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Written by: Mediware on Thursday, August 1, 2013 Posted in: Outpatient Rehab

Here we are just starting August and the impact of claims-based outcomes reporting (Mediware affectionately calls CBOR) has reared some ugly realities.  Not just a few realities;  severe realities that lead you to question, ‘how can this possibly be?’ Inpatients, when billed under part B, must meet the G-code documentation requirement. If a patient is changed to ‘Observation Status’ after the fact, they will also need retrospective documentation to follow outpatient rules of participation. The lines are blurry to say the least. Questions keep pouring into the listserves.

Do you question yourself, ‘will we ever get this right?’ You may also be wondering if all the various scenarios could have possibly been anticipated. Most likely not.  We live in a very complex compliance world despite the long ago promise of administrative simplification – a definition that draws antacids closer.

I believe you can be successful in applying CBOR correctly, but you have to imagine the level of detail necessary, and apply that practice/workflow to meet even the unexpected at times. This is just another challenge you can sweep under the rug but first you have to acknowledge all the ‘what if’ possibilities in your particular setting and prepare the workflow to meet expectations and possibly even what you don’t expect! That is the new challenge. As leaders, expect the unexpected and have process in place to handle 98 percent of the ‘what if’s.’

Let’s take for example the fact that MM8005 has a very extensive review of Services Affected AND Providersand Practitioners Affected. The line between outpatient and inpatient care is blurred by the nature of the business lines. What is the common string? Possibility of Part B reimbursement. The fine lines of manual instruction specific to one line of service vs. another are merging more and more each day. Can you see continuum payment aligning right before you?  You need to! Do you see measurement and goal setting as equally important? You should!

Generally, documentation for payment follows guidelines for condition of participation very specific to the service line/regulations published for that service. In these cases there is a ‘mixture.’ It makes the best sense to follow the ‘highest’ level of specificity, just in case.

The outcomes-based reporting plans leave an entire nation baffled about how to accommodate all realities, and better yet what if you don’t know that the inpatient you are treating can be billed as an outpatient in hindsight? Do you really need to prepare for all scenarios? How long will separate manual instructions be realistic?

What condition of participation should you follow and for which line of service are you attempting to meet regulatorily? I wish I had the answer; the formula, the way to really know what exact advice to give. I don’t, so to be prepared to follow the most stringent practices and you should always be prepared.

Beside the fact that many of the services affected have regulations that reside in different manuals and lines of service, the most stringent rules are for part B documentation. Personally, I would advocate that when charting inpatient acute care, staff should identify the problem through measurement, create the goal and present status to the goal as often as you can during your treatment of the patient to show change. Wait, that doesn’t sound so different than a plan of care we had always worked from does it? Other than applying a measurement that can be reliably repeated for a particular impairment scale; not much else has changed.

If in fact you ask your therapist to apply the G-code principle values and the test/measure they used when they construct the evaluation and plan of care, you will at least have the ability to apply the appropriate information should a billing department request information by code after the fact.

Measurement is not going away. Evaluation, assessment and plans of care to an established goal have always been practice. Let’s make the two as one and move on to the next challenge. The data that can be extracted by these particular values are meaningless ACCEPT to enforce measurement practice. This step is not the end – it’s the beginning. The faster we acclimate to step two the better off we’ll be. What is step two? Getting so annoyed by step one that as a profession we LEAD rather than be steered into outcomes measurements that lead to incomparable data.


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