8 Rehab Documentation Areas Vulnerable to Claim Denials

More hospitals are boosting their rehabilitation services in an effort to treat the patient through the continuum of care and manage population health. One of the challenges of rehabilitation is maintaining accurate documentation. Gerry Stone, PT, MEd, founder and chief clinical officer of The Rehab Documentation Company, or ReDoc, explains how an integrated information technology system can benefit not only rehab departments, but hospitals as a whole by avoiding claims denials for documentation errors.

Gerry Stone shares eight areas in rehab documentation that are vulnerable to claims denials.Rehab documentation challenges
Rehab departments are coming under increasing scrutiny by Medicare Recovery Audit Contractors. Rehab areas are typically low-hanging fruit for auditors because more than 70 percent of hospital outpatient therapists still handwrite their documentation on paper forms, which causes a high rate of error, according to Mr. Stone. Besides human error, manual documentation can also cause errors due to outdated forms.

In addition, the requirements for documentation are increasing in complexity, making handwritten documentation unfeasible. Therapy patients typically receive treatment for several weeks and up to a couple months at a time. Therapists need to provide an initial evaluation, write treatment notes for every session, complete a 10-visit progress report, write a reevaluation with updated goals every 30 days and provide a discharge summary comparing baseline measurements with outcomes at discharge, according to Mr. Stone.

"Professional therapists spend 50 percent of their time documenting what they did the other 50 percent of the time," he says. This significant time commitment makes handwritten documentation a tremendous drag on productivity.

Benefits of electronic documentation

Implementing electronic documentation programs for rehab can solve many of these challenges. These systems are most useful when they interface with hospitals' system-wide electronic medical records and when the program is tailored for therapists. "Rehab is very complex, and it's too small a percentage of revenue for big hospital systems to be willing to provide an adequate rehab component," Mr. Stone says. "The therapy department can go into many hospital information systems and try to make its templates, but it's very time consuming to build and maintain, and usually results in failure.

8 top areas of focus for rehab documentation
Mr. Stone shares eight areas therapists should focus on in documentation to avoid claims denials and how electronic systems can aid their efforts.

1. Physician signature.
One of the first areas auditors look is the physician signature on therapist plans of care, according to Mr. Stone. Currently, most therapists handwrite the plan of care, fax it to the physician for a signature, receive the signed form and then scan it into an electronic file.
Under an electronic system that interfaces with a hospital-wide electronic medical record system, physicians can easily access a shared file and sign the notes. This system can also track which forms have not been signed, preventing denials due to unsigned notes.

2. Medical necessity. Therapists must prove the medical necessity of patients' therapy services, whether physical therapy, speech therapy or occupational therapy. Therapists need to show why the patients require the skilled services of a licensed therapist to reach their maximal level of function. Electronic systems can send alerts that prompt providers to defend the medical necessity of services for each patient.

3. Functional progress. Functional progress is a more recent requirement of rehab documentation. Therapists need to show patients' progress in their ability to complete daily life activities throughout each therapy session.

"Functional progress is how to make this patient more independent in certain activities of mobility and daily living," Mr. Stone says. "If the documentation is conveying increased range of motion or strength of the knee, but it's not tied into how the patient is walking and going up and down stairs, or how it affects the patient's function on the job or in some activity like driving, [the claim] will be denied." Similarly to medical necessity, therapists can receive alerts from an electronic system that remind them to include information on functional progress for each report.

4. Medicare caps. On Oct. 1, Medicare began placing caps on outpatient therapy services for patients. The annual cap is $1,880 for physical therapy and speech therapy combined, and $1,880 for occupational therapy. The caps for 2012 include services provided since January 2012, although the caps became effective only in October.

Medicare patients can exceed the caps, but therapists' documentation must prove medical necessity due to the complexity of the patients' condition and their potential to make progress with a therapist. Electronic rehab documentation systems can track patients' cap status and alert therapists when they need to apply to Medicare for extended treatment sessions.

5. Cloning. Another problem auditors look for in rehab documentation is cloning: when documentation has not been changed across therapy sessions. In an electronic system, the first document's clinical findings flows to the next screen, making it easier for therapists to update the subsequent notes. However, if therapists do not change any information, claims can get denied due to cloning.

"If there's no modification to the progressive exercise program or if the patient is saying the same subjective comments every day, it jumps right out as cloning," Mr. Stone says.

6. Patient self-discharge. In therapy programs, some patients will simply stop going without notifying the therapist or rehab program. If therapists leave documents for the patient incomplete, such as without a discharge summary, the claims can be denied. Electronic systems can track documents for each patient, notifying therapists when a patient's documents have not been updated in several weeks.

7. Recertification.
To receive reimbursement from Medicare, patients need to be recertified by Medicare every 90 calendar days. Electronic systems can alert therapists when their recertification is due.

8. Overbilling or inappropriate use of CPT codes and modifiers. Electronic rehab systems will alert the point-of-care therapists to any charge where the treatment time does not match the units billed or requires an appended modifier. Overbilling or billing irregularity is considered fraud abuse with dire consequences if not corrected in a timely fashion.  

Proving value
While the current environment challenges therapists to improve their documentation, it also provides an opportunity to prove the value of their services to patients and the healthcare system. "If you go back through the last 50 years, there's no data anywhere on all the millions of patients who received therapy because it was all documented on paper and there's no way to capture that data," Mr. Stone says. "Outpatient rehab is an underserved department that needs [hospital leaders'] attention, and the return on investment on this technology is simply unbelievable."

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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