Webinar: PDGM Preparation—Operational Strategies

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Thank you very much. We are excited to be with you today. I know the topic is probably anxiety producing for at least one of you. Probably the majority because we see the time window shrinking from when we go from a theoretical conversation to live action. So what we’d like to do is take a few minutes here and do a quick poll. You’ll see the poll come up on your screen. I want you to go ahead and take a moment or two and select the response that best captures how you feel right now. You are prepared for PDGM ranging from very prepared, somewhat prepared, not sure, somewhat unprepared or totally unprepared. And it’s okay. We want you to be as honest as you are comfortable being we’re not associating with names with the responses, but we’d just like to get a feel before we dig into today’s content, kind of where you guys are as a group, because you know, D and I are giving, getting questions. I know I did, as recently as yesterday of, you know, how should we start to prepare for PDGM and it’s kind of like start, have you looked at a calendar? We’re already into December, so it’s interesting to kind of see where people are. All right, we’ll give you another moment or two.

All right. Let’s take a look D and see what these responses are. Okay. We see some feel very prepared. Some are good portion are somewhat prepared. I think that that’s, that’s a pretty healthy spot to be in reasonably because, well, we have to remember, there’s a lot of people talking about expertise in this area. We really don’t have experts in this area, myself and Dee included, because nobody’s really done this in a real life situation yet. Yes. There’s expertise in the information. And so don’t just say, oh gosh, he just said that they’re not experts. I’m going to hang up, but we have to be realistic. I think somewhat prepared and very prepared are in a good spot. Not sure I’m there with you on some element to this as well. It seems like there’s been some conflicting information and it ranges from doom and gloom to, you know, everything’s going to, you know, burn to the ground.

We have to really look at this and say, how will we make sure we have what we need and the somewhat unprepared or totally unprepared. We’re here to give you some tips and strategies today as well to say, okay, what do I really need to know about this? So parts as we go through this, those of you leaning towards the prepared side of it, if we’re going. Yep. I know that. Yes. I know that. Yes. I know that. Good. Check them off your list. Feel a little bit more secure in your knowledge and preparedness for PDGM and that there’s some things you go, hadn’t really thought about that. Or maybe I need to take a look at, we want to add to your preparation strategy. So without further ado, we have our learning objectives. You can read those D and I are not slide readers, and we want to get to the meat of the conversation today.

And that brings up, I think, a visual that many of you now can see with your eyes closed. And sometimes it wakes you up in the middle of the night. The wonderful representation of PDGM. I think it’s important to understand and, and remind ourselves that this model didn’t just come out of nowhere. It didn’t come from CMS, sitting in a room and throwing darts at a wall, or just kind of saying, Hey, how can we mess with home care people? It came from a lot of data analysis, looking at OASIS responses and claims data that technical expert panel report is still out there when this started out as HGM. And I think what it teaches us is there may be elements of this that we find frustrating. We say, how come this was included in this wasn’t, but some of it, we need to remind ourselves that we kind of created this model as an industry, because they were trying to correlate patient characteristics to agency expenses, to figure out what about a patient costs you more money to provide care so that they could pay you more for those patients when it was appropriate.

This brings up issues that are far beyond the time slot we had today about OASIS accuracy and claims information, but it’s a reminder that going forward, we have to make sure we are accurate in the information we provide on the OASIS, on our claims. So that future renditions of this and refinements of this can really reflect what our patient populations need. The next two slides, I think are important tables because some of you participated in a PDGM content D and I did prior to today, and prior to today, we were functioning under the proposed rule. Now we have a final rule and I give full credit, and it’s on both of these sides. So the national association of home care, I think it’s a great representation of what are any differences between the proposed version of PDGM and the final version and what we can see by these two tables.

There’s not much different, but those things that are different are significant. And the two being the unit rate of payment, the base payment for home health agencies is up slightly in the final rule compared to proposal. Hey, anything that pays us more even a little bit is a positive change. The other being the behavioral adjustment, which in the proposal we know was just over an 8% reduction is now coming through in the final rule at just over half of that 4.36. Okay. Now, yes, that’s a good thing. Not getting hit as hard is, is positive, but it is important to understand that this does not remove behavioral adjustment off the table indefinitely. This was not just a one-time conversation. This has a lot to do with ongoing monitoring of our behavior in real PDGM to say, okay, how much of, what we thought we’re going to give you a little bit more of the benefit of the doubt and not hit you so hard preemptively.

However they’re going to be looking for. Do we start radically changing how we as an industry to start putting people into the highest tank buckets? Do we radically change how we utilize our therapy and go from a high therapy utilizer to a significantly less now, is there room for some adjustment in the therapy? Is there times maybe as therapists, we were a little too complacent and could have been a little leaner and more efficient in the visits. Yes. And PDGM is going to make us look at that, but it’s not intended to slash and burn and reduce therapy by all these wild things. DNI, keep hearing like they’re going to be capped at six or, and shouldn’t do more than three or all I’m going to get rid of half of them. Don’t behaviors CMS is looking for. So we have to make sure that we don’t just say, well, this was a victory in the final rule and move on.

We have to be very careful in those two areas, the remainder of the things you can see, they pretty much stayed exactly the same. So as you were preparing ahead and looking at this for the proposed rule, it’s good to see that there weren’t significantly different issues coming into play in the final version. So there are five things we want to touch on today. Looking at the ones that are directly related to how payment is calculated around coding and OASIS, but then that’s fine. Painted is payment. However, we have to remind ourselves that nothing about the qualifying or coverage criteria for the Medicare part, a home health benefit is changing January one. What patients are entitled to, what they qualify for is exactly the same. So whenever we’re dealing with a payment methodology shift, we have to revisit and make sure that issues around utilization, interdisciplinary care planning, and the full scope of the benefit with respect to things like maintenance, management, evaluation, and observation assessment are running the way they need to be. So that we aren’t making arbitrary. Let’s just cut off three therapy visits and we’ve fixed the budget. How are we making sure that those areas are running the way they should be? So I’m turning the platform over to D because I’m not about to pretend I understand ICD ETF coding to the degree she does. So do what do we need to know with respect to PDGM?

Well, I think this really is an area that all parts of the agency needs to understand whether or not it’s a primary function and a review or a coding or back office responsibility. And I think this includes the frontline staff. And so from intake to, to care delivery and, and submission of a claim we need to understand there needs to be a fluency between the referral documentation, the face-to-face and primary diagnosis selection, because that’s going to impact grouping. And that’s going to make sure that this is the correct document and, and it’s highlighting those reasons why a person needs a home care. Right. we need to make sure that that we have a process for inclusion and exclusion of comorbid diagnoses. We need to make sure that we have demonstration of good quality documentation from the referral sources, whether they other post-acute settings, acute care or community-based through physician practices.

