The very first conference K&K hosted as an official company was about maintenance therapy. Ten years later, we continue to be vocal supporters of this approach to care. To that end, we have to talk about some of the pitfalls that can lead to payment denials when documentation is scrutinized.
Red Flag #1 – Assisted Living Facilities
- No one is saying you cannot provide maintenance in an ALF. The issue is that we must treat this living situation like any other one a home health patient may be in. People choose to move into an ALF because they need assistance of some kind. Needing help does not automatically support the need for skilled therapy care – and that is a critical element of defensibility. We must be clear “why” a therapist should be involved with the care. If staff are not willing or able to assist with the therapy program, we cannot continue to see them as a substitute. Conversations with the family members and including of a medical social worker should occur timely so caregiver issues can be successfully managed.
Red Flag #2 – Dementia / Cognitive Impairments
- Therapy care plans, especially maintenance ones, can contain a significant amount of education. When managing a patient with cognitive issues, we cannot document repetitive “teaching” visit after visit as if we expect the patient to retain the information. “Return demo” and “verbalized understanding” speak only to very short term recall and do not get into a sufficient level of patient specific detail. If teaching strategies need to be modified or someone else needs to be involved in the process then the documentation needs to include those elements. I have read too many notes that basically indicate maintenance therapy should continue because the patient will never be able to recall the program. Needing reminders or demonstration that can be done by someone who is not a therapist means I cannot provide those and claim it is skilled care or reasonable.
Red Flag #3 – “They will only do it with me”
- Working with patients in their homes is a personally rewarding experience and relationships form over time. There are times that the mere mention of discharge brings a patient to tears or push back from family members insisting that they “need” therapy to continue. This may sound a little harsh but we have to be able to demonstrate why a patient needs a specific therapy discipline and it is not about me as an individual. Think about it this way, if the therapist won the lottery and quit the same day, the plan of care should be able to continue with another therapist providing the care. When providing maintenance, professional boundaries may periodically feel a bit fuzzy so attention to “why” this care is necessary / essential must be clear I the documentation.
Red Flag #4 – “Every patient is at risk for declining”
- At a very basic level, the statement is correct. Every person on the planet could be considered at risk for a functional decline as time passes and for a variety of reasons. The need for skilled maintenance therapy is not supported by the risk for decline alone but on the ability to clearly state why a therapist and only a therapist is required to slow or stop it. What does a therapist know that a non-therapist does not? What can a therapist do that a non-therapist cannot do as safely/effectively? The focus on developing a maintenance program and overseeing its impact on the stabilization of function is the core of demonstrating medical necessity.
Denials DO NOT mean that maintenance therapy is a bad idea or is not something that should be an integral part of our care planning. Beneficiaries are entitled to it and as stewards of the benefit we are obligated to both provide the level of care indicated and document in a way that confirms it is skilled, reasonable and necessary.