Documentation

Question 1

Who are the external audiences?

Answer 1

3rd party payers
case managers
lawyers
researchers

Question 2

Documentation demonstrates:

Answer 2

medical necessity
potential to improve
Services provided and if they meet standards

Question 3

reasons for denial?

Answer 3

document deficiency
unskilled
not reasonable

Question 4

How to avoid denials?

Answer 4

document skill
measure/quantify info
avoid jargon

Question 5

APTA member resource for documentation skills

Answer 5

Defensible documentation

Question 6

What are expectations of payer in documentation?

Answer 6

Whats wrong with pt.
POC
daily notes.
Progress
d/c summary

Question 7

Most payers look to medicare to set standards for issues relating to

Answer 7

documentation
reimbursement
fraud
skilled care
utilization

Question 8

Initial exam includes

Answer 8

Hx
Systems review
Test and measures

Question 9

Evaluation includes

Answer 9

Dx.
Prognosis
POC
d/c

Question 10

What is most critical component in documentation?

why?

Answer 10

Initial eval.

it establishes medical necessity

Question 11

What is needed in initial EVAL?

Answer 11

Demographics
date of onset
Medical Hx
Reason for therapy
Current status
Signature

Question 12

POC includes

Answer 12

diagnoses
LTG
Services

Question 13

Session notes include

Answer 13

patient self report
interventions and response
communication with provider
changes in status
equipment provided

Question 14

support for timed interventions based on

Answer 14

CPT

Question 15

Why are soap notes and flowsheets flaweD?

Answer 15

they don’t include skilled assessment.

Question 16

Whenever need for significant modification of plan, or at least every 90 days if medically necessary treatment continues to be required

Answer 16

recertification

Question 17

For recertification, what may be needed?

Answer 17

a physician exam

Medicare does not require unless NCD requires

Question 18

Occurs with unexpected change in patient status, failure to respond as expected, need for new POC, and/or other requirements

Answer 18

Billable reexamination

Question 19

Not required if session notes document clear objective evidence of progress toward goals

if not?

Answer 19

Progress report

1x every 10 Tx days by medicare

does not need to be signed.

Question 20

Summarizes episode of care, including treatment, progress toward goals, final disposition of goals, recommendations for plans for patient moving forward

Answer 20

Discharge summary

Question 21

What are some suggestions for skilled care?

Answer 21

• assessment of response
• document decision making process
• not repetitive
• Only skilled PT can do it.

Question 22

Document complications and safety issues as a result of patient/client status

Answer 22

suggesting medical necessity.

Question 23

Incident reports should be developed in consultation with

Answer 23

attorney

Question 24

Requires reporting of Medicare patient’s functional status on claims

when

Answer 24

Functional limitation reporting

at eval/ on or before 10th visit.

Question 25

What happened with Middle class tax relief act of 2012?

Answer 25

CMS mandated collection of info about function, interventions and outcomes reached.

Question 26

Who has to submit functional limitation data to CMS?

Answer 26

All practice settings that provide outpatient therapy services billing under Medicare Part B

Question 27

What is included on the functional limitation claim form?

why?

Answer 27

nonpayable g codes and modifiers

to capture data.

Question 28

How is primary functional limitation determined?

Answer 28

g code that most closely relates to what is being treated.

Question 29

What needs to be included in claims form?

Answer 29

separate payable service
g-code functional limitation
severity modifier
nominal charge