Payment systems for services: documentation through the care continuum
BARBARA EDMISON, PT and JOHN G. WALLACE, JR., PT, MS, OCS
After reading this chapter the student or therapist will be able to:
1. Value the importance of documentation and its relationship to payment for services.
2. Synthesize different inpatient and outpatient payment systems.
3. Differentiate the continuum of care and documentation needed in different treatment settings.
4. Appropriately assign an ICD-9-CM code to medical and functional diagnoses.
5. Identify and select the CPT codes that best describe therapeutic interventions used in treating patients.
Definition of terms
There is an entire language of terms regarding payment issues. Please refer to the Quick Reference Guide to Acronyms (Appendix 10-A) for assistance. When therapy services are received, either the person pays the therapist directly or someone else pays the bill. Generally a patient will pay directly for therapy in three circumstances: (1) having a need for skilled services and not having insurance; (2) having had therapy interventions, understanding their value, and wishing to continue beyond what insurance is willing to cover; or (3) having a preference for a specific therapist who accepts only cash payment or who is not a preferred provider of the insurance company. When someone else pays the bill, it is the third-party payer that is billed for the services. Third-party payers are usually insurance carriers who, by contract or written agreement, may determine the maximum amount of money paid and under what circumstances.
Correct billing and claims processing are also dependent on accurately communicating treatment diagnoses and interventions to third-party payers. Three primary coding systems are used to communicate diagnoses and interventions in health care. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is a tabular list of medical diagnoses approved for use by CMS based on the World Health Organization’s ICD-9, originally published in 1977. Current Procedural Terminology (CPT) (a registered trademark of the American Medical Association [AMA]) is a coding system that describes health care interventions. CMS has developed its own coding system to meet the specific requirements of the Medicare and Medicaid programs. The Healthcare Common Procedure Coding System uses CPT and alphanumerical codes developed by CMS in conjunction with the AMA to describe interventions, procedures, and supplies for the Medicare and Medicaid programs.1 Use of these coding systems is discussed in greater detail later in this chapter.
Federal programs
Medicare and medicaid
“Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease . . . (permanent kidney failure requiring dialysis or a kidney transplant).”2 The Medicaid program provides medical benefits to groups of low-income people, some of whom may have no medical insurance or inadequate medical insurance.3 Although the federal government establishes general guidelines for the program, the Medicaid program requirements are actually established by each state. Whether or not a person is eligible for Medicaid will depend on the state where he or she lives.
“President Truman was the first President to propose a national health insurance plan.”4 Congressional debate about federal health care coverage continued for 20 years. In 1965, HR 6675, the “Mills Bill,” was introduced. “Congressman Wilbur Mills, Chairman of the House Ways and Means Committee, created what was called the ‘three-layer cake’ by starting with President Johnson’s Medicare proposal (Part A), adding to it physician and other outpatient services (Part B), and creating Medicaid which significantly expanded federal support for health care services for poor elderly, disabled, and families with dependent children. Medicare became Title 18 of the Social Security Act and Medicaid became Title 19.”4 Although HR 6675 passed the House without a single amendment, the Senate version required much more discussion and many amendments. Finally, Medicare Part A, which involves basic hospital benefits and other institutional services for the elderly; Medicare Part B, a voluntary program; and Medicaid were approved by both the House and Senate.
