Writing Goals for Reimbursement
By Michelle Moffa-Trotter and Wendy K. Anemaet
QHow should we be writing home physical therapy goals?
ATherapy goals, when constructed properly, provide an exact description of the patient's expected functional status upon discharge from therapy services.
The Health Insurance Manual (HIM)-11 containing the Federal regulations for the provision of home care services to Medicare beneficiaries addresses goal setting in §234.7 HCFA-485 - Home Health Certification and Plan of Care as follows:
22. Goals/Rehabilitation Potential/Dis-charge Plans. Enter information which reflects the physician's description of the achievable goals and the patient's ability to meet them as well as plans for care after discharge.
Examples of realistic goals:
Independence in transfers and ambulation with walker.
...Rehabilitation potential addresses the patient's ability to attain the goals and an estimate of the time needed to achieve them.
From this brief reference, we can see that Medicare allows a great deal of latitude with goals, requesting only that therapists set realistic goals and establish a set timeframe for goal attainment. The regional home health intermediaries responsible for Medicare claim determination and payment and the plethora of other third party payers, however, have higher expectations. These claim reviewers examine therapy goals for several reasons.
Purpose of Goals
First, goals assist reviewers in determining if therapy services are reasonable and necessary. By comparing the patient's initial functional status to the anticipated status upon discharge, reviewers judge whether therapy services will result in a material change in the patient's functional status. This provides one very good reason to avoid non-specific goals such as "increase strength" or "improve gait," because any person, after a designated amount of time, could achieve such goals without the assistance of physical therapy.
This prompts therapists to set functional goals, describing concretely how a gain in strength, range of motion, balance, etc., translates functionally to the patient in the home environment.
After initially determining that the goals represent an expectation of im-provement in the patient's functional status with therapy, reviewers next evaluate whether the goal timeframes are reasonable and necessary. For example, if the written therapy goal states "increase lower extremity strength by 1/2 grade in four to six weeks," claim reviewers decide whether therapy services are reasonable and necessary (at the set frequency) to produce a 1/2 grade gain in strength by six weeks.
(What will a 1/2 grade strength gain mean functionally to the patient?)
Most peer reviewers and experienced claim reviewers would question not only the general nature of the goal, but also the reason the patient requires such a protracted time period to attain a relatively small gain in strength with restorative therapy services.
Finally, claim reviewers use goals as benchmarks to evaluate the rate of patient progress toward goals when performing concurrent review of therapy claims. By comparing one therapist's goals to the goals other therapists set for patients with similar diagnoses, they determine if material progress is occurring in a reasonable period of time and gauge if the goals appear realistic.
For this reason, it is imperative that therapists use accepted grades, scales and functional tools to ensure their goals are quantifiable.
As a result, home physical therapy goals should be written with these key principles in mind:
Objective: Describe specifically what aspect of the patient's functional status is expected to improve with therapy.
Example: Instead of "Increase strength," write "Increase right hip ab-duction strength."
Timed: Estimate, using professional judgment and consideration of the unique aspects of the patient's condition, when individual goals will be attained.
Example: Instead of "Increase right hip abduction strength," write "Increase right hip abduction strength by 022898."
Measurable: Set goals that are quantifiable using accepted scales, measures or functional tools.
Example: Instead of "Increase right hip abduction strength by 022898," write "Increase right hip abduction strength to 4+/5 by 022898."
Functional: Relate the goal outcome in terms relevant to the patient's function in their home environment. Ensure that goals are patient-oriented by directly asking patients or caregivers their priorities and personal goals regarding physical therapy. Therapists facilitate this thought process by tagging the words "...so that the patient can..." at the end of the goal statement.
Example: Instead of "Increase right hip abduction strength to 4+/5 by 022898," write "Increase right hip abduction strength to 4+/5 by 022898 so that the patient evidences equal weight bearing during the single limb stance phase of gait."
By following these key principles to goal writing, home care therapists ensure that their goals not only meet payer criteria, but reflect the personal goals and desires of the patient as well. The Table lists some of the more common goal topics in home care as well as suggestions for phrasing the goals within the medical record.
About the authors: Michelle Moffa-Trotter and Wendy K. Anemaet are both full-time home care therapists in Florida working in both the Medicare and private insurance sectors. They have authored The User Friendly Home Care Handbook (Learn Publications) and lecture nationally on the topic of home health therapy with GREAT Seminars. See their Web site, Home Care Corner, at http://members.aol.com/homecorner.
* Send questions regarding home health physical therapy to ADVANCE for Physical Therapists, Home Page, 650 Park Ave. West, King of Prussia, PA 19406-4025; fax (610) 265-8293; PTedit@merion.com