And then we’re going to talk a little bit about what do we do about those things. We’ve always known as therapy codes because a lot of those are not assigned to groups or primary diagnosis groups in the PDGM model. And so currently what we see when we’re talking about therapy is that many times for therapy, only patients we, we, we have this understanding. It is a mess. It should be busted. It should, it should die a death immediately, if not now definitely 11:59 PM December 31st, where we look and we’re looking for things that are therapy diagnoses, when we’re providing therapy care, that’s, that’s not what, what this should be about. There really is no true therapy diagnosis. And the ICD 10 code set there is it is basically conditions, the seasons in disorders that are assigned by the physician therapists.

Yes, we commonly list the impairments and body structure and function that arrived from underlying diseases, disorders, and conditions. And when we do that or documentation moving into PDM should closely tie these impairments that we’re treating such as muscle weakness or data abnormality or aphasia or ADL that function or reduce the Rubic capacity to those underlying etiologies and make sure that that communication is fluent with the physician and other interdisciplinary care team members. So that is what we should be doing now. That is a behavior and a practice that should be in place now. And if not, it’s an immediate to do for people because it really should reflect what the clinician obsesses on that either comprehensive assessment or that discipline specific evaluation. So, so what does coding tend to look like for therapy cases now? Well, a lot of times we see these documentation of impairments and body structure reduced range of motion this equilibrium, et cetera, we have to be much more particular about what are the causes of these impairments and document then speak to those in our narrative assessment.

We need to use objective standardized tests and measures, especially when you have agent gender normative data, so that we can incorporate quantifiable information. We need to make sure that we tie that those existing impairments due to those underlying diseases and disorders, conditions are clearly demonstrated unique to that patient. So what they have reduced the Rubic capacity, what does it prevent this patient from doing in this situation with this recent hospitalization, with, or without this caregiving assistance with, or without these comorbidities? And we need to have a very clear understanding what is the patient’s normal functioning in the home? What was it like before they were referred for any medical care, whether it be an acute care hospitalization or a follow-up a referral to home care from the physician’s office, what is their normal? And simply putting things like independence without assisted device in the community is probably not very detailed.

And so what we don’t want to see is this ongoing problem where we are not tied impairments back to underlying etiology. And we’re using non-specific sort of non-measurable statements such as reduced community mobility or severely poor Doris. We want to quantify that we want to measure gait speed. We want to give very specific details. And so looking at that, what does that mean in a coding situation? If we, if we have to change our mindset? Well, first of all, it’d be a good place to start is looking at how you’ve been coding is if you haven’t already. Okay. So if we look at a traditional type coding, how it’s going to play a PDGM you see here, a scenario for an 87 year old female referred by her primary care because she recently fell. And the referral diagnosis were gait abnormality and muscle weakness review.

As a comprehensive intake, paperwork shows a past medical history of diastolic, heart failure, hypertension, COPD, osteoporosis, and osteoarthritis, and the patient lives alone have supportive family about two towns away. She’s independent with their basic eight IDLs and herself care. And she relies on the family for longer outings into the community. And that contributes to her quality of life. The reason why she was referred is she was following up on a resolved bout of pneumonia that kind of resolved two weeks ago. She never went to the hospital, but the doctor had her on antibiotics and that she just doesn’t feel like she’s bounced all the way back. She was carrying her laundry from the upstairs to the downstairs first floor where the laundry is, and she fell and was not able to get get up. So she called her daughter who couldn’t get there, call 911 patient refused to go to the hospital, right?

So, so we’re going to do all our tests and measures. We’re going to quantify where to find out what is normal for this lady. We have a good general scenario there to give us an understanding of how she was functioning before, but what’s critical for a clinician is to document specifically. So let’s look at this clinical narrative note, that would be very helpful in a PDGM coding situation, the patient, we talk about her, the reason for referral, it’s kind of like a modified X-bar. We know that she’s been re in a, in a state of reduced functioning for the last five weeks during this non hospitalizing bout of pneumonia. She’s still seeing that for, for a muscle strength and aerobic capacity impairment, but it’s also related to this long-standing chronic co-morbidities of heart failure and COPD. This is communicated with the physician following the admission.

And we find out that we now know that she has impaired mobility, fall risks, compromise the ability to walk at speeds and distances to re-enter the community safely. We get that all from objective standardized measures, and she subjectively reports only feeling about 50% herself compared to her prior level. And she now has this fear of falling along with that, that fall risk, which we know what that does to elderly patients. It tends to self limit behaviors. And so she wants to be able to resume the activity she always did. So we have a good, a good painting of unique presentation of this patient in an existing PDGM model. And Cindy and I look at a law, excuse me, an existing payment model. So the, and I look a lot of records and I spent a lot of time and coding with records. And so we would typically see in the, in the blue table, what we might see coded based on the physician referral, the generalized muscle weakness, the gait abnormalities in the co-morbidity.

Okay, but in, but moving into a PDGM model, we’re not going to be able to use some of those, what we call therapy diagnoses such as M 62.81 and many of the are 26 codes because they will not assign two groupings. And so we have to tie those reasons very clearly laid out by the clinician in their narrative note, communicated and confirm with the physician that it’s related to those underlying chronic diseases of hypertensive, heart failure, COPD with some risks, with the Roseo paralysis, her generalized arthritis. And then yes, she has a history of falling and some problems living alone. If we wanted to include the muscle weakness and the gait abnormality down there, that’s all well and good, but we have to tie it to those underlying etiologies. As I said, why is that important? Because if we tried to use the existing PDGM group or tool, we, that I’ve pulled here and we’d use this as per the proposal, that you will find that the primary diagnosis of M 62.81 does not track or place in a primary diagnosis grouping, therefore it would fall into a questionable episode.

It would be RTP or return to provider, and this claim would not be accepted for submission with that primary diagnosis. And so we would be reliant on a more updated documentation, and this is where the clinicians narrative and the clinician’s understanding of coding needs to live and needs to show up in the documentation because based on the second a box I believe it was the gold box of coding. We see that now, as we’ve related this weakness, these gate abnormalities to the underlying hypertensive heart failure, that puts I 11.0 as the primary diagnosis falls into the MMTA cardiac group. And we just don’t see any co-morbidity adjustment based on the fact that none of these codes fall into one of those specific groups that will be assigned to a low comorbidity adjustment, or have an interaction between two or more of those codes and grouping that would fall into a high comorbidity index.

And so we don’t receive any, any, any bumps for the comorbidity adjustment in that situation, but we at least are able to go ahead and to submit with a proper primary diagnosis. And so coming becomes critically important. Narrative statements become very important tying impairments. We see, and we treat as therapists particularly become extremely important that we relay that back, or we tie it back to underlying etiologies when appropriate and when in our assessment, that is what they’re due to. So great place to look right now would be to assess your your use of these non, these questionable episodes or these non-primary group assign codes and to eliminate their use, because they’re only going to cause you problems as of January 1st.

