we will see PVD, Neuropathy, Chronic Kidney Disease, Ulcers, and other diagnoses.  We cannot code any of these complications unless they are documented as such.  If you are using the SmartScribe documentation there is a special section marked endocrine status which will list all of the complication.  So, please use this as it will make it very clear to us that these need to be coded as diabetic complications.  If you are using your own agencies documentation please include in the narrative that these diagnoses are diabetic complications.

Also, if there an ophthalmic complication of diabetes, please note what type of complication it is so that your coding is not help up while we determine what it is.

Finally, please make sure that the codes used in M1020 and M1022 match the information shown in the endocrine status.  Many times we see diabetes as a diagnoses, while in the endocrine status it will show diabetes type I or even uncontrolled diabetes.  So, please make sure to document the correct type as well as all diabetic complications which must be verified by a physician.

Select Data serves home health and hospice agencies throughout the country and the Virgin Islands. One agency, not from a POLST state recently asked that we write an article on POLST as they had seen the abbreviation on the Select Data SmartScribe forms. Their state is considering a move toward the Physician Orders for Life-Sustaining Treatment Paradigm program.

The POLST program is designed to improve the quality of care received by individuals at the end of life. It is designed to effectively communicate patient wishes through physician orders on a highly colored form (usually PINK) so as not to be missed by health care professionals.

What is the Difference Between POLST and Advance Directives?

POLST is a document that clearly states a patient’s end of life wishes and includes physician orders and patient signature. Advance Directives generally contain information about a person’s desire to be mechanically ventilated, artificially fed, and comfort measures. Advance Directives will not actively protect against unwanted emergency care, resuscitation specifics, or a transfer to an acute care setting. POLST includes CPR wishes, artificial nutrition choices, and specific statements identifying if a transfer to a hospital is desired. POLST has physician orders to back up the patient’s wishes.

History of the POLST Paradigm Initiative

Despite advance directives, medical ethics leaders recognized that patient wishes for life-sustaining treatments were not consistently being honored. In 1991, in Oregon, the POLST Paradigm Initiative was begun.  The Medical Treatment Coversheet, designed to transport portable medical orders based upon the patient’s wishes emerged from the Initiative lead by The Center for Ethics in Health Care at Oregon Health and Science University. With stakeholders from several health care organizations, the Center coordinated the training of health care professionals regarding use of the form.

In 1995, the name of the Initiative was changed to Physician Orders for Life-Sustaining Treatment and the form was released for full use in Oregon. As the program satisfaction grew, other states sought legislation to initiate the program. West Virginia and New York were forerunners in program adoption and they lead the way in learning to integrate the new program within state specific laws.

Presently,(per www.obsu.edu/polst ), the Medical Treatment Coversheet is used by over 95% of nursing homes in Oregon and used by all hospices. It is considered “the accepted medical standard of care.” Together, with Oregon members, program leaders of New York, Pennsylvania, West Virginia, and Wisconsin joined together forming the original National POLST Paradigm Initiative Task Force. That Task Force has been instrumental in driving POLST Program development in California, Washington, Idaho, Colorado, Tennessee, and Virginia with several other states, such as Texas, Florida, Georgia, Indiana, Alaska, and Ohio actively developing programs.

The National POLST Paradigm Task Force (NPPTF): Program Requirements

The Task Force developed the description of the program with specific program requirements. The Program Structure requires an “effective statewide or regional coalition” working on a strategy to establish statewide implementation.

The Program requires a set of medical orders on the Medical Treatment Coversheet. There must be ongoing training of health care professionals at all levels, that includes an understanding of the POLST Program, its goals, use of the Form, as well as understanding “how to conduct a POLST conversation.” (www.obsu.edu/polst)

The Medical Treatment Coversheet includes physician signature. The patient signature is encouraged to be on the completed form as well which includes informed consent and shared medical decision making. The program requires a mechanism for ongoing evaluation and its processes. In addition, there must be a single “strong entity” within the state or region that accepts responsibility and ownership for the Program.

