WebPT - Documentation

Question 1

Diagnosis Code for Lower Extremities.

Answer 1

R26.2

Question 2

Diagnosis Code for Upper Extremities.

Answer 2

R29.3

Question 3

Documentation for HPI.

Answer 3

• What their diagnosis is
• Where their pain is
• MD recommending PT to improve

Question 4

Documentation for Primary Complaint.

Answer 4

• Primary complaint being their “right knee, lower back, etc.”
• Patient is now having difficulty with… (lower extremity, upper extremity, back injury, neck)

Question 5

ADL difficulties to include with Lower Extremities.

Answer 5

• Standing
• Walking
• Performing ADLs
• Negotiating stairs
• Cleaning
• Cooking

Question 6

ADL difficulties to include with Upper Extremities.

Answer 6

• Carrying
• Sleeping on injured side
• Lifting
• Pulling
• Pushing
• Driving

Question 7

Specific ADL difficulties to include with Hand/Wrist/Elbow.

Answer 7

• Writing
• Gripping objects like combs, etc.
• Turning door knobs
• Using knife to cut food
• Tying shoes

Question 8

ADL difficulties to include with Back Injuries.

Answer 8

• Bending
• Lifting
• Sitting
• Standing
• Walking
• Performing ADLs
• Negotiating stairs
• Cleaning
• Cooking

Question 9

ADL difficulties to include with Neck Injuries.

Answer 9

• Driving
• Reading
• Sleeping
• Lifting
• Carrying
• Working
• Sitting/Standing for prolonged periods

Question 10

Documentation for Prior Level of Function.

Answer 10

• Check off what is pertinent to diagnosis

- In comments, type “no limitations”

Question 11

Documentation for Current Level of Function.

Answer 11

Check off what is pertinent to diagnosis (relevant difficulties to injury).

Question 12

Documentation for Medical History.

Answer 12

• Check PMH eval form & check off diagnoses present
• Pain scale
• Current medications in e-doc
• Social/Occupational History - Medicare: Include who they live with & if they have stairs
• Patient goals (paper eval form)

Question 13

Documentation for Objective.

Answer 13

• Outcome measures
• Posture
• ROM
• Strength

Question 14

Outcome measure for Upper Extremity.

Answer 14

DASH: Higher the number = greater the disabliity

Question 15

Outcome measure for Lower Extremity.

Answer 15

LEFS: Lower the number = greater the disability

Question 16

Outcome measure for Back.

Answer 16

Oswestry: Higher the number = greater the disability

Question 17

Outcome measure for Neck.

Answer 17

Neck Disability Index: Higher the number = greater the disability

Question 18

Outcome measure for Pain.

Answer 18

Pain Disability Index: Higher the number = more pain

Question 19

Documentation for Posture.

Answer 19

• Neck or upper extremity

- Select: Forward head, rounded shoulders

Question 20

Documentation for ROM.

Answer 20

• Average ROM norms (spreadsheet from Steph)
• Rotator Cuff Surgery (No AROM or MMT secondary to post op restrictions) [PROM (flexion/IR/ER numbers only; no passive abduction)]

Question 21

Documentation for Assessment/Diagnosis.

Answer 21

• Patient presents with ____ , surgical date, injury date
• Now presenting/displaying decreased ROM, strength, flexibility, GAIT & balance deficits, TKR/ACL repair: poor patella mobility, decreased quad contraction
• Palpable restrictions felt: Neck diagnosis - Upper traps, rhomboids, sub-occipitals & Low back diagnosis - lumbar paraspinals, quadratus lumborum, piriformis

Question 22

Short Term Goal (4-6 weeks) examples.

Answer 22

• HEP
• Improve ____ ROM by at least 50%
• Improve ____ strength by 1/2 grade
• Pain (decrease pain by 2 points on VAS)

Question 23

Long Term Goal (8-12 weeks) examples.

Answer 23

• Medicare/Medicaid: Percent impaired -> Select long term & input 10 - 12 weeks
• Improve ____ ROM to WFL/WNL
• Improve ____ strength by at least 1 full grade
• Pain (decrease pain to <2/10 on VAS with all ADLs)
• Include functional goal in LTGs: Return to prior level of function pain/symptom free, return to work pain/symptom free, able to climb 12 stairs, able to walk 1 mile

Question 24

Documentation for Untimed Codes.

Answer 24

• PT Evaluation (low or medium complexity) - used only at initial eval
• PT Re-Eval - Used only for progress notes
• Hot/cold packs
• E-stim (pre-mod)
• Cold laser - Unlisted physical medicine/rehab/ service/ procedure
• Custom Codes: Weekend Code (99051 [Saturdays & Holidays only]) & Zimmer (0019T)

Question 25

Documentation for Direct Timed Codes.

Answer 25

``` Most commonly used - 2 units TherEx (Medicare only bill 1) - 1 unit Neuro re-ed - 1 unit manual therapy Other commonly used DTCs - 1 unit ultrasound - 1 unit gait training ```

Question 26

3 Common Modalities.

Answer 26

- E-Stim - Ultrasound - Laser

Question 27

***Stipulations for Medicare Plans.***

Answer 27

- Make sure plan of care dates are valid | - If a date has passed re-cert a note must be done with the first out of date note

Question 28

Question about Progress Notes.

Answer 28

.

Question 29

Documentation for Status Modifiers.

Answer 29

- Current status is based on score from outcome measures | - Put score into website: https://www.mediware.com/rehabilitation/tools/g-code-conversion-calculator/