PPS training essential to maximize reimbursement

Rehab director offers these guidelines

Through a comprehensive educational program, visual cues, and training updates, a rehabilitation facility can educate its staff on how to best document patient status in order to receive the appropriate reimbursement under the inpatient rehabilitation prospective payment system (PPS).

Unity Health System in Rochester, NY, has educated and trained rehab staff with a program that includes guidelines derived from the Centers for Medicare and Medicaid Services (CMS), journals, and other rehabilitation facilities, says Sue Vogl, MPA, physical medicine and rehab administrative director for Unity Health System, which has a 33-bed rehab unit.

"We knew what we needed to do back in 1999, but we were waiting for the final rule to be published," Vogl says.

Once CMS published the final rule and made changes to eliminate its first proposal of using the Minimum Data Set - Post Acute Care and switched to the industry’s preferred system, the Functional Independence Measure (FIM), the rehab facility began to analyze how documentation would change.

Documentation teams worked side by side

Two teams were formed. The clinical team had nurses from all three shifts and representatives from speech therapy, occupational therapy, and physical therapy. The reimbursement team had staff from medical records, finance, information systems, and reimbursement, Vogl says.

"Each team was working side by side but focusing on their particular issues," she adds.

"We were a former FIM user, so therapists were used to scoring on the FIM, but we revised all assessment tools and FIM scoring," Vogl explains. "We used training materials developed by CMS, and we had one other staff person and myself go to three training sessions across the country."

Vogl came back with PowerPoint presentations, videos, flip charts, and other training materials. She also made use of the CMS web site and its question-and-answer information. The training modules were established within four to six months.

"We set up two-hour training blocks, where a nurse manager and I would do the training, including midnight training for the night staff," Vogl says. "We did five or six sessions where everyone would have to sign in and take a post-test."

From the post-test, managers determined what the problem areas were, and they focused on those in follow-up training.

Assessment charts are audited on a weekly basis to make sure they are done completely and accurately, and the rehab facility has an assessment coordinator who has worked in the rehab field for 10 years, Vogl says.

Most of our problem areas were found within the first six weeks of starting the new assessment program, which the facility initiated prior to PPS implementation, Vogl adds.

"Since then, we have an ongoing monitoring program, so if there are isolated problems, we can catch them before they become trends," Vogl says. "We’re very happy with it."

Here’s how the educational modules were established:

Mobility scoring: Under the PPS tool, the patient’s transfer status has to be described according to different scenarios.

Therapists and nurses were taught, through various examples, how the Medicare instrument differentiates between definitions for transferring from bed to wheelchair vs. from bed to chair.

For instance, one question they were asked to consider was: "If a patient uses a wheelchair, can he or she receive a score of seven [the most independent score]?"

"Normally if a patient uses an assistive device, you can’t score a seven," Vogl says. "But in this case there are different possible scenarios, so the answer is yes.’"

However, the score would be a six if the patient is transferring from a wheelchair and is using the wheelchair in such a way that it facilitates the transfer, such as if the patient uses the wheelchair armrest, Vogl says.

"Then it’s considered modified independence, and it’s a score of six," she adds. "We really went through the intricacies."

Staff must set expectations for locomotion

This module also covered locomotion, including walking and wheelchair use. Under PPS, this documentation has a new and more difficult consideration. Physical therapists or other staff who assess patients at admission will need to decide what their expectations are for each patient with regard to locomotion, Vogl says.

"If a patient is in a wheelchair at admission, and the expectation is that the patient will be ambulating at discharge, then you have to project what they would be scoring on ambulation at admission," she says.

In other words, scoring is very different according to what the therapist’s expectations are for a particular patient. If wheelchair patient A is expected to be walking at discharge, then the admission score for patient A would reflect low independence and would perhaps be a score of one. If wheelchair patient B is expected to be in the wheelchair at discharge, then the score for patient B may reflect a higher level independence with a score of five or six, even though patient B and patient A demonstrate the same amount of ability at admission.

In both cases, the therapy goal would be to help the patient improve in locomotion scoring, but the improvements would be different. Patient A might improve to the point of using a walker, whereas patient B might improve to the point of being able to use the wheelchair without assistance.

"Therapists always have goals for patients, but they may not be comfortable on admission to say whether this person is going home with a walker or independently or in a wheelchair," Vogl says. "So the question for us was what would happen if a therapist thought a patient would walk without a wheelchair, and then the patient doesn’t."

The answer was that the therapist should score the admission assessment both ways, with one score for if the patient stayed in the wheelchair and the other for if the patient was walking, Vogl says. "Then, at discharge, you take the correct score."

The documentation would be sent to Medicare after the discharge.

Nursing has a truer picture of deficits

Cognitive scoring: This is another area with a major change. Previously, the cognitive scoring at Unity Health System was done by the staff neuropsychologist, but under the new assessment instructions it will have to be assessed by the nursing staff, Vogl says.

"With the new assessment, the goal is to assess the patient at the lowest level of performance over the first three days," Vogl says. "Typically, what you see in therapy is that the patient will do well for the therapist or psychologist, but not for the nurses or family."

This is why the rehab facility now has nurses provide cognitive scoring.

"Nursing has a truer picture of those deficits in a more normal daily functioning rather than in a half-hour one-on-one session with the neuropsychologist," Vogl explains. "The neuropsychologist will still score and track the patient’s progress in that specific area from admission through discharge."

So the rehab facility had to teach nurses how to do cognitive scoring, and this was an area that they struggled with, Vogl says.

"We had to break it down and show that what PPS was looking for was how these patients function in a day-to-day environment, which is different from a neuropsych setting," she says.

Nurses need to consider questions like these:

— Can the patient ask caregivers for his or her medications?

— Can the patient sequence putting on articles of clothing?