And thank you D I think people look at this slide and go, oh gosh, I don’t think Cindy craft can be on a webinar or anywhere without bringing up OASIS. Seriously. Are we going to do it again? Yes, we do. Because the issue here is a lot of emphasis on PDGM up till now has been about making sure you’re coding houses in order. So D strategy about looking at where your codes are today working to reduce use of those questionable codes. And let’s be clear reducing the use of those is not translated over to I’m gaming the system. It’s the reality that they’re kind of forcing our hand to be, wait a minute. These more nondescript symptom codes never did do the best possible job to be able to create data around the specificity of what’s actually wrong with our patient. So let’s make sure we have that straight, but then the OASIS piece of PGM has gotten kind of lost in the shuffle of it, in my opinion, because it’s looked at as, okay, been there, done that.

We look at the list of items that are going to create the functional element. Really the only thing left of OASIS, that factors into payment and for I’m for one, I’m glad because the thing is named OASIS for a reason, the outcome assessment information set, it will be nice to get back to actually looking at outcome related information and not so necessarily focused on the 20 or so items that influence payment, but some do, these are not new, but we have to remind ourselves of several things. One item, 10 33 make sure that all appropriate responses are being collected by you as the data collector or as a reviewer or an organizational leader. Are your clinicians paying enough attention to 10 33? Yes. One could argue, we should have been this entire time. Am I concerned that if we’d gone from maybe an average of two reasons to six to eight reasons on every patient, CMS is going to question what went on there.

That’s a possibility, but we want to make sure we’re capturing everything appropriate in 10 33. The one that I usually find is I review records that doesn’t get marked enough is the issue of compliance especially on those patients that start with my favorite narrative phrase patient as well known to this organization. Yeah. Okay. They’re back. And usually there’s some reference to issues around their ability to follow through and make sure we all understand what that compliance is related to that’s following through, on issues of medication following through, on their medical care. It also talks about their their issues around following through, on exercise and recommended activities. So I’m not saying all of our patients end up in a problem area there, but I’m not sure as many of them as should be captured, have been getting captured to date. So don’t overlook that particular question and an emphasis of making sure we create a complete picture.

The rest of them. We say these questions are 20 years old. Yes they are. But we have to make sure we are coming at this consistently. But the issue of assistance is what we know it’s been forever. And many of you were looking at this slide going, why am I looking at this I, myself and my agency at the teaching this forever, I’m going to tattoo it onto my clinician, or you’re a clinician going, oh, are we seriously? Okay. We’re not spending time here. You know, assistance is anything another person is needed to do to make this safe. So if it’s verbal cue, if it’s hands-on, it all goes together. And these OASIS items and safety is trying to look at it from a perspective of what could impact it, the environment, cognitive issues, so on and so forth. These are things we already know.

The problem is you probably hear what DNI here. When we talk to clinicians about this, the reviewer should just change the answers. Different reviewers. Tell me different things. You want me to pick an answer because that’s going to increase payment or do something for the whole health compare scores, the patient lives alone. So I have to put down that they, that they do this by themselves. I can’t say they need help. My favorite always is what’s my liability. If I put down, I need help and don’t have it. We say, well, what’s your responsibility then because you keep putting down answers that say they don’t need services. And then you provide services. This doesn’t make sense. I don’t have time to have the patient demonstrate all these tasks. I’ve been hearing this mantra for 20 years as someone who was in one of the original OASIS pilot sites.

So we have to figure out a better way. Some of you may have heard this before, but I’m adding a twist to it today that I want to make sure you have not overlooked in your PDGM prep. The connection between patient risk for falls and how we score function, because we can’t keep talking about, but the patient lives alone and let’s sit everybody in a room and let’s give them a snack and let’s go through the manual for the thousandth time. The instructions around those items, has it changed substantively. The wording of those items has not physically changed in 20 years. So why are we still having to deal with this? I think it’s because we’re stuck in a rut and we’ve gotten deaf on both sides is the reviewer and the clinician. So my strategy is simple. If this patient take your waste this away for a minute, if you’ve assessed a patient and you believe this patient to be at risk for falls, do you think they should be at least supervised, particularly at the start of care?

And the resounding answer from clinicians is yes. Okay then you’re wonderful. Yes. Now needs to show up in your answers to reflect that need for supervision. Now, where does this? What’s the twist? The twist is this always is D one always is D one has minimal actual changes in it in the middle of PDGM. Many are rejoicing that we have not seen an OASIS overhaul going into 2020. Okay. We’re not getting new questions. We’re getting a few things rearranged. And we have this idea that some of the items at a certain time point are now going to be considered optional and can be answered with a equal sign. You may have already had this communication with your electronic medical record vendor who is going to pre-populate the equal sign into these questions so that it’s there by default. And this idea being that this is less of a workload on clinician until we ultimately get to OASIS II and true change can happen at those time points.

I understand that the most heavily impacted time point for this equals business is the followup. Wonderful. Yay. Here’s my issue. There’s only one question that is going to be deemed that you can create, you can choose to be optional, would potentially come from your EMR vendor. Pre-Populated with an equals is M 1910. So this is where we have to look at it and say, optional is truly an issue of optional. And do I really want to, as a clinician, stop assessing for fall risk on admission. Do I want my clinicians stopping, assessing for fall risk on admission? Because we know what’s happened with issues of a way to send the path. If I don’t quote have to, but it saves time if I don’t do it, but wait a minute, this is not about work. This is about comprehensively assessing our patients falls are a huge issue.

Falls are a risk. So let’s make sure as an organization. And again, each of you in your organizations has the ability to make your own decision as an agency. How are we going to handle this? But I think it’s kind of been the well, my EMR vendor took care of it. You, what you may risk is people not doing a fall risk assessment on admission. Then how am I going to use that to ensure that my functional questions are chosen correctly? So something you need to be doing a quick check on before you go into PDGM. So you’d know what you’re potentially getting yourself into. And what is the consistency between that handful of OASIS items, the end version of function and the GG version of function, time and time again, I’m hearing from folks that they’re not really paying that much attention to GG right now.

It affect payment. It doesn’t affect our outcomes. It’s not a PDGM, you know, issue. It didn’t really change going into OASIS D one and we’ll deal with it later. Okay, wait a second. You have to understand two things. One, the Gigi items are definitely not about payment. They are about issues of looking at measuring value across post acute care. These are the same items that are present in inpatient rehab assessments and in skilled nursing facility assessment. We know in the near future, when those cross setting measures start to become publicly reported, they’re not going to use the current year. We’re in. They’re going to go back to a previous year, highly likely now. So we have to make sure they’re accurate, but what are the implications for PDGM? Cause you’re like, wait a minute. I didn’t accidentally sign up for OASIS. Did I? Well, there’s a, there’s a piece here.