The Form and it’s Requirements

Treatment provided requires a specific medical order based upon the patient’s goals of care and their preferences. POLST offers three choices. First, Comfort Measures Only means care that would relieve pain and suffering. The medical orders “explicitly state in the medical orders that comfort measures are always provided.” (www.polst.com ) The patient is to be transferred if “comfort needs” cannot be provided. Second, the choice is “Limited Additional Interventions” that offer comfort measures as well as IV fluids and antibiotics. This option includes a choice to be transferred to an acute care setting only if suffering could not be relieved at home. The third choice is that of “Full Treatment” and includes the Comfort Measures, IV Fluids and antibiotic interventions as well as CPR and intensive care if needed. The orders must be signed and dated.

To protect the patient’s wishes PRIOR to emergency intervention, requires POLST. For more information regarding this subject, go to www.POLST.com or www.ohsu.edu/polst

The Form must provide explicit direction as to resuscitation as well as patient preferences if they become pulseless or apneic. The Form must also include what the patient does NOT want including ICU, acute care, long term care, etc.

The Form must include the state of coverage. It is to be transportable so the patient may carry the Form within a state or region. The Form also clearly identifies a transfer option in case a patient’s comfort measures cannot be maintained in the present setting.

Face To Face Encounters CY2011 Clinical Compliance

CMS was mandated by the Affordable Care Act to provide this encounter. You will be able to look on page 296 on the Final Rule to read the depth of it. But, essentially what CMS is stating is that the physician must see the patient within 90 days prior to the admission in a home health agency.  And that means that also, in seeing that patient for that face-to-face encounter, that diagnosis or that reason for seeing that patient must be directly related to the home health referral.  Now, if they don’t see them within 90 days prior to they must see them within 30 days after admission.

As of December 10, 2010 CMS is sending out a notice to the physician regarding this face-to-face encounter information.  So the home health agencies are going to have to do a lot of education with physicians.  It also requires then, that the physician provide this attestation that they have completed this face-to-face encounter, and it has to be attached to/or a part of the POC.

At Select Data we’ve created a documentation of the face-to-face encounter tool click here to download a copy of this form:  http://www.selectdata.com/wp-content/uploads/2010/12/DocumentationFacetoFaceEncounter.pdf

Summary

The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition

Coding Compliance Open Wounds as a Primary Diagnosis

Open Wound as a Primary Diagnosis

Often we see the term open wound used as a diagnosis, especially as a primary diagnosis.  This is a vague term and should be avoided, because it will need clarification before it can be coded.  Did you know that an open wound can be referred to 10 or more different types of wounds?  And each one of these wounds has a different code or codes.

Some of these different wounds are:

• Decubitus Ulcer
• Diabetic Ulcer
• Venous Stasis Ulcer
• Normally Healing Surgical Wound
• Post-Op Wound Infection
• Dehisced Surgical Wound
• Traumatic Wound
• Burn
• Chronic Skin Ulcer
• Abscess

Each one of these requires as different code.  This stops the coding process until the nature and the origin and the location of the wound can be identified.  All these variables change the code or codes assigned.

Trauma wounds are caused by an outside trauma to the body and they include:

• Gun shots
• Avulsions
• Lacerations
• Punctures
• Not surgical

Surgical wounds are never coded as a traumatic wound.  A superficial traumatic wound is not a full thickness wound and this includes:

• Skin tears
• Abrasions
• Blisters

Skin tear is not coded as a traumatic wound unless it is exceptionally large or the skin flap has been lost.  Remember when you’re tempted to write open wound on that diagnosis line, please stop and consider specifically what kind of wound is this and where is its location, and put that information on the diagnosis line instead.