Medicare and Medicaid implementation did not begin until 1966. Initially, “Medicare was the responsibility of the Social Security Administration (SSA), the agency that controlled the retirement social insurance program through which most people became eligible for Medicare. Federal assistance to the State Medicaid programs was administered by the Social and Rehabilitation Service (SRS). SRS oversaw welfare programs including Aid to Families with Dependent Children (AFDC), through which many people became eligible for Medicaid. SSA and SRS were agencies in the Department of Health, Education, and Welfare (HEW). In 1977, HEW Secretary Joseph Califano reorganized the department to create the Health Care Financing Administration (HCFA). HCFA was designed to improve administration of both Medicare and Medicaid by moving both health programs together, to improve the staffing of the Medicaid program, and to create a new administrative structure to implement national health insurance. In 1980, HEW was divided into the Department of Education and the Department of Health and Human Services (HHS). In 2001, Secretary Tommy G. Thompson renamed HCFA to become the Centers for Medicare and Medicaid Services (CMS) as part of his initiative to create a new culture of responsiveness in the agency.”4
“Coverage for Medicare Part A is automatic for people age 65 or older (and for certain disabled persons) who have insured status under Social Security or Railroad Retirement. Most people don’t pay a monthly premium for Part A. Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B also requires payment of monthly premiums. People with Medicare who have limited income and resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program. There are various benefits available to ‘dual eligibles’ who are entitled to Medicare and are eligible for some type of Medicaid benefit. These benefits are sometimes also called Medicare Savings Programs (MSPs). For people who are eligible for full Medicaid coverage, the Medicaid program supplements Medicare coverage by providing services and supplies that are available under their state’s Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the state’s payment limit. Medicaid also covers additional services (e.g., nursing facility care beyond the 100-day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids). Limited Medicaid benefits are also available to pay out-of-pocket Medicare cost-sharing expenses for certain other Medicare beneficiaries. The Medicaid program will assume their Medicare payment liability if they qualify.”5
The BBA also created the Children’s Health Insurance Program (CHIP), also known as Title XXI of the Social Security Act. “CMS administers this program, which helped states expand health care coverage to over 5 million of the nation’s uninsured children. The program was reauthorized on February 4, 2009, when President Obama signed into law the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3). CHIPRA finances CHIP through fiscal year 2013. It will preserve coverage for the millions of children who rely on CHIP today and provides the resources for states to reach millions of additional uninsured children. CHIP is jointly financed by the federal and state governments and is administered by the states. Within broad federal guidelines, each state determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures. CHIP provides a capped amount of funds to states on a matching basis. Federal payments under CHIP to states are based on state expenditures under approved plans effective on or after October 1, 1997.”6
At least two other federal laws affect children who may not have sufficient health care coverage. The Elementary and Secondary Education Act of 1965 (ESEA), reauthorized as the No Child Left Behind Act of 2001 (NCLB), is standards-based education reform that is directed at disadvantaged students. IDEA, the Individuals with Disabilities Education Act, provides for early intervention, special education, and related services to children with disabilities.7
Health insurance portability and accountability act of 1996
“A major goal of the Privacy Rule is to [ensure] that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public’s health and well-being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.”8
“While the Privacy Rule mandates policies and procedures to protect patient information in all forms, the purpose of the Security Rule is to adopt national standards to protect the confidentiality, integrity, and availability of electronic protected health information. This Rule is directed at the covered entities, which are health care providers, health care clearinghouses, and/or health plans, that transmit or maintain protected health information electronically [and] are required to implement reasonable and appropriate administrative, physical, and technical safeguards. The Security standards require that steps be taken to protect this information from reasonably anticipated threats or hazards. Built into the Security Rule, however, is some flexibility that allows covered entities to determine what is reasonable and appropriate based on their size, cost considerations, and their existing technical infrastructure. This built-in flexibility also makes allowances for the rapid changes in technology.”9
“Congress mandated improved enforcement of the Privacy Rule and Security Rule in the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009. Privacy and Security are naturally intertwined, because they both address protected health information. Combining the enforcement authority in one agency within HHS will facilitate improvements by eliminating duplication and increasing the efficiency of investigations and resolutions of failures to comply with both rules. Moreover, combining the administration of the Security Rule and the Privacy Rule is consistent with the health care industry’s increasing adoption of electronic health records and the electronic transmission of health information.”10
Prospective payment systems
“Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute-care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. This payment system is referred to as the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.”11
Outcome measures
The IRF-PAI, RAI, and OASIS were developed with essentially the same goals in mind: (1) to measure patient outcomes and (2) to improve quality of care. These tools are each used in conjunction with the Medicare PPS to determine payments. However, the functional tools themselves are not related and therefore there is no one system available in the United States to provide “standardized, patient-centered outcome data that can provide policy officials and managers with outcome data across different diagnostic categories, over time, and across different settings where post-acute services are provided (p. 13).”12 For the future, it is hoped that “functional outcome data that [are] applicable to patients treated across different clinical settings and applications, more efficient and less costly to administer, and sufficiently precise to detect clinically meaningful changes in functional outcomes (p. 23)”12 will be developed.