You have to watch. If those particular functional items are what factor into payment in PDGM, and on the very same assessment. I have, oh, look, you can’t dress. You can’t walk. And the M version, but over in the GGS, I got a bunch of five set up or clean up or sixes, wait a minute, this, we can call it an accident. We can call it not paying attention. We can call. Maybe the person needs some education. Okay. It could be all of the above, but I’m telling you is in a behavioral adjustment situation, hypersensitive to behavioral issues influenced by payment. If I on my same assessment, more aggressively score the version that it looks like I’m doing it for payment. So we can’t risk having and consistencies between that and the GGS. We have to look for harmony between those two, because that speaks, then this isn’t accurate comprehensive assessment and doesn’t remotely create the opportunity for someone to come look at that and interpret it as some sort of gaming. So D we’ve talked about coding. We’ve talked about some issues around OASIS, but now, all right, I got my payment. What do I need to be thinking about from a utilization standpoint? Does my utilization have to look radically different in PDGM?

Well, I don’t think the pay, the utilization has to look radically different. I think what needs to happen is we have to really go back to centering on the patient. I believe critical pathways, care pathways, pre pre-built goals and, and, and phrasiology and EMR can be very helpful. I also think that they can be the downfall as they drive us towards being generic. And so what we need to do is make sure that our documentation reflects both the intrinsic and the extrinsic factors that determine me. Okay. And so when we think about the intrinsic factors, we’re talking about those disease processes, right? The acuity, the severity in that disease process, we know an acute comprehensive stroke may look different than an eight year old, mild stroke. Most folks can get services, both can meet their requirements for home care.

Both can be referred from the physician with the same ICD 10 codes, but they may require different things based on the presence or the acuity and severity of that disease. What are the comorbidities? How does the patient, the family, the identified caregivers, if you will, how do they manage, what is the level of self-accountability or management of these disease processes? Where is the knowledge deficits for the people responsible the patient and their caregivers in managing their, their, their medical care, managing their medications following through with care procedures, whether they be post-operative wound care or, or certain therapeutic exercise looking at their functional and safety needs, what is their mobility? What does, how do they do, how do they take care of themselves? And we know that this is going to be extremely important because we have a mobility, if you will score an a and a and a self care score.

So we have these composite scores that go to contribute to their functional need level. And we want to make sure that we get those right out the gate, looking at patients’ needs, based on the environment or extrinsic to the, to the person themselves. We have to look at the support systems around them. Are their caregivers, are they not even just available, but willing? Are they capable? Have we documented? Have we tested that? Do we, do we show where the deficits are? Should we be using a caregiver strain index? What is the environment, the physical plant set up? Is it compatible? Are there accessibility or barriers to safety and mobility? What kind of equipment or adjunct services are needed? Are they coming in the house with our services or do we need to look into the community and collaborate with the entire medical community, besides the active physicians, including the referring physician and look at the meals on wheels public transportation you know other community services that may be in place for these people.

We have to get a very clear picture of that. And so when we start to look at developing care plans, we should not have a one size fits all. We should have a very clear picture that we should be able to identify our patients by their care plans. In fact, if you want to see where you stand, as far as patient unique presentation of the patient and using the technology, the EMR, and all the bills you add, or templates, you have take the last five evaluations or start a care assessment that you or, or, or your clinicians have completed in the last week or two, right. Take all the patient, identifying information off of it, such as their name, their address, you know and, and ask the clinician to identify it simply by the assessment. Hey, go even a little bit further, just pull out parts of the care plan.

Look at if they’re doing medication, teaching, what they’re specifically teaching on. If they’ve have specific patients that have very specialized medications, because they identify those from, from the care plan, have they been highlighted? Can you pull out just the goals statements? Can you read a patient’s goal statement? And can you say, well, this must be Mr. Smith because he lives in a house where he has to go up and down 17 steps, right. To get in and out, or, or to go to the second floor. That’s extremely important. And if you can’t see the unique presentation of the patient captured in the comprehensive document, in fact, they all start to look the same. All the goals start to look the same. Sure. We may work on strengths. We may work on gauge gait speed. We may work on ADL. So we’re going to work on it for different reasons, for different people who present differently, live in different home environments, have different physical and knowledge and caregiver deficits, right?

And so if we can’t pick that out from this and pieces of our care plan, chances are we have room to improve that unique presentation of the patient. I think when we’re talking about utilization, Cindy, we also have to talk about what happens when the care plan is modified I E patients or a visitor myth either over long weekends or holidays, coverage of vacation times what happens. And I think one of the biggest things we have to talk about is what is the impact of that miss visit? If we treated a visit as prescriptive, which it is right ordered by the physician, like we do a medication like an insulin or a blood pressure medication, what if the patient missed a dosage? What would happen? What would we be concerned about if we find after miss visits, we’ve been seeing these people two or three or five times a week and miss a couple of visits, or they want to go on a hold or this, that, and the other.

And we come back and just resume, like nothing ever happened. We didn’t miss a beat. Everything goes on as usual. The question that we need to ask is why are we at that frequency to begin with, if there was no harm, no file. There was no impact of that missed if you will, dosage of prescriptive services, then why are we seeing that at that high intensity? And so we have to be very careful when we think about prescribing or, or recommending visit numbers that we make sure that it’s meaningful across the collaboration of the interdisciplinary team, okay. That we’re proactive to reduce readmissions, right? Acute care hospitalization in those first 30 days that we’re making sure that we don’t leave all opportunities for medication errors. And we’re teaching that hard and fast, especially on new or very complicated medications like Coumadin or warfarin doses that may vary.

We want to make sure that we’re addressing those risks for rehospitalization, such as falls risk. We want to make sure that we’re addressing function, you know, failure to show improvement, or at least maintain a level of stability or slow improvement over the first 30 days. Following discharge from a hospital has been shown to be an increased risk in and of itself for rehospitalization and, and, and and likelihood of death. And so there’s a, in some of the research he’s done that he’s quoted. We find out that lack of functionality or mobility, or moving around is a risk in and of itself following hospitalization. And we want to make sure that when we talk about disease process management, there, we’re talking specifically about where the deficits are. If a patient has a good understanding of 90% of their disease process, but they have some new things they have to learn, then let’s just focus on that and not generically put a broad brush across.

We’re going to teach everything from a to Z for this patient. And so when we look at planning our care, if we’re thinking about that kind of utilization going into it, we really have to stop and say, this isn’t a one you know, a siloed sort of approach where we all get in the huddle. And we all recant what our frequencies are gonna be. And we all stay in our lane, right? We have to share this patient. We have to say, these risks exist for all of us. The mobility risks are not just something that therapists should address the dietary and medication risks are not just something that nursing has to address because we don’t have any part of that. And so we have to look and say, Hey, what does it take to do interdisciplinary care management? And the first and best place to look is one of the risks for rehospitalization.

