therapy document at ions

8/6/2019 Therapy Document at Ions

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Pocket Guide to

Therapy

Documentation

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Contents

Section 1: The basics ................................................................... 1

The medical record ................................................................. 3The purpose of documentation ................................................. 3Date and time of entries in the chart ......................................... 4Basic documentation rules........................................................ 4Quality of entry content ........................................................... 5Omissions, additions, clarifications, and correctionsin documentation .................................................................... 6

Section 2: Initial documentation .................................................... 9

Initial examination ................................................................ 11Evaluation format .................................................................. 12Documentation components ................................................... 13Evaluation process ................................................................ 13Objective criteria .................................................................. 18

Objective observations .......................................................... 20Assessment documentation ..................................................... 26

Section 3: Certification and recertification .................................... 29

Physician referrals ................................................................. 31Physician referral validity ....................................................... 33Outpatient therapy settings .................................................... 34

Plan of care ......................................................................... 35Medicare requirements for the POC ........................................ 35Certification and recertification .............................................. 37


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Section 4: Ongoing documentation.............................................. 43

Daily documentation ............................................................. 45Daily notes........................................................................... 46Progress notes ...................................................................... 59Discharges ........................................................................... 61Delayed progress report ........................................................ 62Reevaluations ....................................................................... 63

Section 5: Maintenance therapy.................................................. 65What is an FMP? .................................................................. 67Coverage criteria ................................................................. 68Covered FMPs ...................................................................... 69Noncovered FMPs ................................................................ 69Documentation requirements .................................................. 70Discharge criteria ................................................................. 71

Reevaluation ........................................................................ 72

Section 6: Common denial reasons.............................................. 73

Denial reason: Insufficient information ..................................... 75Denial reason: No documentation to support serviceswere rendered ..................................................................... 78Denial reason: Therapy services were not reasonable

and necessary ...................................................................... 79Denial reason: Establishment of a maintenance,home exercise, or self-management program ........................... 81


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Section 7: The appeals process ................................................... 85

Assignment of benefits ........................................................... 88Initial determinations ............................................................. 89Levels of appeal ................................................................... 90Redetermination.................................................................... 91Reconsideration ................................................................... 93Administrative law judge hearing ........................................... 95Appeals council review ......................................................... 96

Judicial review in the U.S. District Court .................................. 96


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Section 2

Initial

documentation


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Initial documentation SECT

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Initial examination

The initial examination is usually your first encounter withyour patient, and the resulting evaluation creates a founda-tion for future therapy treatments.

During initial evaluations, determine whether patients meetreasonable and necessary criteria for skilled therapy servic-es. If they do not meet these criteria, it is your professionalobligation to inform them that skilled therapy services are notrequired.

Remember that the evaluation can be billed even if you dontrecommend therapy because it is needed to determine wheth-er skilled services are necessary.

When determining whether patients meet reasonable andnecessary criteria, you must do the following, regardlessof the payer:

Conduct a thorough, subjective history of illness or inju-ry, including date of onset, past medical and surgicalhistory, medications, prior and current functional status,home living situation, and goals for therapy

Perform a thorough, objective examination, document-ing baseline results

Develop a list of problems based on the results of thesubjective intake and objective examination

Determine functional deficits from the examination results


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Establish short- and long-term goals with expected time

frames for achievementDevelop a plan of care (POC) in conjunction with thepatient and his or her physician to meet those goals

Evaluation format

The following list outlines several formats to document exami-

nations, tests, results, goals, and plans of care:Dictation

Electronic documentation

Handwritten documentation

Preprinted forms

The first three options offer flexibility in terms of componentsof the evaluation that therapists may or may not utilize andcan be customized for each patient. Conversely, preprintedforms must be inclusive, regardless of the sections requiredfor that patient.

Never leave any section that is not applicable blank. Enter

N/A (not applicable) or N/T (not tested) in those sections.


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Documentation components

Regardless of the format utilized, evaluations must containthe following information:

Patient name. Include both the first and last name.

Account or medical record number.

Primary and treatment diagnosis.

Start-of-care date. The start-of-care date refers to thedate of the initial evaluation.

Indicate reason for referral.

Evaluation process

The evaluation process can be divided into four common sec-

tions. Subjective information is usually provided by patientsor their caregivers, either verbally or in writing. Informationobtained in this section includes but is not limited to:

Patient database (age, gender, brief history of illnessor injury, onset date, etc.)

Home environment

Past medical and surgical history (e.g., comorbidities)

Pain (i.e., rating, type, and location)

Known allergies


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Medications

History of prior therapy for the same conditionPrior and current functional status

Previous hospitalization

Whether the patient is a caregiver for someone else

Patients goals for therapy

Database informationA patient database provides a brief history of the illness orinjury that requires therapy services and usually includes thepatients sex, age, and onset of injury or illness. It may alsoinclude any prior hospitalization or previous therapy thepatient may have received, particularly if it impacts the cur-rent treatment.