1. All learning is physiological
2. The brain/mind is social
3. The search for meaning is innate
4. The search for meaning occurs through patterning
5. Emotions are critical to patterning
6. The brain/mind processes parts and wholes simultaneously
7. Learning involves both focused attention and peripheral perception
8. Learning always involves conscious and unconscious processes
9. There are at least two approaches to memory

10.  Learning is developmental

11.  Complex learning is enhanced by challenge and inhibited by threat associated with helplessness

12.  Each brain is uniquely organized

(Caine, Caine, McClintic, and Klimek, 2009 and Caine and Caine, 1994)

The principles assist us, as clinicians, leaders, managers, to understand that there are several different processes involved. Yet, we all tend to print up some teaching materials and have the nurses leave them with the patient “for reinforcement”. Many people believe, “If I told you, you have had education”.

The best selling education books, Tellin’ ain’t Trainin’ (Stolovitch, 2011) and Sit and Get Won’t Grow Dendrites (Tate, 2004) help us to better understand Brain-Compatible strategies. Some patients may learn well with the written word, while others are spatial and auditory learners.

Future Select Data articles will explore the constructs further but here is one sample activity.

If a patient treatment has changed or is being compared or contrasted, consider using a Venn Diagram. Draw two circles that have an overlapping center like below:

Information that is overlapping in the center is that information that is alike. The information outside that space identifies differences.

A spider chart with the new treatment or new topic in the center of a circle should be drawn. Then draw “spider-like” lines coming out of the circles. These can be goals to be achieved. As the patient articulates each goal they desire to achieve, linking it to the treatment or med in the center of the chart dramatically diagrams the importance of that treatment or medication.

A pie chart can be used to classify the careplan components. Breakdowns can make the plan seem more manageable. Each component or “piece” of the pie can appear to be managed at a setting, much like a tasty lemon pie.

We will look at this topic with more depth in the future. There is a PowerPoint Presentation on the topic of Learning and Brain Compatibility that is based on the Twelve Adult Learning Principles. This presentation was presented at two state association conferences and it could be shared with clinicians.

Having trouble downloading Learning and Brain Compatibility PowerPoint?

right click on the link > Then choose “Save Target As” > “Save”

]]> http://www.selectdata.com/adult-learning-principles-influencing-patient-outcomes-through-education/feed 0 http://www.selectdata.com/evidence-based-practice-in-establishing-care-plans-for-the-home-health-patient-copd http://www.selectdata.com/evidence-based-practice-in-establishing-care-plans-for-the-home-health-patient-copd#comments Wed, 01 Jun 2011 23:26:05 +0000 admin http://www.selectdata.com/?p=1679 Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following is an evidenced based process for COPD using SmartCues as reminders for clinicians.

A Focus on Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive airway disorder associated with abnormal inflammatory response of the lungs to noxious gas and/or particles. It is primarily manifested as two related diseases: chronic bronchitis with the presence of cough and sputum production for at least three months and emphysema.

COPD and exacerbation is the fourth leading cause of death in US and causes about 500,000 hospitalizations annually. It is expected to move up to the third leading cause of death in the US by 2020 (Crawford & Harris, 2008). Anthonisen defines COPD exacerbation as requiring the presence of at least one or more of the following: increased sputum purulence, increased sputum volume, and worsening of dyspnea. COPD decompensation is seen 1-3 times per year when care is not managed. Exacerbation etiology is usually infection driven. Other triggers include heart failure, pulmonary emboli, and non pulmonary infections.

Though COPD is progressive, literature states, COPD can be managed better to produce improved outcomes. The Home Health Nurse should follow agency protocol, physician orders, and professional nurse evidence-based practice when assessing and planning care with the patient diagnoses with COPD. Consider the following when establishing care:

• Symptom: Assess for signs and symptoms of infection (especially pneumonia)

Instruct patient to note change in sputum quantity, volume, and consistency. Patients should also note temperature with any other sign of infection and not increased temperature > than 100 degrees lasting longer than 72 hours (unless different physician guidelines)

Clinician should reassess each visit.