Now this am 10, 20, 10 33 is not a random or random item. If you go to the CDC aging risks, you’re going to find the client in status fall and history of hospitalization noncompliance, for whatever reason dietary and weight loss issues a falls, risk medications mismanagement, all pain, all these things, land older adults, typically the Medicare population back in the hospital. So this information should be shared throughout the interdisciplinary team. Everybody on the team should understand what are the risks that the admitting clinician identified, and they should be addressing those with each and every visit. I would go so far as to say, if your visits doesn’t answer what I did today to remediate, reduce, or eliminate the risk for rehospitalization in one of the identified areas, then I questioned what the value of that visit was to the patient.

Okay? Because in reducing risks, we’re going to be helping them stabilize or restore a prior level of function. So let’s look at a simple example. In this example, we all can kind of agree that there’s some key issues that land people with congestive heart failure, back in the hospital and things that we are always monitoring and managing with them. And you may have a couple of different ones that should be now. I kind of break it down to daily weights, medication management, dietary, vital signs, and monitoring, and maintain a controlled level of activity. And so the question is here, if we’re all going to work off that one, this interdisciplinary care plan, what role does each of the clinicians play in managing this? And again, we don’t want to divide this to nursing. And then we just, okay, vital signs and monitor activity will be therapy.

We really all have a role in every one of these things because daily weights, medication, and dietary, or something that people do every day when they have heart failure, right? We want daily weight. And so if it’s something a person does every day, we seriously need to consider that it’s an ADL. And so when we start talking about this one beneficiary, let’s have that one care plan. So we’re around CHF. If they had nursing, PT and OT, this may be the focus of care, right? To teach self management of this chronic disease. The nurse is going to talk about it. And the role of the medications, the PT is going to make sure they can get on the scale. And they have a good aerobic program that optimizes their capacity within the constraints of the disease. And OT is going to make sure it carries out in functionality for the completion of ADL and IADL consistent with their prior level. And so this is the way we want to go ahead, keeping it simple, reducing it to what are the risks? How do we coordinate our visits? How do we give them every visit they need not one visit more. And how do we work collaboratively all towards reducing risks for higher cost centers of care, Cindy.

Well, thank you D and I, and I think it’s important to understand, you know, we are trying to cover a lot of areas in our timeframe today, but it’s critically important that we find that balance between making sure we have the mechanics in place for PDGM and looking at the utilization, because that’s how we ended up with PDG on being the way it is. We’ve argued for years about the complexity of the home health patient and the challenges of when they come home and have no caregiver or inadequate caregiver support, or how quickly they’re discharged from inpatient care at a higher level of acuity. That that’s great verbal argument. The challenge is though, when you look at our care planning as an industry, far, too much of it is in that cookie cutter bucket, do you refer to, so from a payer perspective, if the patient’s basically no matter what’s wrong, it’s going to get the same frequency of duration from nursing or the same pattern of frequency and duration from therapy.

Then your cost as an agency is the same. Whether or not they have a, whether or not they have a higher acuity no matter how long they were in the hospital or skilled nursing facility, your costs was basically the same. And if your cost is the same, I’m not going to create a way to pay you differently or more in those situations, just because you verbally told me, does our data really support this? And I think we’ve made this too much about the data is the code. The data is a racist. Yeah, it is. That’s only part of the conversation. The data is also in the cost associated with our utilization. And that’s where the clinician is a primary driver in it. And if we keep going with the DNI, see with DNI here, when we talked to reviewers, but I don’t even need to see the name of the clinician.

I know exactly what the frequency and duration is going to be, because it always is this basically to week nine, that’s an issue. So we have to make sure that we’re looking at all elements of this and to do that, we have to look at all elements of what the beneficiary is entitled to this title, flight alone, maintenance, therapy, management, and evaluation, and observation and assessment is a like, like the trifecta of making people break out in height, either in Highview, you can see or internal hives. They don’t want anybody to see because these are three areas that produce all sorts of. We don’t do that. We do. One of them may be a, we don’t ever want to do them all. We did them in the past. And then we heard people got in trouble, or, oh yeah, we do them all the time.

That’s why our patients are currently on service for five years at a clip. Okay. We got to peel this back and say, wait a minute. Especially in a PDGM environment where we have finally finally obtained after 20 years, a true situation where visits are not the driver of payment. I know as a therapist, you’re probably thinking, why are you sound happy about it? Yes. There were some benefits to getting more patients access to therapy because of the current payment methodology. But a lot of other stuff came along with it. That was unnecessary and unpleasant. Now we’re back to what is this beneficiary need? How do we, as an interdisciplinary team move this plan forward? Not how do we move stuff over to therapy because therapy can stay in there longer. And we’ve got to figure out how to get the nurse out real fast to make therapy, do a bunch of other.

No, that day is over January one should have been over a long time ago. Anyway. So to do this, we’re seeing people reach out to us at Kornetti and craft with, Hey, what, what’s this with maintenance? What’s this with? Yeah. We highly encourage you to revisit if you have not been doing maintenance well, up to now that you revisit this concept, because I will argue with this to anyone and you can reach out to me personally, if you’d like to take that challenge on and take on that argument. What this slide here is maintenance therapy, part of your care delivery today, if you’re saying no, you’re actually wrong. I’m comfortable saying that there is maintenance therapy going on in every single home health agency in this. It is just not being identified properly. It is not being celebrated as this is what I’m doing.

It’s not being documented definitively to make sure that it covers what the beneficiary is entitled to. It’s classically that patient, where we see the trajectory where they’ve started off on a restorative focus of care. They’re getting better for a period of time. And then for some of these patients away, they go, they’re discharged. They’re off. We do not see them come back unless they’ve had some new medical condition developed or unforeseen circumstances warranted it, they went off and then there’s the patient where we get them better. And they go, and those last couple of weeks, it’s like, they went, got better to a point. And then they reach this plateau, which therapist is not a dirty word. We got to stop flinching when people say it plateau. And then the therapy stayed in there for another week. Another two weeks, no more improvement was going on in those two weeks.

So why was the therapist still there? Because in their gut, they knew what was going on. That this was a patient that if I did not ensure that this program was continuing to be effective, to stabilize what they gained. If I discharged two quick, things are going to go wrong. And this is not about patient compliance. This is about their medical processes, their disease issues, all of those co-morbidities interacting. I have concerns that if I take my hand off now, what they gained, they will lose. Yeah. That’s called maintenance therapy. So when we look at this, we have to say, all right, I have to make sure that we are properly identifying patients for this part of the benefit that we are looking at our documentation. I would challenge you to look at those patients where you’ve been concerned, where the last couple of weeks, and if we do not start identifying as appropriately on the claim as maintenance therapy, this is why we get those partial denials.
And we argue, you can’t do that to me, Medicare. Well, yes, they can. If every single visit you build was restorative. Those last two weeks without restoration, they can’t try to take those off. Now you can say, but they were maintenance. Yeah. But you didn’t call a maintenance. You didn’t identify it in the documentation and you didn’t bill it that way. So we have to take a new look at this. Also look at those therapy event only is one in done situation, historically wrought with recommendations, exercises, equipment suggestions, then why didn’t a therapist go back? Cause we thought we couldn’t. So we have to revisit this. And I think it’s a great opportunity in PDG. And when we’re getting off the therapy, visit train to revisit this and say, is this a more effective way to manage some of our patients? And that also ties us to observation and assessment and management and evaluation when D and I do training about maintenance therapy.