Inpatient rehabilitation facility–patient assessment instrument
In an IRF, the IRF-PAI is required by CMS as part of its PPS. On admission to the IRF, the patient is assigned an Impairment Group Code (IGC), which is the condition requiring a rehabilitation stay. “The IRF PPS uses data from the IRF-PAI to classify patients into distinct groups based on clinical characteristics and expected resource needs. These distinct groups are called ‘case-mix groups’ or ‘CMGs.’ To classify a ‘typical patient,’ one who has a length of stay of more than 3 days, receives a full course of inpatient rehabilitation care, and is discharged to the community, into a CMG, the admission IGC, the admission motor and cognitive scores from the FIM,* and the age at admission are required. The CMG and comorbidity tier determine the unadjusted federal prospective payment rate.”13
The Patient Assessment Instrument is best known for having incorporated the Functional Independence Measure (FIM)14 along with function modifiers, quality indicators, and additional patient information. “The FIM instrument is a basic indicator of severity of disability . . . . The need for assistance (burden of care) translates to the time/energy that another person must expend to serve the dependent needs of the disabled individual so that the individual can achieve and maintain a certain quality of life. The FIM instrument is a measure of disability, not impairment. The FIM instrument is intended to measure what the person with the disability actually does, whatever the diagnosis or impairment, not what (s)he ought to be able to do, or might be able to do under different circumstances (p. III-1).”*15
Demographic, payer, medical, admission, and discharge information are included in the IRF-PAI. “The function modifiers assist in the scoring of related FIM items and provide explicit information as to how a FIM score has been determined.”15 These modifiers apply to bowel and bladder control, tub and shower transfers, and distances covered by walking or in a wheelchair. The FIM instrument specifically addresses the amount of assistance required for the functional activities of eating; grooming; bathing; upper body and lower body dressing; toileting; bladder and bowel management; bed, chair, and wheelchair transfers; toilet transfers; tub transfers; shower transfers; locomotion via walking or wheelchair; stairs; comprehension; expression; social interaction; problem solving, and memory. Each has its own algorithm to determine the FIM score. Quality indicators include respiratory status, pain, pressure ulcers, and safety (balance and falls).15
The FIM instrument has a total of seven levels of assistance. These are divided into two main categories, Independent—No Helper, and Dependent—Requires Helper. The two items in Independent—No Helper consist of Complete Independence—7 and Modified Independence—6. The highest score of 7 indicates that the patient completes the task safely, in a timely manner, and without any assistive devices. A score of 6 means that the patient requires a device or takes extra time or safety is an issue. The Dependent—Requires Helper category is further divided into two sections: the Modified Dependence—5, 4, and 3 scores, in which the patient provides 50% or more of the effort, and the Complete Dependence—2 and 1 scores, in which the patient’s effort is less than 50%. Supervision or setup, 5, denotes no physical contact with the patient; the patient requires coaxing or someone standing by, or a helper may need to set up the equipment. Minimal contact assistance, 4, includes touching; the patient is doing 75% or more of the activity. Moderate assistance, 3, indicates that more than touching is required, with the patient giving 50% to 74% effort. Maximal assistance, 2, has the patient supplying 25% to 49% of the effort. In Total assistance, 1, the patient performs less than 25% of the workload. There is a training manual available to assist the clinician in completing this form.15
A similar data or documentation form is used in pediatrics: the WeeFIM II System. “The WeeFIM instrument was developed to measure the need for assistance and the severity of disability in children between the ages of 6 months and 7 years. The WeeFIM instrument may be used with children above the age of 7 years as long as their functional abilities, as measured by the WeeFIM instrument, are below those expected of children aged 7 who do not have disabilities. The WeeFIM instrument consists of a minimal data set of 18 items that measure functional performance in three domains: self-care, mobility, and cognition.”16
Resident assessment instrument
