Documentation

Question 1

Documentation demonstrates what 4 things?

Answer 1

1. Medical necessity
2. Potential for improvement
3. Services provided as billed
4. Services meet accepted standards

Question 2

5 Common reasons for denials (deficiencies in documentation)

Answer 2

1. Poor documentation
2. Lack of sufficient progress in reasonable time frame
3. Unskilled
4. Amount, frequency, duration not reasonable
5. Services not effective, specific to patient condition

Question 3

3 ways of preventing denials

Answer 3

1. Document skill initial and ongoing
2. Measure and quantify info in meaningful way for reader
3. Avoid use of jargon, lingo

Question 4

Medicare documentation requirements for PT services (4)

Answer 4

1. therapy services shall be payable when the medical record and info on the claim form consistently and accurately report covered therapy services.
2. Documentation must be legible, relevant and sufficient
3. Services billed supported by documentation that justifies payment
4. Identify minimal expectations

Question 5

3 components of initial examination in documentation

Answer 5

1. History
2. Systems review
3. Tests and measures

Question 6

4 components of evaluation in documentation

Answer 6

1. Diagnosis
2. prognosis
3. Plan of care/Goals interventions
4. Discharge disposition/planning

Question 7

What is the most critical component of documentation?

Answer 7

Initial evaluation

Question 8

What does the initial evaluation establish?

Answer 8

1. Medical necessity through objective finding and subjective patient self report

Question 9

What 4 things are included in the plan of care?

Answer 9

1. Diagnoses
2. Long term treatment goals
3. Therapy services
4. POC sent for signature (MEDICARE)

Question 10

What 6 things are included in session notes?

Answer 10

1. Patient self report (subjective)
2. Interventions performed
3. Adverse response to intervention
4. Changes in clinical status
5. Equipment provided, instructions for use
6. communication with other providers

Question 11

Support for timed interventions (3)

Answer 11

1. Requirement to support reporting of times procedure and modality codes in clinical documentation.
2. Based on CPT
3. Time reported: total treatment time and one on one contact time with patient

Question 12

Are SOAP notes often incomplete?

Answer 12

Yes, they require a skilled assessment

Question 13

Do flow sheets allow space to document skill, patient status or plans for ongoing care?

Answer 13

No. They record intervention.

Question 14

Can flowsheets satisfy document requirements alone?

Answer 14

No, they can be a component of record but do not satisfy all requirements.

Question 15

When are billable reexaminations necessary? (3)

Answer 15

1. Unexpected change in patient status
2. Failure to respond
3. Need for new POC

Question 16

What 4 things are documented in billable reexaminations?

Answer 16

1. Goals where program has or has not demonstrated
2. Establish new timeframes and goals
3. Reasons for lack of progress documented
4. Changes to interventions documented.

Question 17

What do discharge/discontinuation summaries do?

Answer 17

1. Summarize episode of care, including treatment, progress toward goals, final disposition of goals, recommendations for plans for patient moving forward.
2. Final opportunity to document medical necessity for an EOC.

Question 18

Recertifications needed when?

Answer 18

1. Need for significant modification of plan, or at least every 90 days if medically necessary treatment continues to be required.
2. Physician/NPPs may require a physician/NPP visit for an examination prior to certification.
3. Medicare does not require a visit unless NCD requires.

Question 19

How often are progress notes required for medicare?

Answer 19

Every 10 visits

Question 20

Are progress notes always required?

Answer 20

Not always required for non medicare patients if session notes document clear objective evidence of progress toward goals.

Question 21

Are progress reports required to be signed by physician/NPP?

Answer 21

No

Question 22

what do progress reports document?

Answer 22

Progress made towards goals or lack of progress and reasons.

Question 23

9 suggestions for skilled care

Answer 23

• Provide a brief assessment of response to intervention at every visit
• Document clinical decision-making process
• Be sure documentation is not repetitive
• Be sure that there is no doubt that only a skilled PT could provide the treatment
• Follow documentation policies, ensure that documentation meets minimum requirements
• Record only on proper forms, write legibly
• Date time and sign every note
• Record info as close as possible to the time of care delivery
• Use only approved abbreviations

Question 24

What should be reported on claims for Medicare patient’s?

Answer 24

Functional status

Question 25

All practice settings that provide outpatient therapy services billing under Medicare part B must include what information?

Answer 25

Functional status

Question 26

When is functional status/limitations submitted? (3)

Answer 26

1. At evaluation
2. On or before 10th follow up visit
3. Re-evaluation at D/C

Question 27

What is utilized to capture data on the beneficiary’s functional limitations?

Answer 27

Non-payable G- codes and modifiers.