The nurses that attend will overwhelmingly say, Hey, that sounds an awful lot like management and evaluation. Yes. Because there is a significant amount of conceptual overlap. So if we’re going to look at maintenance, then we need to look at observation and assessment. I don’t think makes people as uncomfortable management and evaluation absolutely does. So this idea that the stuff that makes me uncomfortable, or I’m afraid of letting my clinicians do it, or I’m in home care. And I don’t even know what those things are. I don’t think we do that. That’s not an excuse to say, I don’t provide this, or I’m not going to provide it. I know what this stuff is. And I’m choosing to not have that available. This is going at it from the perspective of what the beneficiary is entitled to, and that is not changing under PDGM. So we have to look at this and say, are we making sure we’re utilizing the full score for the benefit?

So if we’re going to really be getting to the heart of value of focusing on outcome, this is not just what our latest home health compare scores and how many cars do we have. We know that that’s a model that continues to need to be refined, especially with stabilization, but sometimes what helps is to look at this from a queries perspective, not just, Hey, did you di you know, if you didn’t document it, you didn’t do it. Nobody pays attention when you say that anymore. But looking at documentation say, does it reflect impact of care toward those desires outcomes? Not just, what are the OASIS measure? The waist is just measures. It doesn’t do anything. Did we do anything over the course of care to try to make that outcome happen? Do goal statements reflect the anticipated functional impact of improvement or stabilization are our goals solid?

I’m sorry, I’m up in my, opt-in my neck right now in an audit, looking at goals. And if I see one more, half of half a muscle strength or a muscle full muscle strength that did I even tell you this, I find a goal that wanted an eighth of a muffled grade increase an eighth of a muscle grade. Ah, is this really talking about the functional impact? What are those risk areas identified at admission? Are they focused on over the course of care? Looking at clinical utilization decisions are documentations, are impairments being quantified. Do we see evidence of clinical decision-making utilizing these questions to help facilitate that conversation at the clinician level is going to be critically important as we prepare for PDGM and I would argue is going to be a significant ongoing conversation. Yes, maybe first quarter 2020, but that won’t end there.

It will continue going forward because ultimately the reason we’re going to PDGM is to push ahead on this idea of value, that this is not about visit numbers. This is about how is our quality, how do we attain highest possible quality while controlling cost? And that’s why being paid per visit or minutes, or, or days has always messed up the payment methodology, because then they get a bunch of visits minutes a day. That’s why these things are going away and looking at how do we truly quantify our value? So OASIS is part of that. Coding is part of that and elements of the payment methodology, but don’t overlook the rest of it. We to make sure utilization is an intelligent, focused, intentional process to reduce risk for this patient. Not a we’re going to cut therapy off by three or cap everybody at six or not do more than X number of visits in a 30 day, or, you know, we’re not going to go past 30 days anymore because of the billing unit.

That’s not what this intention is. And if we react like that, CMS is going to notice, and it is likely to not be pretty at all. So this slide here speaking pretty these are pictures of DNI. If you haven’t ever seen us in person or students in another video type situation you have our contact information on this slide. There are plenty of questions stacking up in the Q and a box. Some of them are quite deep with respect to the issue of code. If you need additional deeper education on that topic, please feel free to reach out to Deere myself, because we’re going to try to tackle now as many of these as we can, we may go a few minutes over, but we want to be respectful of your time, but we know that there can be quite a few questions related to coding, which is why I’ve already told Dee I am going to volunteer for the management of the QA box because I’m like, oh gosh, please don’t ask me what should be done about the coding. So we have, I’m going to kind of pull this in themes D because some of this, I don’t want to read repetitive overlap questions, but there seems to be some feedback here with respect to the issue of face-to-face review choice, which is kind of like face to face on steroids and coding sequencing. So the idea that it’s supposed to match, but my doctors are participating or has reviewed choice. It kind of messed with how I can sequence things. Where, where do you see those things coming together?

Well, first of all I want to go back to the face to face, especially on the example that I gave. And I’m sure it caused some red flags to go up for some of the people in the audience that are familiar with coding in that the face-to-face that muscle weakness and gait abnormality in the face to face has to match the primary diagnosis. The reason for the referral, what we’re finding is that sometimes through communications with the physician, there needs to be a refinement of the face-to-face document. Once the patient has been seen, because ultimately the doctor can refer them for something like muscle weakness or gait abnormality, but you’re not going to be able to assign that as a primary code on the claim, because it’s not going to get primary diagnosis, grouping that those codes aren’t assigned to any group they’re not considered primary diagnosis and stand in that position across any of the 12 primary diagnosis group categories and the codes under that.

So, so the solution is, and it’s not a work around it’s, you know, one of the first things is to inform your intake staff about, about diagnoses that cannot serve as the reason that face to face to educate your physicians. And I know some people in my colleagues in the audience have developed resources for their physicians, and I strongly suggest that you do that. If you find it, once you get the referral, then, then that may trigger a followup face to face. Cause remember, you can do the face to face up to 90 days before or 30 days after the start. So this would be something where if the doctor wants to see them again you can do that. Or if you’ve got that from the referring physician in the hospital, then they’re going to be followed by their referring physician will be their primary.

I would get those visits scheduled earlier, and I would pursue an alternate face-to-face documentation because then the hospital is continually make the referral, but the face-to-face can be done by the physician. Who’s going to be following the patient. Okay. As far as your other comment about art or review choice, we see that currently in two states it’s in Illinois and it’s in Ohio, and there has been some, some dilemmas that have showed up specific to coding of a coronary artery disease. The [inaudible] code prior to the [inaudible] group of hypertension codes for a primary referral diagnosis of like say hypertensive, heart failure and exacerbation of that condition. Those are very unique to the RCD process. And I know that I’m aware that that’s been happening in those two RCD states. We don’t expect a review choice to hit North Carolina, Florida, or Texas until probably March or sometime thereafter 2020. And so I would suggest that if you have more questions or query about that, feel free to reach out to me. And I can either tell you what I know and spend more time on that question in greater detail that may be of interest to you, or I can refer you to some other resources that can be useful in getting that situation resolved.

Okay. Another, I’m going to just group the coding questions as I scan through kind of the themes of them are still, there seems to still be some lack of clarity around your whole. There are no therapy diagnoses. So we see some questions about what if the, you know, a patient doesn’t really have a clear diagnosis at the time we get them. Like they, there there’s a mask that hasn’t been really diagnosed yet. They’ve been in the hospital, they’re gotten, you know, de-conditioned for being in the hospital, you know, or a situation where they don’t seem to have a convenient underlying primary or it’s OT. What do I use for OT? Well, how would you kind of group that in relation to what seems to be holding desperate, to find a therapy?

