Medicare reviewers often stop short

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L
What is prior level of function, or PLOF? Our typical standard definition is the status of functional abilities prior to the condition causing the need for rehabilitation services.

Our Medicare auditors seem to think it's the level of function prior to the hospitalization. This may be true, but nothing is ever just black and white.

Our goal as a therapist, of any discipline, is to allow our patients to achieve the highest level of independence and function as possible. So let me provide these examples:

1.     An individual suffers a stroke, and was independent in all aspects of life prior to the stroke. This individual now suffers from hemiparesis and has become completely dependent with all aspects of function. This is a black-and-white scenario. The patient has a clear-cut PLOF, a severe change in medical status, and easily definable rehab goals. Our long-term goals might or might not include achieving an independent status upon discharge.

2.     An individual suffers with degenerative joint disease in his knees. It has caused the patient to require minimal assistance with bathing, constant supervision or assistance with all mobility tasks, and he maintains only a few areas of function independently. The patient undergoes knee replacement surgery, has fantastic rehab potential in mobility and functional activities of daily living. Pain management is under control and the patient is highly motivated with excellent carry-over skills. Do your long-term goals include independence in mobility and ADLs? Or do your long-term goals match the patient's level of function prior to surgery?

As a clinician, if the patient can achieve his or her highest level of independence, I say, let's go for it. To Medicare reviewers, too often they say stop at the prior level of function. So I often challenge the reviewer to explain this terminology.

I also argue the point that prior level of function for individual No. 2 was many months or years ago before the person became debilitated from his condition. There is no clear cut definition on “WHEN” prior level of function occurred.

However, the burden of proof is on us. If your short-term and/or long-term goals exceed a patient's prior level of function, leading up to the hospitalization, we need to provide strong documentation. We must explain our clinical reasoning of how and why the patient can achieve a higher level of independence, the patient's rehab potential, any subjective statements from the patient and/or family, and so on.

Unfortunately, we live in an environment of avoiding red flags and minimizing our risk for denials. But we should never let that process limit or restrict the level of care we provide when it's clinically indicated.

Shelly Mesure ("Measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.


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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.