Rehab

Five therapy mistakes that affect reimbursement in skilled nursing facilities

Rehab Regs, March 11, 2003

You deserve to get paid for the work that you do-and so does your facility.

However, misunderstandings between nursing and rehab, along with inadequate therapy documentation, cost facilities thousands of dollars in revenue a year.

Kelsey Schwartz, RN, C, MHA, a licensed nursing home administrator, says therapists who work in skilled nursing facilities often make mistakes that fall into the following six categories. Below, Schwartz outlines the mistakes and offers some solutions:

1. Inconsistent documentation. Often, the number of minutes in the therapy notes does not match what has been communicated to the MDS team and the business office. This may be a red flag to the Office of Inspector General (OIG) and ultimately cost you reimbursement.

Make sure patient goals match what's in the care plan, Schwartz says. "Basically, throughout the documentation, everybody needs to be saying the same thing-that the resident has the same potential and is receiving the services to attain these goals."

  • How to document better. Keep daily therapy logs that include therapy rendered, the support needed, the number of therapy minutes residents received, and progress toward goals.

2. Poor tracking of therapy minutes. Schwartz says one facility she helped used to predict how many therapy minutes a patient would receive, then tell the business office what category Resource Utilization Group (RUG) the resident would be in. You can't do that.

Tracking minutes must include the actual time a resident spends in therapy. If minutes are not tracked accurately, you may be paid in a lower RUG. If you accidentally bill for more therapy than the resident received, you risk allegations of fraud.

  • How to track minutes better. Hold daily Medicare meetings. Anticipate how many minutes of therapy a resident will need, but record only the minutes of therapy the resident did receive.

    Anticipating therapy minutes will help better ensure that the resident receives the amount of therapy that's needed. And if, for example, a resident only received 30 minutes of therapy when he or she should have received 45 minutes, you'll know you need to make up some lost time, if appropriate.

    In these situations, come up with solutions to help the resident meet care plan goals. Remember to focus on the needs of the resident before your financial goals.

3. Lack of communication. Nurses and therapists are sometimes territorial regarding patients, and that can get in the way of therapy. Talk with nursing staff about a resident's condition, schedule, status, and anything that may hinder a resident from receiving therapy.

"Frequently, therapy does not occur because nursing hasn't communicated that the resident has an appointment somewhere," Schwartz says. "Or, therapy hasn't communicated the therapy schedule to nursing, so nursing doesn't have the resident ready for therapy. Communication is critical."

When a resident misses therapy, it affects both the resident and the facility's bottom line. Therapists may not have been told that a resident has an appointment outside the facility, or the resident may not be dressed and ready for therapy.

  • How to communicate better. Develop clear communication and tracking policies. It's important that facilities are clear about when a resident is scheduled for therapy, as well as changes in the schedule. Discuss the type of documentation needed for therapy, who is responsible for therapy, and who is responsible for tracking therapy minutes.

    For example, create a therapy schedule that shows when residents are supposed to go to therapy. Make sure the schedule is displayed prominently, but it should not be seen publicly to protect resident privacy. The schedule system must also be available to the certified evaluation nurse aides, who are responsible for preparing the residents for appointments and making sure they are on time.

    By getting cooperation from the nursing staff, you'll maximize therapy productivity and minimize wasted time.

4. Nurses don't know therapy. Too often, nurses don't understand the importance of therapy. They should. Schwartz points out that therapy generally receives the most reimbursement. If nurses don't understand how important therapy is, care and reimbursement may be sabotaged. "Nursing needs to buy into what therapy needs to do to get their job done," Schwartz says.

  • How to work with nurses. Educate nursing staff about the therapist's role in PPS. What are your policies regarding therapy documentation? What are your policies regarding therapy scheduling? Where can the therapy schedules be found? What is the nurses' responsibility for meeting those schedules?

5. Lack of minutes spent on treatment recorded in restorative nursing notes. It's just as important to help residents maintain or improve function using restorative nursing. Make sure therapy minutes are being documented even if it's not a therapist who delivers the care. It's no longer enough to simply follow the care plan. Actual minutes of restorative nursing must be documented as well.

"What we're finding is that some places feel that if it's on the care plan, that's enough," Schwartz says. "If the care plan says, 'Give the resident range of motion for 15 minutes a day,' nurses cannot just sign off that they are following the care plan. The OIG is looking for the actual minutes spent giving the care, on a per-day basis, to be signed for."

  • How to improve restorative nursing: Clearly define the restorative nursing program and the policies, procedures, systems, and forms that go along with it. Include the number of minutes of restorative therapy delivered.

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