The MDS is completed on a set schedule. After the initial 5-day, then 14-, 30-, 60-, and 90-day reports, the MDS is filed on a quarterly and annual basis. The MDS requires input from residents, their families, physicians, therapists, and dieticians. Facility staff from direct care, social services, activities, billing, and admissions is also consulted. The resident’s performance over the entire 24-hour day is reviewed and recorded to create an individual picture of strengths and needs. The MDS includes a complete review of the resident’s health, sensory systems, activity levels, behaviors, continence, activities of daily living (ADLs), physical and functional status, medications, procedures, and discharge plans. Although the MDS assesses activities similar to those of the FIM, the format is quite different. The Functional Status section is composed of Activities of Daily Living Assistance, Bathing, Balance during Transitions and Walking, Functional Limitations in Range of Motion, Mobility Devices, and Functional Rehabilitation Potential. The Activities of Daily Living Self-Performance subcategory of Activities of Daily Living Assistance includes bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene. The scoring system is based on an activity occurring three or more times. Use code 0 for Independent, no help or staff oversight; 1 for Supervision—oversight, encouragement, or cueing; 2 for Limited assistance if the resident is highly involved in the activity; 3 for Extensive assistance if the resident is involved in the activity and staff members provide weight-bearing support; and 4 for Total dependence if full staff performance is required every time. This section has a separate but related area to record the ADL Support Provided. In this case, the coding is 0 for no setup or physical help from staff; 1 for setup help only; 2 for one-person physical assistance; and 3 for physical assistance from two or more persons. The MDS has a training manual available to assist with completing the instrument.17
In response to providers, consumers, and others, CMS implemented the new and improved MDS Version 3.0 effective October 1, 2010. This redesigned version incorporated many significant changes. Based on a RAND/Harvard team effort, the MDS 3.0 is much easier to read and accomplishes several goals. These include improved resident input, improved accuracy and reliability, increased efficiency, and improved staff satisfaction and perception of clinical utility. A new development with MDS 3.0 is the addition of the Care Area Assessment (CAA) Process to assist with the interpretation of the information gathered from the MDS. As of October 2010, the RAI components are the MDS 3.0, the CAA process and the RAI utilization guidelines. An updated classification system, RUG-IV, was scheduled to be introduced at the same time as the MDS 3.0. However, while Section 10325 of the Affordable Care Act allowed CMS to implement the MDS 3.0 as scheduled, this same Section mandated a delay of the implementation of the RUG-IV classification system by one year. Portions of RUG-IV were implemented on an interim basis on October 1, 2010. The purpose of RUG-IV is to more accurately allocate payments. RUG-III bases payments on predicted therapy minutes from the MDS, causing inaccurate classifications and payments to SNFs in some instances. RUG-IV calculates the average daily number of therapy minutes based on the actual number of minutes provided to assign patients to Rehabilitation categories. The number of minutes of therapy received affects the reimbursement rate. This is why it is very important to correctly document the time spent treating the resident in addition to the resident’s functional status.18
Outcome and assessment information set
“The Outcome and Assessment Information Set (OASIS) is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement. The OASIS is a key component of Medicare’s partnership with the home care industry to foster and monitor improved home health care outcomes. The goal was not to produce a comprehensive assessment instrument, but to provide a set of data items necessary for measuring patient outcomes and essential for assessment—which home health agencies (HHAs) in turn could augment as they judge necessary. Overall, the OASIS items have utility for outcome monitoring, clinical assessment, care planning, and other internal agency-level applications.”19
The OASIS includes sections on patient demographics, clinical record items, patient history and diagnoses, living arrangements, sensory status, integumentary status, respiratory status, cardiac status, elimination status, neuro/emotional/behavioral status, ADLs and instrumental activities of daily living (IADLs), medications, care management, and therapy need and POC. The ADL/IADL category is divided into grooming, upper body dressing, lower body dressing, bathing, toilet transferring, toileting hygiene, transferring, ambulation/locomotion, feeding or eating, ability to plan and prepare light meals, ability to use telephone, prior functioning ADL/IADL, and fall risk assessment. In the OASIS format, choices to describe patient function vary with the activity. Grooming, upper and lower body dressing, and toileting hygiene scales are 0 for independent; 1 for setup, no assistance; 2 if someone must help with the activity; and 3 if the patient is totally dependent. With bathing, the range is from 0, or independent, to 6, bathed totally by another person. For transfers, 0 is independent and 5 is bedfast, unable to move self. Ambulation/locomotion scores are from 0, able to independently walk on even and uneven surfaces, and negotiate stairs with or without railings and