**The down low on Skilled Nursing Facilities.
Disclaimer: If you want to be in the know about the new CPT codes used for evaluation purposes, RUG levels and important documentation, you have come to the right place! (If you would rather read about the in’s and out’s of my rotation, please see my blog post, “Week 3 & 4: title”)
It seems there is a language for most fields of work. I don’t happen to be proficient in anything to do with business or technology (sorry to any friends working in these fields as I likely have to have a mini review on what exactly you do for a living every time we see each other and still only understand parts :D). Occupational therapy and healthcare, in general, are no different with a plethora of acronyms, crazy words we use for activity analysis and the always fun attempts to name nameless uncommon objects we use in therapy.
Example: What would you call this apparatus?
Answer: Velcro Hand Exerciser (other acceptable answers: Velcro dowels, resistive velcro activity promoting increased grip and pinch strength and fine motor coordination (FMC)) You could really use any of these terms to describe the board so long as the individual reading the documentation for billing purposes understands that the activity is therapeutic and therefore, billable.
Now that we have made reference to the interesting language of OTs, we are going to hit the ground running and address the new CPT codes we use for evaluation of patients. These new codes were implemented January 1, 2017, and are based on patient complexity. Evaluations are determined to be of Low (CPT 97165), Moderate (CPT 97166) or High Complexity (CPT 97168) based on the time spent developing an occupational profile and reviewing prior medical history (PMH), assessments of occupational performance, clinical decision making and development of the plan of care. Part of what distinguishes the levels from one another is the number of performance deficits identified during the evaluation. These are classified as physical, cognitive or psychosocial skills.
In my time at my current site, I have had the pleasure of leading evaluations and determining complexity levels. I have had maybe one individual of low complexity as they had some generalized weakness, but were very strong at their prior level of function (PLOF) and had been hospitalized for pneumonia and were now experiencing just a few performance deficits–enough that it made sense for them to be in the facility and receiving skilled occupational therapy services, but not enough to be labelled as moderate complexity. The majority of the individuals I see have 3-5 performance deficits which is partially why they were determined to be of moderate complexity. I have had just a couple of individuals that fell into the high complexity category–one of these individuals had sustained a stroke or cerebral vascular accident (CVA) and displayed fine motor deficits, gross motor deficits, decreased strength, decreased range of motion (ROM), poor balance, right sided neglect and potential cognitive deficits all leading to a decline in function. With more than 5 performance deficits in addition to extensive time reviewing her medical history and evaluating her current function, this individual was determined to be at a high level of complexity.
Another part of the intake process that rehab managers do is deciding on what Resource Utilization Group or RUG levels to set people at in order to determine how much therapy they will receive during their stay at a SNF. The first 100 days of a SNF stay are paid for by Medicare Part A when the individual has had a qualifying stay (3 days or more in a hospital). No two residents are alike particularly in their utilization of resources. Some individuals require total assistance with their activities of daily living (ADLs), which would coincide with a higher RUG level. On another note, some residents may require less assistance with ADLs, but may need rehabilitation or restorative nursing services. RUG levels are determined on a case by case basis and are driven by the patient’s needs. I am excited to work with my mentor in the last couple of weeks of direct patient care trying my hand at helping to assign RUG levels to further understand this process.
To wrap up, there is a lot to know about the in’s and out’s of working as an occupational therapist in a SNF, and there is so much I have yet to learn! In regards to documentation–it is very time consuming, but is also a very important part of being an occupational therapist. Taking on leadership roles as an OT also comes with increased paperwork and an even deeper knowledge of the payment systems in SNFs and how to navigate this in addition to managing staff.
I am thankful that my mentors have been teaching me more about documentation. I feel like I have gotten a lot of experience with completing daily notes at this point in time and feel confident in my ability to write ‘reimbursable notes.’ It takes me a long time to write out plans of care at this point in time, but I think I will get faster as time goes on and as I get used to documenting about the new CPT codes for evaluation within the plans of care. I began a progress note the other day and will do several this week in addition to some discharge summaries, so this will be a great review from completing this documentation during my Level IIA rotation last summer.
Last summer I didn’t see people through the entire continuum of care all that often as my clinical instructor and I were mostly responsible for evaluations, foremost, and treatments secondarily, as she was the only OT for miles, and we had a lot of COTAs available to treat. I’m glad I made the decision to spend the first 6 weeks of my final rotation doing direct patient care as I believe it will help me to feel ready to hit the ground running once I find a job this summer/fall.
American Occupational Therapy Association. (2017). What are performance deficits in new OT evaluation CPT codes. Retrieved from http://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Coding/performance-deficits-new-evaluation-cpt-codes.aspx?utm_source=Alerts-2-7-17&utm_medium=email&utm_campaign=Help%20With%20CPT%C2%AE%20Codes%20%2B%20Who%20Won%20AOTA%20Elections