In our previous story, we reprinted a letter from a payment denials and appeals consultant who told a client he would stop representing their appeals until they improved their staff’s clinical documentation skills. At the end of the letter, he offered some examples of what kind of documentation they were giving him when he argued their case before the Administrative Law Judge. First, comments about Physical Therapy documentation. Below, his critique of skilled nursing.

I typically work on appeals from various regions. The following is a compilation of what I have found in 38 different physical therapy charts. Compare them to what you are doing and please realize they are all being denied all the way to the ALJ level just like yours are.

Two agencies have on their evaluation forms checkboxes indicating many of the following maladies:

  • Antalgic gait a limp adopted so as to avoid pain on weight-bearing structures, characterized by a very short stance phase.
  • Ataxic gait an unsteady, uncoordinated walk, employing a wide base and the feet thrown out.
  • Festinating gait a gait in which the patient involuntarily moves with short, accelerating steps, often on tiptoe, as in parkinsonism.
  • Helicopod gait a gait in which the feet describe half circles, as in some conversion disorders.
  • Hip extensor gait a gait in which the heel strike is followed by throwing forward of the hip and throwing backward of the trunk and pelvis.
  • Myopathic gait exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip.
  • Quadriceps gait a gait in which at each step on the affected leg the knee hyper extends and the trunk lurches forward.
  • Spastic gait a gait in which the legs are held together and move in a stiff manner, the toes seeming to drag and catch.
  • Steppage gait the gait in foot drop in which the advancing leg is lifted high so that the toes can clear the ground.
  • Stuttering gait one characterized by hesitancy that resembles stuttering.

Your agency frequently creates notes such as the ones I received for one patient:

  • “Was in hospital for bronchitis, had decline in function.”
    • Which functions? How can one tell?
  • Living situation “capable”
  • Pain: = 0
    • Why are we in this home?
  • Prior Level of function: “Independent”
    • How does “independent” differ from “capable?”
  • Posture: “Kyphotic”
    • To what extent? And how is it adversely affecting the patient?  This is never again mentioned in any note. Where did the posture issue go?
  • Full weight bearing, with standby assistance.
  • Quality/Deviations/Postures: “Decreased endurance with ambulation”

This is the logical place for any of the aforementioned abnormalities to be recorded. Detail on these brief notes would go far when it comes time to defend a denial of payment for this patient. Poor endurance with walking is the primary driver for the care to be delivered but I know that from talking with this therapist. I could not know it from these notes.

This example leaves a judge not only with a suspicion that this nurse was practicing documentation cloning but also that the patient’s welfare was placed in jeopardy due to the nurse’s lack of response .

Skilled nursing visit dated January 18, 2009 9:00 AM
the skilled nurse focused on the new diabetes regimen with the change doses three times a day with the insulin, and assess compliance and effectiveness of the antibody therapy that was completed on January 17 to assure that no side effects or adverse reactions occurred. Blood sugar of 180 MG/DL, which is approximately 80 points higher than the normal range. It is to be expected that the patient’s blood sugar will come down with the new medication regimen but an infection and the stress of being in the hospital can elevate blood sugars and is a very common side effect of the patient’s illness.

Skilled nursing visit January 20, 2009
demonstrates the blood sugar is now 216 MG/DL, which is 116 points above normal, and the patient is hypertensive at 184/94. Before leaving the house, the patient’s blood pressure was reported as being 150/80.

Skilled nursing visit January 22, 2009 at 10:15 AM
blood sugar continues to climb at 289, which is 189 points above normal. Blood pressure is 170/80 in the right arm left arm records 165/80.

Skilled nursing visit January 27, 2009 8:00 AM
the patient is still experiencing difficulty with blood sugar levels as level as noted to be 305MG/DL

Skilled nursing visit January 30, 2009 10:30 AM
the patient continues to have challenges with the diabetic regimen, blood pressure 159/76 as noted in the right arm and left arm 155/80. Skilled nurse continues to check the patients for signs or symptoms of hyperglycemia yet the patient states that she is feeling fine, the caregiver verbalize that she is comply with blood sugar checking in insulin management has ordered. The skilled nursing instructed the caregiver on the purposes and action of humulan insulin and reinforced the need to monitor the diet and the blood sugar to achieve optimal results with the new medical regimen.

Skilled nursing visit February 3, 2009 9:30 AM; the nurse notes the blood pressure to be elevated at 165/99; when queried the patient denies symptoms of hypertension, the nurse reported the findings to the case manager and M.D. The M.D. decided not to deliver any new orders.

Skilled nursing visit dated February9, 2009 12:00 PM; patient’s blood pressure continues be 156/578 on the right arm 155 are in the left arm with a blood sugar of 280 mg/dl.

Skilled nursing visit dated March 1, 2009 1:15 PM; blood sugar of 264 milligrams/DL.

Analysis: This nurse admits in this six-week narrative that she waited until February 3 to alert the physician of a patient who had been spiraling out of control since January 18. My conclusion not enough was done for this patient. This type of documentation is rampant in your agency’s notes but is not being managed by case managers or the QA staff. As owners, you must ask why not.

It is this type of documentation that leaves you wide open for a continuous series of post payment reviews. Medical necessity is not clearly defined; patient’s conditions are not being responded to; yet bills for services continue to be submitted. Every agency that allows this to go on has a limited life expectancy. I fear yours is nearing its end unless ownership attends to these patterns.

2 Responses to “Real-world Examples of Clinical Documentation that Will Result in Payment Denials”

  1. Dave Says:

    What is the previous article mention at the beginning of this one?