no device, to 6, bedfast, unable to ambulate or be up in a chair. Feeding or eating starts with 0 for able to independently feed self and extends to 5, unable to take in nutrients orally or by tube feeding. Ability to plan and prepare light meals (make cereal or sandwich or reheat delivered meals safely) ranges from 0 for independent or was able to but did not before this admission to 2 for unable. Ability to use telephone is 0 for able to dial numbers and answer calls appropriately and as desired to 5, totally unable to use the telephone. Prior functioning requests information about self-care, ambulation, transfer, and household tasks. Finally, the fall risk assessment asks if the patient is at risk for falls. A score of 0 means that no multifactor fall risk assessment was conducted, 1 indicates that the fall assessment was completed but does not indicate a risk for falls, and 2 indicates that the patient is at risk for falls. The care management section assesses the level of caregiver ability and willingness to provide assistance if needed in activities ranging from ADL assistance to patient advocacy. Note that although the OASIS is very precise, it also makes it difficult to measure progress. For example, in the ambulation category, a score of 4 indicates “chairfast, unable to ambulate but is able to wheel self independently”; 3 indicates “able to walk only with the supervision or assistance of another person at all times”; and 2 indicates “requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.”20 This is another example of the importance of documentation to report significant improvement in therapy.
Documentation recommendations
Medicare guidelines provide the minimum context standards required for adequate documentation. Satisfying minimum guidelines is not sufficient for the therapist who is thinking critically. This therapist should always be asking determinative questions (Box 10-1).
When the answer is “yes,” the therapist must be able to answer the additional questions in Box 10-1. These important questions justify treatment and payment. The patient may have insurance or may be receiving federal, state, or county aid. Either way, the therapist must not forget that someone is responsible for paying the bill and that someone deserves a meaningful and beneficial product in return.
The American Physical Therapy Association (APTA) has published Guidelines: Physical Therapy Documentation of Patient/Client Management.21 These guidelines can be found on the APTA website (www.apta.org) under About Us—Policies and Bylaws—Board of Directors Positions and Policies, Section I—Practice. Although the general guidelines in Box 10-2 were written as part of an APTA document, they set a standard for therapists in the health care industry.
The LCD standards and other helpful information are available through specific websites or through the Medicare Coverage page of the CMS website (www.cms.gov). Nongovernment third-party payers can follow guidelines of their own design. These may or may not be similar to Medicare guidelines. In general, when a therapist’s documentation meets Medicare requirements, it satisfies the expectations of other third-party payers as well.
1. Intervention, as related to the specific profession, is an accepted standard of care for this diagnosis. There are specific and effective interventions (evidence-based practice) successfully used to treat the condition.
2. The treatments require the skilled services of a professional. Knowledge and judgment are required because of the complexity of the problem and sophistication of the therapist’s unique body of knowledge.
3. Therapeutic intervention creates significant improvement, demonstrated by measurable gains in range of motion, strength, function, level of assistance, and so on.
4. The amount, frequency, and duration of treatment are reasonable. This is clarified by a POC with short- and long-term goals, predicted end of treatment, and reasonable potential to achieve the stated goals. Weekly reassessments or changes in the patient’s condition will require the plan to be modified as necessary.
Recovery audit contractors
As part of the Medicare Modernization Act of 2003, Congress initiated a Recovery Audit Contractor (RAC) demonstration project to fight fraud, waste, and abuse in the Medicare system. “The demonstration resulted in over $900 million in overpayments being returned to the Medicare Trust Fund between 2005 and 2008 and nearly $38 million in underpayments returned to health care providers.”22 The RACs were so effective that Congressional legislation made them permanent in Section 302 of the Tax Relief and Health Care Act of 2006. This Act expanded the RAC program to cover all 50 states in January 1, 2010. These audits were designed with three purposes in mind: first, to protect Medicare beneficiaries; second, to protect taxpayer dollars used to make payments; and third, to ensure that claims were paid only for services that met Medicare requirements. The RAC teams, which are required to include nurses and therapists, are paid on a contingency fee basis in which the fee is returned if the provider wins at any level of appeal.
