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Necessity knowledge is necessary

Rehab Regs, January 8, 2005

Avoid the common stumbling blocks that lead to denials

Establishing medical necessity is an essential part of ensuring reimbursement for the services you provide. But unless you can adequately document the need for those therapy services, Medicare and other insurance carriers may not always agree to pay.

As you probably suspected, it all boils down to adequate documentation. Regardless of how well you provide rehab services to your patients, if your fiscal intermediary (FI) or carrier can't clearly understand how and why you provided them, your reimbursement could be in jeopardy.

"If therapists aren't showing that the services [they provided] were of such a level that only a therapist could provide them, the claim may be denied," says Rick Gawenda, PT, director of rehab services at Detroit Receiving Hospital.

The bad news is that there is no foolproof way to document medical necessity because each claim reviewer is different and the denial process is often subjective. But the good news is that you can arm yourself with the basics to make a medical necessity denial less likely.

When you write notes, consider what services you provide and why you choose specific exercises or modalities. Do you make this information known to your FI through what you write down?

You can't simply write a note explaining that a patient has completed activities of daily living, says Monika Shumbo-Poissant, OTR, rehab manager at Bennington (VT) Health and Rehabilitation Center.

"If you do a 60-minute treatment of [a patient's] bathing and dressing routine, a payer will want to know why it took that long," says Shumbo-Poissant. "You need to document rest breaks, use of adaptive equipment, etc."

The following is an example of a do and a don't:

Poor documentation: "Lower-extremity strengthening exercises, all joints, times 10 reps."

Good documentation: "Therapy exercises to increase strength-sitting knee extension with 20 lb weight, three sets times 10 reps to increase quad strength for stair climbing."

Be sure to answer the following questions, says Gawenda:

Documentation isn't any therapist's favorite activity, but doing it right can free up time to spend with patients.

You can apply the formula for meeting medical necessity in your notes to other documentation requirements as well. It includes

-time management. If you allot a specific amount of time per day to paperwork, you can use that time to concentrate and thoroughly complete each patient's progress notes.

-communication. You might never know that your claims are being denied because of medical necessity if your therapy director doesn't pass that information along to you. And if he or she isn't informed about denied claims from the billing department, you could lose out on opportunities to appeal those denials.

Avoid making the same mistakes by ramping up your communication skills. "The billing department and the therapy department really need to be on the same page," says Shumbo-Poissant. "The key is to work as a team."

-education. This may come in the form of inservice trainings, conference attendance, or continuing education course enrollment. Some facilities also create mentoring programs in which senior staff can help newer therapists improve their documentation skills.

"If we find a documentation problem, our reaction is immediate," says Shumbo-Poissant. "It may be an impromptu meeting or a formal change in the way we document," she says.

-flow sheets. If the forms at your facility contain blank space, it may be a daunting task for a therapist to document a significant amount of descriptive writing. Try a flow sheet instead.

"Anytime something requires narrative writing, people don't tend to write much," says Gawenda. "That's why I'm a fan of flow sheets."

These flow sheets can include modalities and variations that occur over time.

"Every two to three treatments, you need to document why the patient still requires skilled therapy," says Gawenda. "You must show his or her progress, and what the patient can now do and what he or she still can't do," he says.

Editor's note: To learn more about medical necessity and other common denial reasons, listen in to "Denials and Appeals for Rehab: Successful Strategies to Increase Your Reimbursement," a 90-minute live audioconference on Thursday, January 27, at 1 p.m. EST. Call 800/639-8511 or go to www.hcmarketplace.com for more information or to register.

To start your new year off right, here are seven tips from industry experts to help you establish medical necessity:

Editors' note: This information was adapted from The How-To Manual for Rehab Documentation, written by Rick Gawenda, PT, and published by HCPro, Inc. Call customer service at 800/650-6787 for additional information.

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