what diagnosis ot's see in inpatient rehab include

What is rehab diagnosis?

The main difference is that in rehabilitation the presenting problems are limitations in activities and the main items investigated are impairment and contextual matters, whereas in medicine the presenting problems are symptoms, and the goals are the diagnosis and treatment of the underlying disease.

What do OTs do in acute care?

Acute care OTs focus on helping to medically stabilize patients, facilitate early mobilization, perform therapeutic interventions, and create discharge plans. By contrast, patients in rehab settings have chronic issues that OTs treat over time.

What is the purpose of inpatient rehabilitation?

From your first therapy session to your last check-in, the goal of inpatient rehab is to help people with serious medical conditions like stroke, heart failure, joint replacement or serious injury recover faster, as fully as possible.Aug 16, 2018

In which therapy setting is it very important that the patient be able to tolerate 3 hours of therapy services in order to qualify for services?

Here is the kicker: While in a skilled nursing facility (SNF) a patient would typically receive less intensive therapy in a shorter duration (such as 1-2 hours), in order to qualify for admission to an acute inpatient rehab unit (ARU), a patient must typically be able to tolerate 3 hours of therapy 5 days per week.Dec 22, 2018

What is a OT evaluation?

The purpose of an evaluation visit is to assess areas of function so that the occupational therapist can develop a treatment plan to meet the patient's specific needs. The areas assessed during an OT evaluation depend on the patient's age, diagnosis, and rehabilitation needs.

What settings do OTs work in?

About half of occupational therapists work in offices of occupational therapy or in hospitals. Others work in schools, nursing homes, and home health services. Therapists may spend a lot of time on their feet while working with patients.Feb 17, 2022

What are the CMS 13 diagnosis?

Understanding qualifying conditions for admissionStroke.Spinal cord injury.Congenital deformity.Amputation.Major multiple trauma.Fracture of femur.Brain injury.Neurological disorders.More items...

What are some CMS criteria for inpatient rehabilitation facilities?

Recently, the Centers for Medicare & Medicaid Services (CMS) advised its medical review contractors that when the current industry standard of providing in general at least 3 hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics) per day at least 5 days per week ...Dec 20, 2018

What is the difference between rehab and PT?

Rehabilitation is the process that assists a person in recovering from a serious injury, while physical therapy will help with strength, mobility and fitness.Nov 25, 2016

What is included in physical therapy?

You treatments might include: Exercises or stretches guided by your therapist. Massage, heat, or cold therapy, warm water therapy, or ultrasound to ease muscle pain or spasms. Rehab to help you learn to use an artificial limb.Jul 31, 2021

What factors need to be taken into consideration by the patient family and case manager when choosing a rehabilitation facility?

10 Tips to Help You Choose a Rehab FacilityDoes the facility offer programs specific to your needs? ... Is 24-hour care provided? ... How qualified is the staff? ... How are treatment plans developed? ... Will I be seen one on one or in a group? ... What supplemental or support services are offered during and after treatment?More items...•Dec 17, 2020

How do you write an OT goal?

Let's dig into why OT goal writing can be challenging:SMART: Significant, Measurable, Achievable, Relates to person, Time based.RHUMBA: Relevant, How long, Understandable, Measurable, Behavioral, Achievable.COAST (my all time fav): Client, Occupation, Assist level, Specific, Time bound.

My Morning Routine

I clock in at my unit at 7:00 AM. After clocking in, I check my schedule for the day and write it down.

Back to Work for the Afternoon

The afternoons are definitely my favorite since I start treatments right at 1:00 and finish at 2:30. I only have 1.5 hours of treatments in the afternoon. I usually have one 30 minute treatment and one 60 minute treatment.

Other Afternoon Treatments

If I’m working with a patient that is extremely limited by weakness, I might run their treatment a little bit differently. I might skip the I-ADLs and focus on beneficial therapeutic exercise or neuro re-education. I’ll try to get at least one unit of self-care retraining if they did not have any OT in the morning, though.

Wrapping Up After Treatments (AKA the Paperwork Fun!)

From 2:30 to about 3:30, I sit down to work on notes, sometimes with the help of some extra caffeine if I had an especially physical day.

Last But Certainly Not Least: The Billing Sheet

Once I’m finished with all of my necessary paperwork, I fill out a billing sheet with each patient’s individual treatment times with the units billed for the treatment.

What is acute inpatient rehab?

Acute inpatient rehab, whether it is in a hospital unit or at a stand-alone rehab hospital, is an in-hospital based rehab setting that is the most “intense” form of rehab patients can get, meaning patients will get the most therapy possible here.

What is a special outpatient clinic?

Treatment takes place weekly in a special outpatient clinic that is set up to address building underlying skills in a playful manner.