“The goal of the recovery audit program is to identify improper payments made on claims of health care services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Health care providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills Medicare Parts A and B.”22 Because a complex review requires the medical record, documenting comprehensible reasonable and necessary skilled services is critical.
Documentation: a legal document
Motivation
A therapist should believe that a patient is motivated to improve. Sometimes there is damage to the brain that affects initiation, insight, or judgment; sometimes there is depression, pain, or another medical reason. It is the therapist’s responsibility to find the key to unlock the patient’s ability to participate. Do not record that the patient is unmotivated. The lack of motivation usually belongs to the therapist. (See Chapter 5 for additional information.)
Pain
The Joint Commission has brought the patient’s pain level to the forefront, making a patient’s pain level the “fifth vital sign.” It is required that a comprehensive pain assessment appropriate for the patient’s age and condition be recorded at regular intervals. The most common pain scale is 0 to 10, with 0 signifying no pain and 10 signifying the worst pain the patient can imagine. To further explain the scale to the patient, the numbers 1 to 3 correspond to minimal pain, 4 to 7 to moderate pain, and 8 to 10 to severe pain. A score of 4 or higher requires immediate attention. It is important to explain to the patient that his or her pain scale response is accepted at face value and belongs only to the patient; the patient’s numbers are not compared with those of anyone else. For children ages 3 years and older, the Wong-Baker FACES Pain Rating Scale23 may be easier to understand. The purpose of a pain scale is to ascertain the effectiveness of pain medication or pain-reducing modalities. It is important to document the pain number at rest and during treatment, whether pain interferes with or prohibits participation in therapy, and what the therapist has done to remedy the painful situation. (See Chapters 5 and 32 for additional information.)
Continuum of care
Acute care
Subacute care
A patient who is admitted to the hospital and then requires the use of both a ventilator and a feeding tube may benefit from a subacute setting before moving on to acute inpatient rehabilitation. In the subacute setting, respiratory therapists and the nursing staff have key roles. Patients who have had respiratory failure in addition to their neurological deficits require a much slower pace to achieve their rehabilitation goals (see Chapter 3). These patients, with extremely impaired endurance and low functional levels, may stay in subacute settings for several months before they develop sufficient strength to progress to acute inpatient rehabilitation or return home. Short-term goals are set month to month, in contrast to acute-care hospitals, where short-term goals may be met in a matter of visits or days.
Home health
Patients who are discharged from hospitals and facilities may still require additional therapy. They may not have the ability or the endurance to travel to an outpatient setting and then also participate in the various therapies. In these cases, home health therapists provide the solution. To receive home therapy, a patient must be homebound. According to CMS, the definition of homebound is “Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn’t keep you from getting home health care.”24 Documentation must explain why the patient is homebound. As the patient improves, this becomes more difficult and facilitates a decision for outpatient therapy or discontinuation of therapy services altogether.
Therapy and discharge planning
When discharge options are considered, there are questions a therapist should ask as part of the critical-thinking process (Box 10-3).
There are many aspects to consider. The patient’s prior level of function is essential information, followed closely by the situation at home. The medical and surgical histories are also pertinent factors. Contemplate the questions listed in Box 10-4.
Medical and functional diagnosis and intervention coding: diagnosis coding
Organization and characteristics of ICD-9-CM
ICD-9 codes can be up to five digits long: at least three digits are to the left of the decimal and up to two digits to the right of the decimal. The three digits to the left of the decimal define the diagnosis category, and the two available digits to the right of the decimal define more specific characteristics of the diagnosis by further defining site and location. We will look at several examples to illustrate the coding process (Box 10-5).