• Symptom: Assess for hypoxia and dyspnea

Instruct patient to utilize airway tolerance techniques (cough and deep breathing exercises that may include incentive spirometry. Instruct patient when to call home health agency, physician, or to seek emergency care (severe SOB, severe wheezing, or uncontrollable coughing). If Oxygen is used, instruct in importance, in safety and appropriate use of flow rates.

Clinician should assess VS (TPR and B/P), pulse oximetry, and evidence of accessory muscle use.

Clinician should assess for jugular vein distension, peripheral edema, and peripheral edema.

Clinician should assess for anxiety and restlessness

• Symptom: Smoking

Instruct patient and family in need to cease smoking. First hand and second hand smoke is contraindicated with the patient with COPD.

Clinician must assess each visit.

• Symptom: Assess for signs of orthopnea

Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.

Clinician should note baseline and changes each visit.

• Symptom: Increased wheezing (prolonged expiration)

Instruct patient to identify and eliminate triggers.

Instruct patient on stress reduction and stress management techniques such as guided imagery with simple exercises that can be utilized quickly.

Instruct patient in use of music therapy and choose a piece of music that is associated with calm and piece.

Instruct on airway clearance techniques that may include coughing and deep breathing exercises. Coughing is a general manifestation of COPD and may be worse in the morning. Patient should pace activities.

Instruct patient when to contact home health agency, contact physician, or to seek emergency care especially if there is severe SOB that is uncontrollable.

Clinician should assess incidences upon each visit and effect of instruction.

Clinician should inquire if “tripod” position has been necessary (patient leans forward with head tilted and arms resting on legs or table). Note visible use of accessory muscles in neck, abdomen, and chest. Teach patient to take slow deep breaths through pursed lips. (“This will help him relax and inhale oxygen and exhale carbon dioxide at a slower pace, decreasing the respiratory rate and preventing alveolar collapse” Crawford & Harris, 2008).

Clinician should assess lung sounds and listen for not only wheezes but crackles and may also note diminished breath sounds.

• Symptom: Assess activity tolerance

Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Wheezing can worsen with activity so a strong assessment and measured activity schedule is necessary.

Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate. Conditioning exercises aid to strengthen the muscles used in breathing.

Clinician should note baseline and assess activity levels and evidence of dyspnea changes each visit.

• Symptom: Assess for increased weakness and fatigue
• Instruct patient in energy conservation to achieve ADLs life quality. Patient should note when the symptoms occur.
• Clinician should note baseline and progress each visit.

• Symptom: Assess nutrition and hydration status (may have low levels of serum protein)

Instruct in high protein foods that do not require significant energy for preparation. Maintenance of adequate caloric intake should be taught. Nutritional supplements should be considered.

Clinician should assess nutritional status at each visit.

• Symptom: Medication compliance

Instruct patient as to medication actions, side effects, contraindications, when and how to take, and how to store meds. Likely medications may include bronchodilators, steroids, antibiotics, mucolytics, antivirals, and antipyretics.

Clinician to assess medication changes as well as  patient use of meds such as metered-dose inhaler; exhale completely, take a slow deep breath when inhaling, and holding breath for 5-10 seconds. Verify directions re use on each med.

Patients should have pneumonia and flu vaccine if agreed to by physician.

• Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.

Instruct patient as to psychosocial coping skills to maintain optimum self care-management.

Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.

Caring for COPD can present a challenge for home health nurses, but proper patient education, using a variety of techniques, while gaining family and friends’ support can assist to motivate patients to strive for optimal outcomes.

Sources:

CMS Appendix B Guidelines for Surveyors

Crawford, A & Harris, H (2008) COPD Help your patients breathe easier. AHC Media. www.modernmedicine.com/modernmedicine/CE+Library/COPD-Help-your-patients

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

The CMS Publication 100-2, Chapter 7, §40.1.2.14, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”  MACs can establish the special training and experience required.  A home health agency should contact its MAC and look at the MAC website for any special qualifications needed.

Introduction

CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide, proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement psych programs and there are many reasons for these decisions.

First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.

CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.”  The homebound status of patients with psychiatric needs require well written, clearly stated clinical visit notes, because there may not be physical impairments, and homebound status must be clearly delineated. Any patient in a certified home health program may leave their home for specific reasons, as identified in Chapter 7 of the Medicare Provider Benefits Manual. Homebound status for a patient suffering from a mental health issue may be just as painful and debilitating, but may not manifest itself with physical symptoms or behaviors.

Homebound status (for a patient suffering from a mental illness) may need to be evaluated as a clinician would evaluate a patient suffering from dementia or Alzheimer’s diseases That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound.

However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound; the same as any other home health patient in the certified agency.  An example may be that of patient with a mental health issue attending partial hospitalization.

Partial Hospitalization

In 1999, CMS, then known as HCFA, stated that a patient in a partial psychiatric hospitalization program does not qualify for psychiatric home care services.  The partial hospitalization program should be able to provide necessary psychiatric services. The homecare services must be psych-related. If they are not focused on a psychiatric issue, the home health agency must evaluate the patient’s needs, just as it would normally do with any other patient, and evaluate whether home care services are in keeping with medical necessity and homebound status.

What is Psychiatric Home Health Nursing?

What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and document those plans and interventions, as well as work closely with the physician.

On the surface, psychiatric care appears to be very eclectic, but there is much depth of choice for intervention strategy. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993) and Beck’s or Montgomery-Asburg Depression Inventories, Young Mania Scale, Sheehan Anxiety Scale along with Cognitive Restructuring therapy, there are a number of other psychiatric intervention models that can be very useful: psycho-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior therapy, relaxation, contract, and reward provisions.

The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept. This is important with patients of all ages, but the need is seen often with elder patients who are suffering significant losses in life.

With patients suffering from depression, the psych nurse frequently seeks ways to displace internalized anger outwardly. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.

Stress management and education of stress strategies are commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.

Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings an existential/spiritual concern and dimension to patient care. The clinician frequently provides support to a patient with low self esteem and a belief that the community has prejudged them. The clinician can assist the patient to cope with behaviors and approaches patients with an attitude of respect, reinforcing or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains physical, emotional, and spiritual life,

Relationship Building and Trust

The clinician will build relationships established on trust, caring, compassion, empathy, education, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, to assist with care planning and goal achievement, and to clarify the boundaries of the relationship, and lastly to affirm the patient has value and worth.

Medication Management

Medication management is frequently a need for patients and is one of the main reasons for hospitalization. CMS identifies a significant portion of hospitalizations are due to poor medication management. Some patients do not understand the reasons they has been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten. One patient once shared, “I look in the mirror, put the pill in my mouth, bring the glass to my lips, and know I am ill.” Unless this issue is addressed, the chance that this patient will become medication non compliant is great.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. It is this tangible “document” that assists with compliance reinforcement. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be a part of  an empowering strategy.

Summary

Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built upon trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist the individual to improve links with family, friends, and the community and be more compliant with their medication regime.

The psychiatric program can be a strong support to total quality care and improved outcomes.

Medicare Rehab Therapy V Codes

There are v-codes (meaning the ICD-9 code begins with the letter “V” followed by 2-4 digits) that designate care involving use of rehabilitation procedures. These are used when the purpose of the admission or encounter is rehabilitation. Coding guidelines only allow these encounters for rehabilitation V codes to be used as a primary diagnosis, in M1020a. They cannot be used in M1022b or beyond or in M1010 or M1016. If skilled nursing is seeing the patient for the billable visits then these encounters for rehabilitation V codes cannot be used.

There is encounter for rehabilitation V codes for physical therapy of PT is the only rehab services ordered. This is code V57.1. There is an encounter for rehabilitation V code for speech therapy if ST is the only rehab service ordered. This is code V57.3. There is also an encounter for rehabilitation V code for occupational therapy if OT is the only rehab service ordered at recertification time, this is code V57.2. Because OT cannot open a home care case under Medicare, this code will be used at recertification when OT is the only skilled discipline remaining, and going forward into the next 60 day episode.

