Documentation Flashcards
Who are the external audiences?
3rd party payers
case managers
lawyers
researchers
Documentation demonstrates:
medical necessity
potential to improve
Services provided and if they meet standards
reasons for denial?
document deficiency
unskilled
not reasonable
How to avoid denials?
document skill
measure/quantify info
avoid jargon
APTA member resource for documentation skills
Defensible documentation
What are expectations of payer in documentation?
Whats wrong with pt. POC daily notes. Progress d/c summary
Most payers look to medicare to set standards for issues relating to
documentation reimbursement fraud skilled care utilization
Initial exam includes
Hx
Systems review
Test and measures
Evaluation includes
Dx.
Prognosis
POC
d/c
What is most critical component in documentation?
why?
Initial eval.
it establishes medical necessity
What is needed in initial EVAL?
Demographics date of onset Medical Hx Reason for therapy Current status Signature
POC includes
diagnoses
LTG
Services
Session notes include
patient self report interventions and response communication with provider changes in status equipment provided
support for timed interventions based on
CPT
Why are soap notes and flowsheets flaweD?
they don’t include skilled assessment.
Whenever need for significant modification of plan, or at least every 90 days if medically necessary treatment continues to be required
recertification
For recertification, what may be needed?
a physician exam
Medicare does not require unless NCD requires
Occurs with unexpected change in patient status, failure to respond as expected, need for new POC, and/or other requirements
Billable reexamination
Not required if session notes document clear objective evidence of progress toward goals
if not?
Progress report
1x every 10 Tx days by medicare
does not need to be signed.
Summarizes episode of care, including treatment, progress toward goals, final disposition of goals, recommendations for plans for patient moving forward
Discharge summary
What are some suggestions for skilled care?
- assessment of response
- document decision making process
- not repetitive
- Only skilled PT can do it.
Document complications and safety issues as a result of patient/client status
suggesting medical necessity.
Incident reports should be developed in consultation with
attorney
Requires reporting of Medicare patient’s functional status on claims
when
Functional limitation reporting
at eval/ on or before 10th visit.