ICD-9 coding is a five-step process
The following five-step process will guide the reader through the ICD-9 coding process:
Step 1: Start by consulting the alphabetical index (Volume 2) to identify the diagnostic category before using the tabular index (Volume 1). By identifying the correct name of the diagnostic category in the alphabetical index, therapists will avoid coding errors that will result in denied services.
Step 2: Identify the main medical or functional diagnostic term or category. The alphabetical index is arranged by condition. Conditions can be expressed as nouns, adjectives, and eponyms. Some conditions have multiple entries under their synonyms. Be sure to read any notes listed with the main term or category because these categories will help the reader identify the specific diagnostic code he or she is trying to identify.
Step 3: Interpret abbreviations, cross-references, and brackets. Cross-references used are “see,” “see category,” and “see also.” The abbreviations NEC and NOS follow main terms or subterms. Identify a tentative code and locate it in the tabular index.
Step 4: By reading the entry in the tabular list, clinicians will be able to determine whether the code is at its highest level of specificity. Assign three-digit codes (category code) if there are no four-digit codes within the code category. Assign four-digit codes (subcategory codes) if there are no five-digit codes for that category. Assign five-digit codes (fifth-digit subclassification codes) for these categories where they are available.
Box 10-5 provides two ICD-9 coding examples.
Intervention coding
Current procedural terminology
Current Procedural Terminology,26 Fourth Edition, is maintained, updated, and published by the AMA and is a registered trademark of the AMA. It is a code set designed to identify the interventions and other services performed by health care providers. Each intervention or service is described by a five-digit code. CPT is mandated by HIPAA as the appropriate code set for use in health care transactions in the United States.
The AMA first published the fourth edition of CPT in 1977. CPT is continually updated to keep the codes current with the community standard of practice by a process led by the AMA CPT Editorial Panel.26 For the rehabilitation disciplines, the Health Care Professional Advisory Committee develops CPT coding changes and updates. The Committee consists of representatives from 16 nonphysician provider groups, including physical therapy, occupational therapy, and speech and language pathology.
It is important to recognize that the listing of a service or procedure and its code number in a specific of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.26
Physical medicine CPT codes
The Physical Medicine codes are organized into six groups of codes. The codes in these subsections have specific attributes.26
Other procedures
Each year therapists should review the codes and sections commonly used for changes and additions that will better describe the interventions performed with their patients. All therapists should consult the CPT codes directly and avail themselves of training specifically designed to help them accurately describe their interventions. CPT coding resources are available from a number of sources, including the AMA and professional associations such as APTA.27
Outpatient payment policy
Medicare and medicaid
Both the Medicare and Medicaid programs are overseen and regulated by CMS. Medicare, as a federal program, is heavily regulated. These regulations are readily available to providers through a number of resources, but the primary access to information is through the Internet at http://cms.gov. As previously discussed, Medicare pays for outpatient services through MACs. Each of these entities must maintain a website for beneficiaries and providers to allow for ready dissemination of pertinent information. MACs use Medicare’s national policies to process and adjudicate claims. Although Medicare has national policies, MACs have some discretion in how these policies are implemented locally. Any MAC regulations or policies specific to particular services, interventions, or provider types are contained in LCDs that must go through a lengthy draft and approval process before they are made available to providers and implemented. Most MACs have LCDs specific to physical rehabilitation providers (physical therapy, occupational therapy, and speech and language pathology) as well as specific services or interventions such as wound care, biofeedback for incontinence, vestibular problems, and cardiac rehabilitation. Because MACs have defined geographic coverage areas, it is advisable for therapists to be sure they are familiar with Medicare’s payment policies in the areas where they practice.
*Copyright © 2001, 2002 UB Foundation Activities, Inc. (UBFA, Inc.) for compilation rights; no copyrights claimed in U.S. Government works included in Section I, portions of Section IV, Appendices I and K, and portions of Appendices B, C, E, G, H, and J. All other copyrights are reserved to their respective owners. Copyright © 1993-2001 UB Foundation Activities, Inc. for the FIM Data Set, Measurement Scale, Impairment Codes, and refinements thereto for the IRF-PAI, and for the Guide for the Uniform Data Set for Medical Rehabilitation, as incorporated or referenced herein. The FIM mark is owned by UBFA, Inc.