For an acute injury or illness, the onset date will correspondto the date the injury or illness requiring skilled therapy ser-vices occurred.

Home environmentObtain complete information regarding the patients home

environment, and document it accurately.


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Ask the following basic questions regarding the home

environment:How many steps do you need to climb to enter thehouse?

On what floor are your bedroom and bathroomlocated?

On what floor are the washer and dryer located?

How many steps do you climb to get to the secondfloor?

Are there handrails on the staircase? If so, on whichside?

Do you live alone? If you do, will you have temporaryassistance while you recover? If not, is someone whoresides with you home all the time or are you alonein the house for long periods of time?

Past medical and surgical historyThe past medical and surgical history includes the patientspertinent history. You do not need to list the patients entirepast medical and surgical history, but list history or comorbid-ities that are relevant to his or her current injury or illness orthat may affect therapy.


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Pain

Pain is a category often unaddressed in the therapy evalua-tion. Although insurance carriers do not reimburse for skilledtherapy services solely due to pain, they do reimburse forskilled therapy services when pain interferes with the patientsfunctional ability and causes functional deficits.

Therapists should document their patients pain rating using

one of several accepted standards of practice.In addition, document:

Whether the pain is constant or intermittent

Whether the intensity of pain varies based on the timeof day or the activity the patient performs

The location of the pain

A description of the type of painWhat activities increase pain

What activities relieve pain

AllergiesAsk all patients about any known allergies, including to tape,hydrocortisone, or other items so you do not cause allergicreactions during therapy.


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Prior and current functional status

Ask patients specific questions regarding what they coulddo prior to their injury or illness and what they either cantperform or are having difficulty performing since their injuryor illness occurred.

Inquiries should include but are not limited to the following:

Ambulation

Bed mobility and transfers. Inquiries regarding bedmobility and transfers should include:

Whether physical assistance is required

What type of transfer is performed (e.g., tub, toilet,sit to stand, bed to wheelchair)

What type of assistive device is utilized to complete

transfer (e.g., walker, sliding board, cane)Verbal cues

Dressing

Hygiene

ADLs. Specifically address the patients ability to dothe following:

Cook and prepare meals

Complete laundry

Complete household cleaning, including vacuuming,dusting, cleaning the bathroom, etc.


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Make a bed

Perform other general household tasksDriving

Sitting and standing tolerance.

Problem solving

Speech/swallowing

EmploymentGoals

Objective criteria

The objective section of the examination is when you performthe appropriate tests and measurements based on the subjec-

tive interview. The areas you must assess differ based on thepatients diagnosis and functional ability.

The levels of physical assistance include:

Independent. Patient requires no physical assistance,verbal cuing, assistive device, or extra time to completethe task.

Modified independent. Patient requires an assistivedevice to complete the task independently, forexample requiring a walker to transfer or ambulateindependently.


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Supervision. Patient requires verbal cuing for the perfor-

mance of the task being assessed, or there is a safetyconcern on behalf of the therapist.

Contact-guard-assist. Patient requires steadying duringthe performance of the task. If you use contact-guard-assist to describe the amount of assistance, state thatit is due to patients unsteadiness.

Minimal physical assist (min PA). Patient performs75%99% of the task. The therapist provides 1%25%of physical assistance to help the patient completethe task.

Moderate physical assist (mod PA). Patient performs25%75% of the task. The therapist provides 26%75%of physical assistance to help the patient completethe task.

Maximum physical assist (max PA). Patient performs lessthan 25% of the task. The therapist provides more than75% of physical assistance to help the patient completethe task.

Dependent. The therapist provides 100% of physicalassistance to the patient in completing the task.

Three levels of verbal guidance include:

Minimal verbal guidance (min VG). Patient requires ver-bal cuing less than 25% of the time to complete the task.


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Moderate verbal guidance (mod VG). Patient requires

25%75% verbal cuing to complete the task.Maximum verbal guidance (max VG). Patient requiresverbal cuing more than 75% of the time to completethe task.

Objective observations

General observation. When you first meet patients inthe waiting room, observe:

How patients are sitting

How patients come to a standing position from theirchairs

Patients gait patterns when you walk with them

back to the treatment area

How patients take off their coats, if applicable

How patients sit down in a chair or on the treatmenttable

Posture. Assessment of a patients posture is dependenton the diagnosis and area of the body involved.

Sensation testing. Assess for a patients intact sensationif you are going to provide any type of modality thatcontains heat, cold, or electrical current.


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Bed/mat mobility. Unless the patient has a hospital bed

at home, bed mobility should be assessed from a flatsurface without the use of any assistive device. Breakdown the components of bed mobility and rate theamount of physical assistance and verbal cuing foreach component.

Transfers. Assessment of transfer should include the typeof transfer performed, physical assistance and verbal

cuing required, and any assistive device used for orduring the transfer.

Types of transfers include but are not limited to:

Sit to stand

Bed to wheelchair (W/C)

Bed/W/C/to bedside commode, tub/shower,

and toilet

In addition, document modified standing pivot, standingpivot, or sliding board transfer when applicable.Assistive devices include ambulatory devices, such aswalkers or canes used during the transfer, or orthoticssuch as ankle-foot orthosis.

