In our last article, we discussed trends in inpatient rehabilitation facility (IRF) audits and a noticeable increase in scrutiny of therapy services, particularly the intensity of therapy services. We are seeing IRF claims denied due to failure to meet the intensity-of-service requirement as well as when the preponderance of therapy minutes is not delivered in the 1:1 mode of service. This article will focus on missed therapy minutes, and in our next segment we will address documentation of therapy needs from the preadmission assessment through discharge.
What’s the Trigger?
While the generally accepted standard for measuring intensity of therapy services is demonstrated by the IRF providing three hours of therapy per day at least five days per week, the IRF may demonstrate that the intensity of therapy services is met if the patient receives 15 hours (900 minutes) of therapy over a seven-day period beginning on the date of the admission.
When the IRF provides a modified treatment program – something different from the standard three hours per day, five days per week, it is essential to document the reason(s) for the modification. Typical reasons for providing a modified treatment schedule might include chemotherapy, dialysis, or a diagnosis that includes complex medical conditions that would limit the patient’s daily participation (but where there is a reasonable expectation that the patient will make significant practical improvement).
Are Missed Minutes Allowable?
The Centers for Medicare & Medicaid Services (CMS) has outlined a “brief exception policy” in which the agency notes that while patients requiring an IRF stay are expected to need and receive an intensive rehabilitation therapy program, this may not be true for a limited number of days during a patient’s IRF stay, because patients’ needs vary over time. When an unexpected clinical/medical event occurs during the stay and this event limits the patient’s ability to participate at the required intensity for a brief period not to exceed three consecutive days, CMS indicates that when the reasons are appropriately documented in the medical record, this break in service will not affect the determination of medical necessity of the IRF admission. Typical clinical reasons for a break in therapy include extensive diagnostic tests, prolonged IV infusions of chemotherapy or blood products, bed rest due to signs of DVT, or procedures that interfere with care. Again, documentation is the key to supporting the reasons for missed therapy.
There has been no specific guidance from CMS regarding scenarios in which therapy is missed for non-clinical reasons, and while some of the Medicare Administrative Contractors (MACs) have noted that these missed minutes must be “made up” during the seven-day period, other MACs have been silent on the issue. We advise IRFs that when minutes are missed due to non-clinical patient issues – refusals due to family visits, personal business, etc. – the therapist should make every attempt possible to make up the minutes the same day, and if this is not possible, to schedule extra time to make up those minutes within the seven-day period. While there has been no specific clarification related to this area, we believe that the more robust the documentation related to multiple attempts to see the patient on a given date of service (and, when services are not delivered on a specific day, the delivery of “make-up” minutes), the more it provides an IRF an opportunity to appeal a denial based purely on a tally of minutes of therapy.
What to Do If a Patient Misses Therapy
Consistent, precise, and detailed documentation related to missed minutes, reasons they are missed, and attempts to deliver therapy on the same date of service and make up therapy time will provide an IRF with a basis to defend a claim. Many organizations utilize an “exception” note or a “decreased level of intensity of therapy” note to document missed minutes. Using this type of documentation will assist any organization in supporting claims and in demonstrating consistent attempts to deliver the required intensity of therapy services. Additionally, when a patient consistently misses therapy, the organization should document this in the team meeting notes and show evidence of discussion of the issues for missed therapy and changes in the treatment plan (and other efforts that are being made to ensure patient participation).
The Bottom Line
Therapy appears to be moving onto the radar screen for audits, and IRFs should be well-prepared to demonstrate compliance with all the requirements related to the delivery of therapy services. Key success strategies include:
- Real-time monitoring of daily therapy delivery for each patient;
- Development of a standardized documentation practice and/or template to document why therapy is missed, and the plan for delivery of missed minutes;
- Establishing methods for delivery of missed minutes via staggered staffing schedules to pick up late-day treatments; and
- Establishing methods for the interdisciplinary team to address barriers to patient participation in therapy.
Therapy appears to be moving onto the radar screen for audits.