By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource
Of the many exciting and challenging things our therapy teams look forward to doing every day, it is probably safe to assume documentation is not at the top of anybody’s list! Yet, in spite of the wonderful work that is done in our gyms, patients’ rooms and hallways — what we choose to document about those services may result in a denial of payment for your facility down the road.

Some of the most common reasons for claim denials include:

  • Ongoing services did not meet the requirements of medical necessity and reasonableness per Medicare criteria.
  • Documentation did not support the requirement that services shall be of such a level of complexity and sophistication or the condition of the patient shall be of such that services required can only be safely and effectively performed only by a therapist.
  • By (Date) the PT and OT plans of care did not document any significant changes or interventions that were needed or could only be done by or under the supervision of a licensed rehabilitation therapist.

The best defense for these types of denials is a good offense. We must proactively document the medical necessity and skilled interventions provided by our therapy staff.

Although a patient’s medical diagnosis or recent surgical intervention may play a strong role in determining whether skilled intervention is needed, it cannot be the only factor supporting medical necessity.

POC Justification Opportunities:

  • Reason for Referral should make it clear why treating discipline is involved.
    o Sub-optimal: “Physician Order.” “Routine admission evaluation.” “New admit.”
    o Optimal: “Pt. referred by nursing due to increasing weakness noted with recent falls in the patient’s room.” “Pt. referred to PT by physician due to new onset of weakness and reduced activity tolerance with increased assistance needed from caregivers for bed mobility, transfers and gait.” “Pt. referred to ST due to increased episodes of confusion with decreased memory for safety precautions while completing ADLs.”
  • PLOF should be a detailed summary of performance levels of the patient prior to becoming ill and should tie to functional areas addressed in both short-term goals and long-term goals.
  • Clinical Impression should specify areas where deficits were noted on assessment.
  • Reason for Skilled Services based on identified deficits (Clinical Impression) what specific interventions are needed that can only be provided by a therapist? What will happen if skilled interventions are not provided?
    o Sub-optimal: “Pt. would benefit from skilled occupational therapy to improve activity tolerance and strength.”
    o Optimal: “Skilled OT treatment interventions to include instructing and training patient in energy conservation techniques, positioning maneuvers, proper body mechanics, safe transfer techniques, safety precautions and use of assistive device(s) in order to facilitate safe return home alone.”

UPOC Justification Opportunities:
Continued Skill should describe the reason why therapy services need to continue based on the patient’s response to treatment. If the patient is progressing towards their goals, this case can be easily made as progress made before is the best prognostic indicator of more progress to come.

However, if patient is not progressing, this can be more difficult to document and the therapist must modify goals and/or approaches with the expectation that the patient will respond to those changes in the Updated Plan of Care. Sometimes new areas of focus arise during the course of treatment and those new areas are incorporated into the UPOC. These are all examples of why the skills of a therapist are needed to adapt and adjust the therapy plan.

Stay tuned for our next FlagPost when we’ll review how to make the best justification in a progress note and a TEN. We know you can’t wait!