— If the patient can’t reach something, how can he or she get around it?

During the nursing cognitive assessment module, the staff neuropsychologist gave some suggestions and recommendations on how to assess severity of deficits and what is the best mechanism for working through those deficits.

Cognitive scores updated throughout stay

Another example of where a cognitive deficit may appear is in the task of problem-solving. Nurses were asked to answer this question: "What is the problem-solving score for someone who solves routine problems 75% of the time, but does not initiate or participate in any complex problem-solving?"

The answer is that the score is a level four because the patient only requires minimal direction for occasional assistance for routine problems, but does not solve complex problems, Vogl says.

Routine problems might include the patient asking for help when dropping a spoon, the patient putting on more clothing when he or she is cold, or the patient asking for assistance prior to transfer or when he or she needs help in buttoning a shirt. Complex problems are anything that requires a three-step direction, such as planning for a day’s activities.

To assist nurses in making these decisions, the rehab facility has decision trees that walk them through the process of assessing cognitive function.

Nurses on all three shifts now have to assess cognitive function for the first three days, and the scores are updated throughout the patient’s length of stay on a weekly basis and again at discharge, Vogl says.

"This took nurses a lot of time in the beginning, and they were concerned about being able to do this accurately, as well as taking care of patients," Vogl says. "But with more training, and with a lot of visual aids and the decision tree at nurses’ stations, they could do it."

Activities of daily living: Previously, the rehab facility’s occupational therapists would complete the assessment and score the patient’s activities of daily living (ADL).

Now the nurses on all three shifts must score the ADLs for the first three days and then each week and at discharge.

"These include eating, grooming, bathing, and then two dressing categories for the upper body and lower body," Vogl says.

Each category includes specific instructions, such as whether the patient can apply make-up or clean his or her own dentures. 

Nurses need to pay close attention to details and nuances in the patient’s ADLs in order to score these correctly. For example, scoring a patient who eats a pureed diet requires the nurse to know the answers to these questions:

— Does the patient eat a pureed diet because of swallowing problems?

— Can the patient eat the pureed diet independently?

"If the patient is eating a pureed diet independently, then it’s considered a score of six," Vogl says. "If the patient needs utensils put out and maybe pouring sauce or putting dressing on food, then that would be a level five, but if the patient needs total assistance for feeding, then that’s a level one."

Likewise, scoring for dressing requires some knowledge about the patient’s pre-injury habits.

What does the patient typically wear?

For instance, if the patient typically wore a shirt or blouse that required buttoning and now the patient cannot button his or her own clothing, then that may be scored a four, Vogl says.

But if another patient who can’t button clothing is able to put on and wear a sweatshirt, and if this patient had always worn sweatshirts before the injury, then he or she may be given a score of seven, because the expected level of independence is there, Vogl explains.

This means nurses need to check the patient’s history assessment to see if the type of clothing the patient typically wears is indicated on it, or ask the patient and family what the patient is accustomed to wearing.

"Another form we developed is added to the psychosocial assessment, so in addition to basic demographics we’ve added a section about pre-hospital functioning," Vogl says.

Typically, the case manager will collect the historical data from the patient and family members.

Bowel and bladder management: Nurses score this, but the way they score it has changed.

"Now they’re asking you to score the level of assistance they need, as well as to score the number of accidents the patient might have had within the last seven years," Vogl says.

"That’s difficult to get, especially when you’re trying to score that upon admission and you don’t have the luxury of a completed previous chart to know what the patient’s functioning level is," Vogl adds.

The patient’s acute care chart may not have documentation about a patient’s bowel and bladder accidents.

The rehab facility will request that the referring institution send the last week’s progress notes, but those do not always help, Vogl says. Another option is to ask the patient and family about it.

It’s easier for rehab nurses to assess continued bowel and bladder management, because this much has not changed from previous practice. They simply keep nursing flow sheets that track frequency of bladder accidents and frequency of bowel accidents. (To see sample function modifier form, click here.)

Various factors can affect comprehension

Communications: The staff who do this assessment are the speech language pathologist and nurses. There are two categories that need to be assessed under communications — comprehension and expression. "Do they understand when you speak to them, and are they able to express back what they’re thinking and feeling?" Vogl says.

Under comprehension, the scoring is based on assessing the patient’s ability to understand, but it can be affected by various factors. For example, a question may be: "How do I rate a patient who is unable to understand what I am saying because of a hearing deficit?"

The answer is that if the nurse or therapist has to significantly increase the volume of the voice or repeat a message as a form of prompting, and if they have to do this most of the time with the patient, then the score could be as low as two. If the prompting is only necessary occasionally, then the score is a five, Vogl says. Again, nurses are encouraged to use a decision tree to help them with the scoring.

Another example involves aphasia, which is a common comprehension issue with stroke patients. The question to consider is: "When a patient with aphasia can understand what people mean by looking at gestures, how is this rated?"

The answer would be that if the patient is only understanding commonly used voice expressions such as "hi" and "good-bye," and if he or she understand more by the gesture than the words, then the score is two.

But if the patient appears to have only slight aphasia and understands most of what is being said but misses some words, then the score is a five or six.

With regard to expression, the question to consider might be: "How do you score patients who can only express themselves by simple words or by using a communication board, but they can point to words and write things down?"

The answer is that if the patient can only express by pointing to words, the score is a two because that requires maximal prompting. But if the patient can write full sentences and only uses a pen and paper because he or she is not able to verbally express it, then that’s a six because the patient can express all needs and desires, Vogl says.

Need More Information?

  • Sue Vogl, MPA, Physical Medicine and Rehab Administrative Director, Unity Health System, 89 Genesee St., Rochester, NY 14611. Telephone: (716) 368-3360. Fax: (716) 368-3838. E-mail: svogl@unityhealth.org.