Physician Documentation Tips

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.

Recently, a reminder was sent to providers with results of an Office of Inspector General (OIG) audit, which found non-compliance in a large percentage of inpatient rehabilitation claims. I do not know if there was an implied message behind the warning, or if it was just a friendly reminder. In either case, it seems like the right time to dust off the cobwebs and review the Medicare documentation requirements for inpatient rehabilitation providers.

The OIG report, states that a large percentage of requested records did not meet eligibility requirements for an inpatient rehabilitation stay due to missing documentation. In the past, these were referred to as technical errors or lack of proof of medical necessity. The following list of requirements can be shared with physicians to ensure awareness of the requirements for Medicare patients.

CMS Requirements 1. Sign the pre-admission screening no more than 48 hours prior to the patient’s admission. 2. Assess the patient within 24 hours of admission and complete the H&P. 3. Complete the overall plan of care by the end of the fourth day of rehab. 4. Complete at least three documented face-to-face visits per week (in addition to the H&P). 5. Include updates on medical and functional progress and participation in your progress notes at least three times per week.

Medical Necessity 1. Thoroughly document the conditions that will be managed. 2. Discuss the strategies and interventions necessary to manage those conditions. 3. Be explicit about the patient’s need for medical management by stating what you saw, thought, and did during your exam. 4. Mention function and state whether the patient’s progress or lack of progress is meeting your expectations. 5. Note all order changes and tests in the progress notes to reflect close medical management. An auditor may not put these items together or read far enough into a record to see orders.

Team Conference Per CMS, the purpose of team conference is four-fold: 1. Discuss progress made. 2. Note barriers to discharge. 3. Identify interventions necessary to remove barriers. 4. Update the plan of care.

Ways to achieve this: • Discontinue repeating the admission, current, and goal function, which is already stated in the team progress notes. • Solicit barriers to discharge from staff. • Document interventions that will be attempted to remove barriers. • Note if staff indicate that the plan of care needs to be modified.

Team conference must take place weekly. No more than seven days should elapse between team conferences, regardless of whether the conference day falls on a holiday. All members of the treatment team must be present for conferences, or have a designee attend on their behalf.

Remember that the timelines for completion of the CMS requirements are firm. If your medical record does not strictly adhere to these time frames, you risk denial of the record when it is reviewed. The quality of the documentation is equally as important, as it establishes the need for close medical supervision and an intense rehabilitation program. Less is not more in physician documentation. Careful and thorough documentation is critical to proving that an inpatient rehabilitation stay was reasonable and necessary. Use these tips to ensure that documentation reflects the stellar care provided in your rehabilitation hospital or unit.

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AMRPA: Working Together To Preserve Access To Medical Rehabilitation AMRPA: Working Together to Preserve Access to Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org, 202-207-1102.