DOCUMENTATION OF

MEDICAL NECESSITYJill Bustin

Manager, Health Information Management

& Privacy Officer

Mary Free Bed Rehabilitation Hospital

GOALS

CMS Rule

Intent of the rule

What you will have to defend – “Keep the Intent of the Rule in

Mind

DOCUMENTS TO MEET MEDICAL

NECESSITY

Pre-Admission Screen

H&P-Post Admission Physician Evaluation (PAPE)

Overall Plan Of Care

Interdisciplinary Team Conference

Physician Daily Progress Notes

Discharge Summary

PRE-ADMISSION SCREEN

• Can be documented by licensed/certified clinician

• In person

• Via telephone/records review

• Must scan pertinent records into EMR

• Must be signed by rehab physician prior to admission

PRE-ADMISSION SCREEN

Required elements to include in pre admission screen

1. Prior level of function

2. Expected level of improvement

3. ELOS

4. Risk of clinical complications

5. Conditions that caused need for rehabilitation

6. Treatments needed in IRF

7. Frequency/Duration

8. Anticipated discharge destination

9. Anticipated post-discharge treatment

H&P-POST ADMISSION PHYSICIAN

EVALUATION (PAPE)

Can be combined into one document but make it clear in title

that PAPE is included

Resident or physician extender can complete H&P portion

Rehab physician must complete PAPE

Identify relevant changes since PAS

Complete within 24 hours of admit

PA

PE E

XA

MP

LE

Have seen and examined the patient at bedside on admission to [rehab

program] on 7/30/18.

I reviewed the pre-admission screening data and compared the data to

patient presentation. I have reviewed the clinical history, current

medication condition and functional data with the APP [Attending Primary

Physician]. I agree with the APP's history, information, physical

examination, prognosis, and estimated length of stay. The patient's

condition and functional status are such that the patient can reasonable

be expected to make measurable improvement during rehab inpatient stay.

During patient's inpatient rehab stay we will focus on improving the

patient’s functional impairments to increase her independence and

discharge home. To help achieve the return to home we will regulate her

constipation complaints, poor appetite, and sleep dysfunction which will

be needed to achieve her overall rehab goals.

PA

PE E

XA

MP

LE

Have seen and examined the patient at bedside on admission to [rehab

program] on 7/30/18.

I reviewed the pre-admission screening data and compared the data to

patient presentation. I have reviewed the clinical history, current

medication condition and functional data with the APP [Attending Primary

Physician].

I agree with the APP's history, information, physical examination,

prognosis, and estimated length of stay. The patient's condition and

functional status are such that the patient can reasonable be expected to

make measurable improvement during rehab inpatient stay. During

patient's inpatient rehab stay we will focus on improving the patient’s

functional impairments to increase her independence and discharge home.

To help achieve the return to home we will regulate her constipation

complaints, poor appetite, and sleep dysfunction which will be needed to

achieve her overall rehab goals.

PAPE EXAMPLES

I have reviewed the preadmission screen. There are no significant

changes in the patient's condition. This rehabilitation stay remains

reasonable and necessary. She is at risk of complications

including but not limited to recurrent stroke, cardiac event, fall

with injury, significant bleeding.

no change from preadmit note—(NOT SO GOOD EXAMPLE)

OVERALL PLAN OF CARE

OPOC is the rehab physician’s responsibility

Must build on PAS and PAPE and include information gained from

therapy evaluations

Must be completed by end of the 4th day following IRF admission

OVERALL PLAN OF CARE

Rehab physician brings together all information collected on

patient and synthesizes information into overall plan of care to

guide patient’s treatment during IRF stay.

Definition of synthesize for English Language Learners. : to make

(something) by combining different things. : to combine (things)

in order to make something new. : to make (something) from

simpler substances through a chemical process.

TEAM CONFERENCE

Meet weekly—what about the 8th day?

Assess patient’s progress towards rehabilitation goals

Consider resolutions to problems/barriers to progress

Reassess validity of established goals and monitor/revise

treatment plan as needed

TC ATTENDEES

Rehabilitation Physician

Registered Nurse

Social Worker/Case Manager

Treating OT, PT, SP

Additional team members (O&P, Psychologist, Therapeutic Rec)

PPS Coordinator, CDI Specialist/IRF Coder

TEAM CONFERENCE

Critical to have authentication/proof of attendance for each

team member at conference

COTA/PTA not able to represent OT/PT

No LPN—Must be RN

Occur once a week

Rehabilitation physician must lead the conference

Also must document they agree and concur with decisions made by

interdisciplinary team

PHYSICIAN PROGRESS NOTES

At least three face-to-face visits by rehabilitation physician each

week throughout IRF stay

Document medical issues being addressed

Discuss medical and functional status of patient

Identify any modifications needed in treatment plan to maximize

rehabilitation process

Discuss interactions with other professionals

PHYSICIAN PROGRESS NOTE

Reflect on medical decision making to support medical necessity

Conditions you are actively treating

Conditions you are monitoring

Conditions you are thinking about

Progress in therapy

Problem list—update daily

PHYSICIAN PROGRESS NOTES

As the rehabilitation physician, show that you are directing the

care of the patient

Document decisions made based on lab results

Document why you ordered additional tests/procedures and how

results will impact rehab participation

Discuss interactions with other professionals/consulting physicians

DISCHARGE SUMMARY

Summarize the patient’s stay

Might be the only document the reviewer looks at

Provide detail to justify patient being in IRF setting

Document a strong “hospital course” so you will be able to

defend the case in an appeal situation

DOCUMENT TO DEFEND AGAINST

AUDITS

CERT (Comprehensive Error Rate Testing)

SMRC (Supplemental Medical Review Contractor)

MAC (Medicare Administrative Contractor)

RAC (Recovery Audit Contractor)

OIG (Office of Inspector General)

TPE (Targeted Probe and Education)

LEVELS OF APPEAL/MEDICARE

ADR (Additional Development Request)

Redetermination

Reconsideration

ALJ Hearing

Medicare Appeals Council

Federal District Court

WHAT ARE THE BEST PRACTICES?

DOCUMENTATION OF

MEDICAL NECESSITYJill Bustin

Manager, Health Information Management

& Privacy Officer

Mary Free Bed Rehabilitation Hospital