There is an encounter for rehabilitation V code that is used when multiple therapies are ordered and provided but no nursing. This code is V57.89. It is used with any combination of PT, OT and ST or if all 3 therapies are involved with no nursing. Again, this code can only be used as the primary diagnosis in M1020a.
There is one more encounter for rehabilitation therapy code we see in home care, V57.81, For Orthopedic training, meaning cat training in the use of artificial limbs. This can only be primary diagnosis as well. The patient’s amputation stump has matured and has been fitted for prosthesis and a physical therapist will train the patient in the use of the prosthesis in the home setting. Documentation must show why the patient remains homebound since this training is usually several months after the original surgery and often done in an outpatient setting.

Remember, use encounter for rehabilitation V code only as a primary diagnosis in therapy only cases when skilled nursing has not been ordered.

Therapy Requirements:

Questions are rampant about the reassessments required every 30 days and those required on the 13^th and 19^th visits. In the March 28, 2011 issue of Home Health Line the journal states “the visit count that will trigger the need for a reassessment is based on the total number of visits when multiple therapy disciplines are involved rather than the visit count for each individual discipline, the fact sheet states.”

The fact sheet referred to is the CMS Therapy Requirements Fact Sheet that can be found at:

https://www.cms.gov/HomeHealthPPS/Downloads/Therapy_Requirements_Fact_Sheet.pdf.

This fact sheet was meant to provide guidance. However weeks of implementation of the new regulations have caused more questions to arise.

The Therapy Requirements Fact Sheet states, “Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to or no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.”

HHL, March 21, 2011 edition cites, “Therapy services won’t be covered after the 13th and 19th visits unless a qualified therapist completes a reassessment.”

In addition, the Fact Sheet identifies:

“Therapy services provided after the 13th and 19th visit (sum total of therapy visits from all therapy disciplines), are not covered until:

The qualified therapist(s) completes the assessment/measurement/documentation requirements.

The qualified therapist(s) determines if the goals of the plan of care have been achieved or if the plan of care may require updating. If needed, changes to therapy goals or an updated plan of care is sent to the physician for signature or discharge.

If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.” CMS expects these requirements to be followed or expect no payment for the visits.

The CMS Therapy Requirements Fact Sheet also identifies that “At least every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally assess the patient, and compare the resultant measurement to prior assessment measurements.” It notes that “The thirty-day clock begins with the first therapy service (of that discipline) and the clock resets with each therapist’s visit/assessment/measurement/documentation (of that discipline).

Per NAHC Regulatory Affairs, ‘the thirty day reassessment count would begin with the initial therapy evaluation through discharge from therapy. The 13th and 19th reassessments are counted per episode since they serve as justification for meeting the therapy threshold.”

Remember, the overall mission of the CY 2011 new rules, for therapy, include continuing or discontinuing treatment or having treatment plan revisions with changes in goals made by a qualified therapist. If therapy is to continue, there must be:

• Clear documentation of objective evidence of patient improvement, or
• A clinically supportable statement of expectations that the patient’s potential to improve is yet to be attained and is expected in a reasonable and generally predictable period of time

CMS clarified regulations at 42 CFR §409.44(c)(2)(iii) by adding that:

• There must be significant improvement
• The clinical record must demonstrate functional improvements that are ongoing and of practical value
• The improvements are to be measured against the patient’s condition at the start of treatment
• Covered therapy services are to be rehabilitative therapy or maintenance therapy (New G-codes for both were included in CY2011).

CMS defines “rehabilitative therapy” as requiring the skills of a qualified therapist, with recovery or improvement in function and, when possible, restoration to the previous level of health. Therapy is meant to assist a patient to improve function and assist a patient to a prior level of well being. The new regulations are meant to capture objective reassessment data at least every 30 days, by a qualified therapist, as well as require a reassessment prior to the higher payment thresholds of the 14^th and 20^th visits.