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Complaints about documentation

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1. poor legibility 2. Incomplete 3. No documentation 4. Abbreviations 5. Documentation doesn't support billing 6. Does not demonstrate skilled care 7. Doesn't support medical necessity 8. Doesn't demonstrate progress 9. Repetitious daily notes showing no change in status 10. Interventions with no time, frequency, duration

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What is Medical Necessity?

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Services that are reasonable ; necessary for the diagnosis ; treatment of illness or injury or to improve the functioning of the malformed member

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Why should consumers care more about Medical Necessity?

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Decisions about coverage affect them directly Should demand more disclosure of information

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Why should providers care more about Medical Necessity?

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Share treatment decision authority with payers Should participate more actively in guideline development

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What is the court's role in deciding what is Medical Necessity?

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Referees of last resort

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What are government agencies role in deciding what is Medical Necessity?

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Mediate conflict between clinicians, payers, and consumers

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What are regulators' role in deciding what is Medical Necessity?

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Apply the laws and standards of practice Need to improve consistency of their external review process

question

What is the background of functional reporting (G-Codes) and what is it for?

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*Beginning January 2013, CMS required by Middle Class Tax Relief Act of 2012 to collect data from outpatient therapy settings* 1. Beneficiaries' function & condition 2. Therapy services furnished 3. Outcomes achieved on patient function *Info will be used to reform payment for outpatient therapy services*

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Components of ICF

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Health condition Activities Participation Body structures & function Environmental factors Personal factors

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Medical Model of disability

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Characteristic/ attribute directly caused by disease, trauma, or health condition Intervention: correct/ compensate for the problem

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Social model of disability

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Disability is a socially created problem created by inflexible environment Intervention: political response/ solution (fix environment)

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Biopsychosocial model of disability

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Medical + social

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Aims of ICF

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Provide scientific basis for understanding and studying disability, outcomes, changes in health/ functioning Establish common language Permit comparison of data Provide coding scheme for information systems

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Body functions

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Physiological functions of the body

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Body structures

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Anatomical parts of the body

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Impairments

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Problems in body function and structure

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Environmental factors

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Physical, social, and attitudinal environment in which people live and conduct their lives

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Functioning

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Body function, body structures, activities, and participating (+ or neutral)

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Disability

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impairments, activity limitations, participation restrictions (-)

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ICF Qualifiers, generic

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0 no problem 1 mild problem 2 moderate problem 3 severe problem 4 complete problem 8 not specified 9 n/a

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ICF qualifier for environmental barriers/ facilitators

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0 no barrier/ facilitator 1 mild barrier/ facilitator 2 moderate barrier/ facilitator 3 severe/ substantial barrier/ facilitator 4 complete barrier/ facilitator 8 not specified 9 n/a

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Capacity

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what an individual can do in a standardized environment

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Performance

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What a person actually does in usual environment

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Skilled interventions

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Documents critical thinking and clinical decision-making

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Who participates in functional reporting?

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Physical therapy Occupational therapy Speech therapy

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What are the outpatient therapy settings that report G-Codes?

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Hospitals Skilled nursing facilities (Medicare Part B) Comprehensive outpatient rehabilitation Rehabilitation agencies Home health agencies (when beneficiary is not under a home health plan of care) Private office

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What is reported in functional reporting

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2 Non?payable G?codes and their severity modifiers

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At what points in the rehab process are G-Codes used?

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*1. Current functional status*: Eval, every 10th visit, or Formal re?evaluation *2. Projected goal functional status* *3. Discharge*

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What are severity modifiers?

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% of limitation as determined by the clinician

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How many categories of G-Codes?

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14 categories

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How many G-Codes to PTs/ OTs report on?

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4 codes + 2 others = 6 codes

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How many G-Codes to SLPs report on?

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7 codes + 1 other= 8 codes

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*True or False*: Speech?Language Pathologists will typically use 8 codes, 7 specific categories & 1 "other" categories

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*True*

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The term "functional limitation" generally encompasses which of the following? a. activity limitations & participation restrictions b. activity limitations & work restrictions c. activity limitations & environmental restrictions d. activity limitations & functional restrictions

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a. activity limitations & participation restrictions

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*True or False*: We must select G-Codes based on the one most clinically relevant to successful outcome, would yield the quickest and/or greatest functional progress, and is the greatest priority for the clinician

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*False*: We must select G-Codes based on the one most clinically relevant to successful outcome, would yield the quickest and/or greatest functional progress, and is the greatest priority for the *PATIENT*

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*True or False*: We use the "other" category when the functional limitation is not defined by 1 of the 4 specific categories, therapy services are not intended to treat a functional limitation; or functional limitation is assessed with a measurement tool that provides a composite functional status score AND the therapist is unable to clearly identify a functional limitation defined by 1 of the 4 specific categories

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*True*

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*True or False*: We may change G?code selection if one goal is met, but need to continue work on another

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*True*

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When do we report current functional status

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Therapy outset Reporting intervals (10 days) Re-eval

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When do we report projected goal functional status

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All reporting intervals

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When do we report discharge functional status

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discharge or to end reporting

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How do you choose a severity modifier? a. functional assessment tool b. clinical judgement c. results of evaluation d. all of the above

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d. all of the above

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When do you use CH modifier

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when services being furnished aren't intended to treat a functional limitation (something that won't change functional status of pt)

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What are some of the recommended functional assessment tools?

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*NOMS* (National Outcomes Measurement System) *FOTO* *OPTIMAL* (Outpt PT Improvement in Movement Assessment) *Activity Measure: Post Acute Care* (basic mobility, daily activities, applied cognition)

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Where can you go for info on evidence based practice and functional limitations?

answer

PTNow

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Including information about how the severity modifier was selected ensures: a. validity b. reliability c. specificity d. sensitivity

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b. reliability

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What is PT's therapy modifier?

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GP

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What should claims submitted at the designated intervals contain?

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*2 G?codes* (unless 1 therapy or one-time visit) Severity modifiers for both G?codes Therapy modifier DOS Nominal charge

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Performance-based instruments used to measure function

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Measure pt actual ability (ex: Berg, 6 min walk)

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Patient self- report instruments used to measure function

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Measure pt perception of impact of a disorder or associated symptoms (ODI, Parkison's Disease QoL)

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Psychometric propertieis

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Reliability Validity

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Reliability

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Degree to which assessment produces consistent results

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Validity

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Measures what it says it will measure

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MDC

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Minimal Detectable Change Minimum amount of change in a pos score that can be detected by a measure that corresponded to a noticeable change in ability

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MCID

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Minimal Clinically Important Difference Smallest amount of change in an outcome that might be considered important by a pt or PT

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Specificity

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test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate)

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Sensitivity

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specificity is the ability of the test to correctly identify those without the disease (true negative rate)

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