Okay. Well, first of all, the therapists are going to treat the impairments and body structure and function that reduced or restrict participation in normally occurring activities and restrict participation in and, and, and, and roles and responsibilities, right? According to the ICF model and those impairments and body structure and function come from an underlying pathology or pathophysiology, very typically. Okay. And so the idea is that those underlying conditions, diseases, disorders, events that are causing those impairments. If we speak about it in that bio-psychosocial model, the ICF, which all the therapy disciplines have adopted multiple years ago APA, AOPA, and Asher, I would say that the physician has to prescribe a side diagnosis. So yes, they may have data ever about yes, they may have eroded reduced aerobic capacity. Yes. They may have joint contractures. Yes. They may have these conditions, these impairments that we’re treating, but many times they arise from something.

Now, if you’re dealing with reduce the aerobic capacity and, and fatigue and whatever and and reduce mobility related to prolonged hospitalization the doctor has to refer them for home care with some diagnosis. So what is it that lent to that for long hospitalization and tying that together in your notes with the reason for the referral, the assigned diagnosis by the physician is the way you’re going to get a valid face to face, and you’re going to get the fluency in your documentation. Okay. So, and a lot of times it’s an exaggerates, maybe not exacerbates, but exaggerates these chronic diseases. You take a person with CHF or COPD and you lay them in an ICU for 10 or 15 days, and they’re not moving around. They’re very sedentary on top of maybe the pneumonia with the respiratory failure that they went into that caused them to be intubated and put in the ICU.

Then you’re going to see, even though that may have resolved, you’re going to see the long-term effects of those other chronic diseases that you now, the patient is not getting up, moving around again, it’s our job to start to pull those pieces together, to paint by numbers. If you will, what produces answering the question, developing a query for your clinicians that says, what are you treating and what is, what is the reason for that problem? Okay. Now, if it’s a diagnosis, disease or condition like [inaudible], and that it could be muscle weakness, Ms. It could be gait abnormality, right? Diabetic peripheral neuropathy could be lower extremity muscle weakness could be gait abnormality could be ADL. Dysfunction could be falls, risk. It’s our job to pull that together and to communicate that in our narrative and make sure that there is a fluency with that physician referral reason, because they will send you with diagnoses. They will tell you there a reason for this referral. And if they’re not, then your intake staff needs to get on steroids real quick and get diagnoses that are accepted into the primary groupings, or at least have a basic understanding of what not to accept.

Okay. Do you, before I ask you yet another OASIS question I slipped their coding question. I just wanted to let our attendees know our host has said that we could go to for another 15 minutes while Texas be 14. Now to address these because quite a few are coming in and it looks like once we address this, the shift is moving to maintenance therapy. So this particular one I want to read exactly it. You segwayed it beautifully, and I hate it to take you off track, but I wanted to let people know we were going to stay on here a little bit longer. This one states that their coders are coding only from physician documentation. How do you recommend that they would incorporate the clinicians findings at the start of care for coding?

Well, first of all, we have the code from physician documentation. It’s a physician, doesn’t say they have a condition. Doesn’t have it assigned a diagnosis for a condition. We cannot, in other words, we cannot assign a code because there are, we see that they have a high A1C. We cannot assign a code because they’re on a specific medication like insulin. We cannot assign a code because the patient says, oh, I found a tumor. I went in and they found a tumor. I got to go to the oncologist. I have cancer. When all we see the doctor, right, is a mass of unknown, unspecified, math up with oncologists. We have to code only to the greatest level of specificity and know more detail regardless of what the clinician of scribes or the patient tells us. So yes, we are tie to having confirmation of every diagnosis.

What the clinicians need to document is purely yet. This is the reason, this is how the patient is presenting now. And this is why we’re seeing all these other problems. The clinician’s documentation will help reinforce what is the primary reason for the episode of care. Okay. because that will be the most intensive services. The most acute was getting the most attention, okay. That that should be in their narrative. That should be supported by their utilization and their care planning activities and their interventions. And then all the secondary diagnoses should be listed, not just as a reading off of the past medical history, but how they are impacting the patient. Just because we have up to 24 spaces for chronic co-morbidities or secondary diagnoses in the PDGM model, where now we have six that contribute to payment in the existing PPS payment model does not mean that we should lift everything the patient has.

If it’s not going to either be actively monitored treated, or have the ability to impact care. So I challenge you to go back to your waste discards manual, read the instructions for answering M 10 21 a and then pen 23 B through app secondary diagnoses or additional diagnoses, because we should be including those that are relevant and that have a role in impacting the patient and will take time and services, the dedication of time and services. And so then we have a fluid face-to-face. We have a evaluation of those areas identifying yet. These are problems. We have a narrative statement that tells a little story, maybe an S bar format would be great, as I mentioned. And then we see a care plan. That’s very individualized to the patient with utilizations and frequencies and durations. That make sense based on where the deficits are and what the focus of care will be, and what is the likelihood of stabilization or improvement for this patient. And so that’s how we kind of follow it down the line. So I’m not saying we come from anything other than confirm physician diagnosis that is according to official coding and reporting guidelines. We must do that, but the clinician will understand the impact of these, these diseases and disabilities. And well, it will help drive the utilization of care and interdisciplinary care planning and the building of the plan of care in the home care setting.

Okay. D I appreciate that. And now I know you probably need a drink of water, so I will take questions, come up for air. There’s been some, some question about, you know, educating physicians about issues around PDGM and diagnosis coding. We’ve had some folks share their suggestions, one being the generation of basically a fact sheet to give to the discharge planners, to the physician to the social workers at, at facilities to help them better understand the issue of, of codes, which ones are appropriate, which ones would end up on the, you know, return to provider list, giving them those key elements. I do know I saw it again this morning that the national association of home care has put together a toolkit for educating physicians and are doing a webinar on that in the middle of December. So you can check out the national association of home care website that has that webinar information on it, either in the live, if you’re listening to this live, if it’s past that time, I’m sure the recording is also available to give you some tools and strategies specific to dealing with physicians, because app, I know it’s to say, well, we should all be on the same page, but it doesn’t always work out that way.

So some strategies to be able to help with that are available to you. And there’s a question here I want to take in particular because it’s an interesting one. Not that they’re, they’re all interesting, but it hits a nerve with me and that is about denials. And we know we’ve seen issues around whether it’s ATRs or targeted probe and educate, and the classic scenario being, you know, they chop off X number of therapy visits, and sometimes I’ve been in situations and working with agencies where it’s like, wait a minute, maybe yeah. I’d agree. Your documentation isn’t necessarily, you know, ideal. However, have you noticed that every denial isn’t a full denial, it’s always driving you down to five visits because that puts you in the therapy group, that is the lowest paying. So there’s always been this kind of perceived incentive from a reviewer standpoint to just knock out a few therapy visits, because even if I took out three or five, I put you in a new payment group and then I get to recoup cash.