What is acute care therapy?

Therapists who work in acute care often work with patients who have recently suffered injuries and illnesses requiring urgent medical care. Acute care can be a high intensity setting, with high volume caseloads of very diversified patients.

What is the next level of rehab?

The next level of rehab is subacute rehab, which is a less intense form of in-house rehab where the patient stays in a skilled nursing facility (or a hospital’s subacute rehab unit) to receive 24 hour nursing care and an hour to an hour and a half (on average) of occupational therapy, physical therapy and sometimes speech therapy daily.

What is home health occupational therapy?

In the home health setting, occupational therapists work with patients in their own homes. Home health OTs help ensure that their patients are able to put into practice the strategies and treatments they learned in the hospital or rehab setting, since many patients receive home health after their rehab stays.

What is hand therapy?

Hand therapy is a specialization of outpatient therapy in which the occupational therapist with advanced training on the upper extremity treats individuals that have upper extremity impairments affecting their function. Most often, these are certified hand therapists (or CHT).

What is neuro outpatient therapy?

Neuro outpatient occupational therapy is another outpatient setting with a focus on rehabbing patients with neurological impairment. In this setting, OTs will treat individuals affected by stroke, brain injury, spinal cord injury, Parkinson’s, multiple sclerosis, and other neurological impairments that contribute to a decline in function.

Hey! Can you tell us a little about yourself?

Hello, my name is Emily! I graduated from University of Wisconsin-Madison in December 2020 and passed the NBCOT in February 2021. I recently accepted a dual position working 20 hours/week in inpatient psychiatric and 20 hours/week in outpatient pediatrics.

What setting are you sharing about today and can you give a brief description of it? What qualifies a person to receive therapy in this setting?

Inpatient rehab! Inpatient rehab is generally where an individual will go following an acute care or ICU setting but only if they are:

Did you feel prepared going into this setting based off of your classes? And how did you prepare before starting?

I felt prepared going into this setting based on my background of exercise science and my OT program’s anatomy and adult classes. Before going into the setting I looked into common diagnoses, reviewed how to use my goniometer, and studied stroke symptoms based on location.

What resources were the most helpful during your time there?

My CI was an incredible resource, she has been in the field for over 20 years! In addition to my CI, I liked the free handouts from Seniors Flourish, AOTA’s condition specific TIP sheets, and notes from my MSOT adults class. I also made my own resource of skilled phrases so that I could copy and paste them to speed up documentation.

How did you stay organized and manage your time?

I always brought a notebook with me. I would write the first initial of the patient and their time slots that day, the diagnosis, level of assistance required, specific treatment ideas, and any fun facts I learned about them from previous sessions so I could bring it up again or ask more questions.

What assessments did you use most?

During admission and discharge we would typically use: goniometer measurements of the upper extremities, 9 hole peg test, MMT, an informal mental status check with orientation questions (day, year, time, what brings you here, remember these 3 words etc), and IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument) scores.

What did a typical session look like?

Usually OT and PT would see the patient for two 45 minute sessions each day, if the patient also required speech that would sometimes bring us down to one 45 minute session and one 30 minute session depending on the needs of speech.

When was the CMS rule for major multiple traumas?

In the proposed rule dated September 9, 2003 (FR 68, 53272) CMS clarified which patients should be counted in the category of major multiple traumas to include patients in diagnosis-related groups 484, 485, 486 or 487 used under the IPPS.

What is Medicare certified hospital?

Section 1886(d)(1)(B) of the Social Security Act (the Act) and Part 412 of the Medicare regulations define a Medicare certified hospital that is paid under the inpatient (acute care hospital) prospective payment system (IPPS). However, the statute and regulations also provide for the classification of special types of Medicare certified hospitals that are excluded from payment under the IPPS. These special types of hospitals must meet the criteria specified at subpart B of Part 412 of the Medicare regulations. Failure to meet any of these criteria results in the termination of the special classification, and the facility reverts to an acute care inpatient hospital or unit that is paid under the IPPS in accordance with all applicable Medicare certification and State licensing requirements. In general, however, under §§ 412.23(i) and 412.25(c), changes to the classification status of an excluded hospital or unit of a hospital are made only at the beginning of a cost reporting period.

What is Medicare IRF?

All hospitals or units of a hospital that are classified under subpart B of part 412 of the Medicare regulations as inpatient rehabilitation facilities (IRFs). Medicare payments to IRFs are based on the IRF prospective payment system (PPS) under subpart P of part 412.

What is 412.23(b)(2)?

