PPS training essential to maximize reimbursement
Rehab director offers these guidelines
Through a comprehensive educational program, visual cues, and training updates, a facility can educate its rehab staff on how to best document patient status in order to receive the appropriate reimbursement under the inpatient rehabilitation prospective payment system (PPS).
Unity Health System in Rochester, NY, has educated and trained rehab staff with a program that includes guidelines derived from the Centers for Medicare and Medicaid Services (CMS), journals, and other rehabilitation facilities, says Sue Vogl, MPA, physical medicine and rehab administrative director for Unity Health System, which has a 33-bed rehab unit.
"We knew what we needed to do back in 1999, but we were waiting for the final rule to be published," Vogl says.
Once CMS published the final rule and made changes to eliminate its first proposal of using the Minimum Data Set — Post Acute Care and switching to the industry’s preferred system, the Functional Independence Measure (FIM), the rehab facility began to analyze how documentation would change.
Two teams were formed. The clinical team had nurses from all three shifts and representatives from speech therapy, occupational therapy, and physical therapy. The reimbursement team had staff from medical records, finance, information systems, and reimbursement, Vogl says.
"Each team was working side by side but focusing on their particular issues," Vogl adds.
"We were a former FIM user, so therapists were used to scoring on the FIM, but we revised all assessment tools and FIM scoring," Vogl explains. "We used training materials developed by CMS, and we had one other staff person and myself go to three training sessions across the country."
Vogl came back with PowerPoint presentations, videos, flip charts, and other training materials. She also made use of the CMS web site and its question-and-answer information. The training modules were established within four to six months.
"We set up two-hour training blocks, where a nurse manager and I would do the training, including midnight training for the night staff," Vogl says. "We did five or six sessions where everyone would have to sign in and take a post-test."
From the post-test, managers determined what the problem areas were and would focus on those in follow-up training.
Assessment charts are audited on a weekly basis to make sure they are done completely and accurately, and the rehab facility has an assessment coordinator who has worked in the rehab field for 10 years, Vogl says.
Most of their problem areas were found within the first six weeks of starting the new assessment program, which the facility initiated prior to PPS implementation, Vogl adds.
"Since then, we have an ongoing monitoring program, so if there are isolated problems we can catch them before they become trends," Vogl says. "We’re very happy with it."
Here’s how the educational modules were established:
• Mobility scoring: Under the PPS tool, the patient’s transfer status has to be described according to different scenarios.
Therapists and nurses were taught, through various examples, how the Medicare instrument differentiates between definitions for transferring from bed vs. to wheelchair vs. to chair.
This module also covered locomotion, including walking and wheelchair use. Under PPS, this documentation has a new and more difficult consideration. Physical therapists and/or other staff who assess patients at admission will need to decide what their expectations are for each patient with regard to locomotion, Vogl says.
"Therapists always have goals for patients, but they may not be comfortable on admission to say whether this person is going home with a walker or independently or in a wheelchair," Vogl says. "So the question for us was what would happen if a therapist thought a patient would walk without a wheelchair, and then the patient doesn’t."
The answer was that the therapist should score the admission assessment both ways, with one score for if the patient stayed in the wheelchair and the other for if the patient was walking, Vogl says.
"Then, at discharge, you take the correct score," she explains.
The documentation would be sent to Medicare after the discharge.
• Cognitive scoring: This is another area with a major change.
Previously, the staff neuropsychologist did the cognitive scoring at Unity Health System, but under the new assessment instructions, it will have to be assessed by the nursing staff, Vogl says.
"With the new assessment, the goal is to assess the patient at the lowest level of performance over the first three days," Vogl says. "Typically, what you see in therapy is that the patient will do well for the therapist or psychologist, but not for the nurses or family."
This is why the rehab facility now has nurses provide cognitive scoring. "Nursing has a truer picture of those deficits in a more normal daily functioning rather than in a half-hour one-on-one session with the neuropsychologist," Vogl explains.
"We had to break it down and show that what PPS was looking for was how these patients function in a day-to-day environment, which is different from a neuropsych setting," she says.
• Activities of daily living: Previously, the rehab facility’s occupational therapists would complete the assessment and score the patient’s activities of daily living (ADL).
Now the nurses on all three shifts must score these ADLs for the first three days and then each week and at discharge.
"These include eating, grooming, bathing, and then two dressing categories for the upper body and lower body," Vogl says.
• Communications: There are two categories that need to be assessed under communications: comprehension and expression. "Do they understand when you speak to them, and are they able to express back what they’re thinking and feeling?" Vogl says.
The staff who do this assessment are the speech language pathologist and nurses. Under comprehension, the scoring is based on assessing the patient’s ability to understand, but it can be affected by various factors.
• Bowel and bladder management: Nurses score this, but the way they score it has changed. "Now they’re asking you to score the level of assistance they need, as well as to score the number of accidents the patient might have had within the last seven years," Vogl says.
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