Well, what does that mean in PDGM if that those days are done and the idea that I can just flick out a couple therapy visits and drop you into a different group, it take back the difference to me that they big positive from this situation going forward. Now, the challenge we have to watch is the change in the lupus. The lupus have gone from a here’s the one line in the sand essentially to anywhere from two visits to six visits can be a Lupa and PDG, and it all depends on what group you’re in to me that makes it clear to the clinician that this is not about Lupa avoidance. This is back to the utilization and clinical decision-making that I’m providing every PA visit. This patient needs not one to many and not one to few and at my responsibility to defensible documentation roommate.

So I think the idea that the whole nit pick and pick off a few therapy visits, I think we’re going to see that go away in PDGM. But if we’re going to talk about audits, we got to talk about this. If we start radically changing how we utilize therapy, that is not just a flag issue in PDGM many have discussed that if we significantly drop our utilization is an organization in PDGM that also raises question and opportunity for questioning your decision-making the three years prior, because if you were willing to drop it in 2020 in light of a payment methodology change, then what are you saying that you were over providing it the three years prior? So again, we’re always back to where we gotta be at, which is every visit has to count. Every visit has to have a purpose, and every visit has to be well-documented regardless of discipline.

Now, D we’re switching gears, because I think we, we successfully poked the bear with respect to maintenance, and I’m going to say in advance that these are great questions. Some of them are complex questions, so we’re not overlooking them or ignoring them. D and I have created a maintenance education that is essentially either a full day or three webinars to be able to peel this onion, because there are a lot of things deeper than, Hey, just go do maintenance as are reflected in these questions, I’ll take care of some of the low-hanging fruit first. How do you bill it’s a visit is a visit and the current payment methodology just counts as a therapy visit in PDGM is just a visit on the client. We do have a specific G code that identifies it as maintenance therapy and utilization of that G code is critical under both payment methodologies, because then if you go into my documentation and it is maintenance therapy, and I have build it as such that it is much more defensible that I am following the rules of the benefit, as opposed to documenting what clearly looks like maintenance therapy, but we didn’t call it that, or we did call it that in the documentation, but not on a claim.

Those inconsistencies can still trigger denial risk. So you want to make sure you’re using the appropriate G code on the claim. So as a therapist, you may say, I didn’t even know there was one, yes, because some organizations out of anxiety about maintenance therapy, kid, that code from the clinician, not please, we’re not talking about his conspiracy theory. They just felt it was better that you couldn’t hit it by accident, but it does exist by extension. We’re getting questions about the issue of assistance in this. Yes, there will be a different code now that will account or assistance or rolled into the other. But there we are going to be able to identify that utilization piece going forward because effective January 1st, 2020, we can use assistance for maintenance therapy. So the bottom line is make sure your claim lines up with your focus of care when we’re doing maintenance therapy, because this is something D and I hear quite a bit, there are several variants on the, I’ve been doing a restorative course of care.

I want to switch to maintenance. Do I have to discharge a patient? Absolutely not. You do not discharge a patient and then reevaluate them for focus with maintenance when you’ve been doing restorative to begin with. And then you’re going to go to maintenance. The regulations are clear that at the end of the restorative focus is when you’re clearly documenting your intent to change that your care planning is taken care of. This is what I’m going to do going forward. The communication with the physician has occurred. So I might need significantly different intervention focuses or goals or communication with the physician that should be documented on this as well. And then I proceed to deliver the maintenance therapy. So yes, there are things I have to do. I can’t just who I decided is maintenance today. And, and just do it. I need to make sure that I’m very clear in my documentation, the intentionality, that physician collaboration and the deliberate nature of my change to a maintenance focus of care. But I do not have to discharge somebody before an intern around and evaluate them on the very next treatment visit as, as if they were a brand new patient that that is not recommended. The we’re getting, I’m gonna read this question to you. You ready for it?

Are you back? Want to make sure you’re not on mute? Okay. Take a deep breath when you’re ready. What is the close to perfect way to provide our patients with maintenance therapy? First of all, I think you have to identify it when it exists. Okay. You have to understand if your skills are needed to, to stabilize their functioning, to prevent them from deterioration or decline, but I don’t know how the perfect way is because every patient I see has their own unique presentation. So I think that the perfect way starts with identification. But this idea that we can prescribe visits sometimes I don’t see patients, but once a month, sometimes I wouldn’t see patients, but once a week, it just depends on how often do I need to go to make sure that they in the plan are appropriate and it’s doing what it’s intended to do.

I just kind of, you know, kind of poke the bear a little bit there. You know, as well as I do that, trying to figure out a perfect program does require a lot more conversations and we technically have time for today because it really is about understanding by proper identification of patients. And also I think dealing with what you would, I hear a lot of is the, oh my gosh. You know, if I take a patient on maintenance, I’ll have them forever. That maintenance means never ending therapy. It does not. There is absolutely discharge planning involved with maintenance therapy. This is not meant to be a forever benefit. It is about what does the patient need from you skilled, reasonable, and necessary. Absolutely still apply. This has to be something that requires the skills of a therapist to create the maintenance program, to educate the maintenance program, to ensure the program is effective.

And in some situations provide that maintenance program because it would be deemed completely unsafe for someone else to do it, who isn’t a therapist, but it always is subject to the requirement of being skilled. It is not less than it is not just repeating things. It’s not, they don’t have a caregiver, so I could just go and do it cause I’m nice. So this is why we have to be very clear about this and, and seek out those resources about how do I make sure if I’m doing it now that I’m doing it the way it needs to be done. If I haven’t done it, how do I make sure we do this program effectively? And if I’m meeting resistance, I get off this webinar and say, Hey guys, we’re going to do maintenance. So they all, you know, look like you swore in church, you, you may have to facilitate that conversation going forward with external support, because this is not an easy thing to get some clinicians to be willing to do.

And it’s not because we’re belligerent it’s because therapists have spent their entire careers in many cases the, I need to get people better and if they’re not getting better, I need to be responsible and discharge. And to find out that’s not really true and never was true, can be a very pill to swallow and a hard behavior to change. And I think PDGM by folks saying, Hey, it isn’t all just about more therapy as an industry. Hey, can we get people better with less conversations around maintenance and conversations around management evaluation are important ones to have? No, unfortunately we are at the end of our time slot.

Is there a G code for the assistance and maintenance? Do we know that
I want to go double check that because all the stuff we’ve seen has it really come down on that they may just roll it into the physical therapy, occupational therapy, one we already passed. But yeah, I, I, we need to go back and take a look at that. I don’t want to give the wrong information, but it should be easily accessible by going in and looking at the final rule where it clarified that we were going to be able to utilize that. So it’s accessible information. I just, in what I was reading, it didn’t jump off the page at me and I don’t want to speak out of turn.