Under revised §412.23(b)(2), a specific compliance percentage threshold of an IRF’s total patient population must require intensive rehabilitation services for the treatment of one or more of the specified conditions. Based on the final rule, CMS issued a Joint Signature Memorandum including instructions related to Regional Office (RO) and Medicare fiscal intermediary (FI) responsibilities regarding the performance of reviews to verify compliance with §412.23(b)(2) as detailed in CRs 3334 and 3503, which revised Medicare Claims Processing Manual Chapter 3, sections 140.1 to 140.1.8. (CR 3503 corrected some errors or clarified the instructions in CR 3334 and presented additional instructions to implement revised §412.23(b)(2).

When was the 412.23(b)(2) review suspended?

On June 7 , 2002, CMS notified all ROs and FIs of its concerns regarding the effectiveness and consistency of the review to determine compliance with §412.23(b)(2). As a result of these concerns, CMS initiated a comprehensive assessment of the procedures used by the FIs to verify compliance with the compliance percentage threshold requirement and suspended enforcement of the compliance percentage threshold requirement for existing IRFs. The suspension of enforcement did not apply to a facility that was first seeking classification as an IRF in accordance with §412.23(b)(8) or §412.30(b)(2). In such cases, all current regulations and procedures, including §412.23(b)(2), continued to be required.

What is the ICD-10 code for occupational therapy?

It gives occupational therapists the freedom to select diagnostic codes that include a high level of detail about their patient’s condition. But with expanded choices comes an increased risk for coding mistakes. By paying careful attention, becoming familiar with the codes most often used by occupational therapists, and keeping good documentation, you’ll be able to avoid many of the common ICD-10 coding pitfalls.

What is the ICD-10 code for HIPAA?

ICD-10 codes are a combination of three to seven alphanumeric characters. There are two types of ICD-10 codes: medical diagnosis codes and treatment diagnosis codes. The patient’s physician assigns medical diagnosis codes. A therapist can assign treatment diagnosis codes.

Why use unspecified codes?

Use Unspecified Codes Sparingly. There’s certainly a place for using unspecified codes if there’s insufficient information in the patient’s medical record. But unspecified codes tend to get overused in favor of less common, but more specific codes. Using an unspecified code too often can be a red flag for insurers.

When was the ICD-9 replaced?

ICD-9 was replaced in 2015. Although it’s been several years, if you were familiar with the old way of coding, it may be easy to inadvertently revert to outdated codes, especially if you’re rushing or tired. If you use an old code, your chances of an insurer rejecting your billing claim are all but assured. 2.

What happens if you choose the wrong ICD-10 code?

When you choose the wrong ICD-10 code, incorrect information about a patient goes on the record, making it difficult to show the medical necessity of the treatment you provided. This can lead to billing claims rejections, time-consuming resubmission, and payment delays. Here are some helpful tips to ensure you choose the best ICD-10 code for every patient the first time.

What is the World Health Organization's classification system?

It’s a standardized system that allows medical and therapy professionals to code a wide variety of diseases, external causes of injury, treatment of conditions, and more.

What is inpatient rehab coding?

Inpatient rehab coding involves reading proper, clear documentation, as well as skillful, accurate, and detailed abstraction of the POA diagnosis code, sequela effects, ongoing comorbidities, forever diagnosis codes, chronic conditions, use of assistive devices, and complications.

What is ADL in healthcare?

While providing quality care, skilled clinicians must assess the patient’s activities of daily living (ADL) functions in the presence of illness. They must also justify the patient’s etiology for complications and comorbidities in the medical record.

Who is Tamara Thivierge?

Tamara Thivierge, MHA, CPC, is a certified medical coder with over 25 years of broad professional history in diverse settings, including inpatient rehab, behavioral health center, family physicians, and auditing with an insurance payer. She has also led workshops on billing in the Hampton Roads, Va., area.

How Can Occupational Therapy Help Me?

You had a stroke and your memory has been affected, making it hard to remember to take your medication or remember what you need to get done every day.

What Does Occupational Therapy Include?

Regaining the physical skills needed to use an arm/hand that was affected by a stroke or brain injury.

What are the criteria for IRF?

An IRF must meet certain criteria to be excluded from the Inpatient Prospective Payment System (IPPS) and the DRG payment methodology. One of the criteria states that 60 percent of the IRF’s total patient population must require treatment for one or more of 13 specified conditions. These conditions include: 1 stroke 2 brain injury 3 spinal cord injury 4 fracture femur (hip) 5 congenital deformity 6 major multiple trauma 7 neurologic disorders 8 burns 9 amputations 10 active polyarticular rheumatoid arthritis, psoriatric arthritis, and seronegative arthropathies 11 systemic vasculidities with joint inflammation 12 severe advanced osteoarthritis 13 knee or hip replacement immediately preceding the IRF admission and also must meet additional criteria

Who is Patricia Trela?

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience. As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH). Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).