Gait. The gait assessment must include:Distance ambulated

Physical assistance and verbal cuing required

Assistive device used during gait


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Comparison of stance phase and stride length

between the two extremitiesCadence of gait

Ability to ascend and descend stairs

Balance. Provide objective balance tests, when appro-priate, such as the Tinetti, Berg Balance, get up and gotest, single leg stance with eyes open and eyes closed

test, functional reach test, etc.Hygiene and bathing. Include information in the initialevaluation about where the patient bathes (e.g., thetub, shower, or in a sponge bath). The amount of physi-cal assistance required should also be documented andmay vary depending on the patients location.

Document the use of any assistive devices such as a

long-handled bath sponge, tub bench or seat, or show-er seat.

Range of motion (ROM). Document specific measure-ments of the involved joint, as well as specific measure-ments of the contralateral joint for comparison.

Strength. Typically referred to as manual muscle testing

(MMT), strength is typically graded using one of twoformats.

The numbering system uses numbers zero to five, andthe word system uses the terms zero, trace, poor, fair,good, and normal:


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Zero or 0/5. Upon observation and careful palpa-tion, no increase in tension is felt or movement seenor palpated upon the muscle bulk being assessed.

Trace or 1/5. Upon observation and careful palpa-tion, there is an increase in tension or movement isseen or palpated in the muscle bulk being assessed.

Poor or 2/5. The patient is able to move theinvolved joint through the complete ROM with gravityeliminated.

Critical Concept:

Using minus/plus (/+) signs

The minus and plus symbols are used when a

patients strength is better or worse than one cate-

gory but still does not meet the category above or

below. An example is a patient lying on her left side

able to flex her right shoulder up to 110 in the

gravity-eliminated position. Because she cant com-plete the full ROM with gravity eliminated, she cant

receive a poor (2/5) grade, but she is also better

than trace.

It would be appropriate to grade this movementas Poor or 2/5.


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Fair or 3/5. The patient is able to move the involved

joint through the complete ROM against gravity.Good and normal or 4/5 and 5/5. The amount ofresistance given to determine a good or normalgrade differs between individuals and the musclegroup being tested. First assess the uninvolved sideto analyze the patients normal strength and com-pare the results to the involved. If the contralateral

side is involved, rely on experience when determin-ing the grade.

Dressing. Assess both lower- and upper-extremity dress-ing in terms of physical assistance and verbal cuing,position the patient is in while getting dressed, and anyassistive devices used by the patient to perform dress-ing tasks.

Be specific when evaluating the patients dressing skillsand dont group all lower- or upper-extremity dressinginto one general category unless the patient is com-pletely independent.

ADLs. Other tasks that may be appropriate to assessinclude the patients ability to perform include:

Meal preparation and cookingHousework such as dusting and vacuuming

The completion of laundry

Washing and putting away dishes, etc.


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Communication. Assess how patients communicate their

needs to other people by asking the following questions:Do they communicate verbally or use a messageboard?

Are they able to communicate in complete sentencesthat are appropriate and understandable?

Do they require excessive time to communicate their

needs?Does the patient understand verbal communication?

Swallowing. Assess patients ability to chew their foodand drink liquids. Also observe for signs that may indi-cate patients are aspirating or having difficulty swallow-ing certain consistencies of food or liquid. Documentliquid consistency, voice quality postconsumption, etc.

Do patients pocket food, drool, cough, or choke wheneating food or drinking liquids? Document patients pos-ture, as posture may be the root cause or secondarycause of the swallowing problem.

Problem solving. Assess patients ability to completesimple and complex tasks. These tasks may include:

Getting into and out of bedGetting dressed

Calculating change, etc.


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Memory/cognition. Assess patients ability to remember

tasks/components of tasks.

Assessment documentation

The assessment section of the evaluation is where you canprovide a concise overview of patients functional deficits dueto their injury or illness. Assessments are completed by the

physical therapist (PT), occupational therapist (OT), or speechlanguage pathologist (SLP).

PT assistants (PTAs) and certified OT assistants (COTAs) mayprovide information to assist the PT or OT in his or her com-plete assessment of the patient; however, PTAs and COTAsmay not provide assessments because assessments require

professional skill to gather data by observation and patientinquiry and may include limited objective testing and mea-surement to make clinical judgments regarding the patientscondition(s).

Along with the assessment, you can develop a list of problemsand functional deficits of patients, and short- and long-termgoals. The development of the problem list and functional defi-cits list can be grouped into one category or can be separated.


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GoalsEstablish short- and long-term goals based on patients func-tional deficits. Goals should reflect your description of whatpatients are expected to achieve as a result of therapy, andthey should be stated in functional, objective, measurableterms, with a predicted date for achieving those goals.

Short- and long-term goals must have a time frame forachievement that can be listed in visits, days, weeks, ormonths.


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