Lec 8 - Documentation To Support Payment/Reimbursement Functional Limitation Reporting Flashcards
Purposes of documentation (8):
- Record of patient care
- Tool for planning and provision of services
- Communication vehicle among providers
- Provides info to others about abilities, body of knowledge, and the services
- Demo compliance with federal, state, payer, and local regulation
- Provides historical account of pt encounters that can be used as evidence in potential legal situations
- Demo appropriate service utilization and reimbursement for many third-party payers
- Policy or research purposes, including outcomes analysis
Internal audiences for documentation (7):
- You (at a later date)
- Colleagues
- Other staff
- Other HCP
- Referral sources
- Students
- Patients/families
External audiences for documentation (5):
- Third party payers
- Reviewers
- Case managers
- Lawyers
- Researchers
Relationship btw documentation and payment: Documentation demonstrates:
- Medical ____________
- Potential for ___________
- Services provided as ________
- Services meet _____________
- Medical necessity
- Potential for improvement
- Services provided as billed
- Services meet accepted standards
Preventing Denials: Requires process to ensure claims are ______ and _______ (“_____”) before submitting
Complete
Accurate
Clean
Preventing Denials: Denials and appeals process add ____ to the provider - administrative time, loss of professional ______ _______ ______
COST
Productive billable time
Preventing Denials:
Reasons for denials: Low hanging fruit:
1. Payors will look at areas where there are known deficiencies to ________ amount paid on claims
2. Known deficiencies in PT documentation: ____ documented = ____ done = _____ paid for
3. Anecdotal reports that PTs are less likely to appeal _______
- REDUCE
- NOT, NOT, NOT
- DENIALS
Common reasons for denials:
Documentation deficiencies: (5)
- Poor documentation
- Lack of sufficient progress in reasonable time frame
- UNSKILLED
- Amt, freq, duration = not reasonable
- Services not effective, duration not reasonable
Common reasons for denials: PREVENTING DENIALS (3):
- Document SKILL - initial and ongoing
- Measure and quantify information in MEANINGFUL WAY
- Avoid use of JARGON
Defensible Documentation:
APTA member resource for __________
Documentation skills
Defensible Documentation: It is the therapist’s responsibility to be aware of any:
_______-specific,
_______-specific,
_______-specific,
and/or _____ specific documentation requirements
Payer
Setting
Employer/organization
State
Defensible Documentation: Resources for clinicians:
5
- Medicare manuals
- Medicare Admin Contractors Local Coverage Decisions
- Payer specific websites
- State practice acts
- APTA Guidelines for Documentation
Documentation and Medical Necessity - Payer Expectations: 5 questions you should be asking:
- What is wrong with the pt?
- What is planned for the pt?
- What skilled interventions are required and what specific services are being provided?
- What progress is being made toward D/C?
- What is the final result of the services delivered, patient prognosis, and status at discharge?
Details on what is wrong with the pt?
Exam/eval
Diagnosis
Details on what is planned for the pt?
POC
Goals
Prognosis
Details on what skilled interventions are required and what specific services are being provided?
Daily notes
Details on what progress is being made toward D/C?
Daily notes, progress reports, re-eval
Details on what is the final result of the services delivered, PT prognosis and status at D/C?
D/C summary
Most payers look to \_\_\_\_\_\_\_ to set the standard for issues relating to: 1. 2. 3. 4. 5.
MEDICARE
- Documentation: explicit requirements
- Reimbursement
- Fraud and abuse
- Skilled care
- Utilization
Documentation requirements for therapy services:
Therapy services shall be payable when the medical record and the info on the claim form consistently and accurately report _____________
Covered therapy services
Documentation requirements for therapy services: Documentation must be ______, ______, and ______ to justify the services billed
Legible
Relevant
Sufficient
Documentation requirements for therapy services: Medicare requires that the services billed be supported by __________ that _________ _________
Documentation that justifies payment
Documentation requirements for therapy services: Identify ________ expectations
MINIMAL
Initial examination includes? (3)
History
Systems review
Tests and measures
Evaluation includes what? (4)
Diagnosis
Prognosis
POC/Goals/Interventions
Discharge disposition/planning
Components of documentation: (3)
Visit/encounter/session note
Re-examination/progress note
Discharge/discontinuation summary
What is the most critical component of documentation?
Initial Evaluation
An IE establishes ___________ through documentation of ___________ findings and _________ patient self-report
Medical necessity
Objective
Subjective
I.E. should list complexities present, impact on ________ and/or plan for _____________
Prognosis
Intervention
Medicare documentation of I.E.
- _____ dx and ______ dx
- Support for _____, ______, _____
- Identification of medical care before ___________, if any
- Identification of _______, including where patient lives, who they live with
- Provision of ______, _______ physical function
- _______, __________ with other providers
- THERAPY AND MEDICAL
- Illness, disease, injuries
- Current episode
- Social support
- Objective, measurable
- Communication, consultation
Key Factors for Medicare Documentation of I.E.:
Demographic information including:
Age
DOB
ICD10 diagnosis
Facility and patient ID numbers
Key Factors for Medicare Documentation of I.E.: Date of onset of symptoms or exacerbation of chronic symptoms required new _____
EOC
Key Factors for Medicare Documentation of I.E.: Medical history including impact of ________ on POC
Unrelated conditions
Key Factors for Medicare Documentation of I.E.: Reason for _________
Therapy intervention
Key Factors for Medicare Documentation of I.E.: Current status, including:
Subjective
Objective Evals
Relation between impairments and functional limitations
Key Factors for Medicare Documentation of I.E.: Signature with ___________ and _______
Professional designation
Date
Contents of POC (minimum): 3 things:
Diagnoses
Long term treatment goals
Therapy services
Therapy services include:
Type (discipline)
Amount (times per day)
Duration (number of weeks, or treatment sessions)
Frequency (times per week)
What does ABCDE stand for?
Actor Behavior Conditions Degree Expected time
Session notes should include:
Patient ______
Self report
Session notes should include:
__________ ________ performed
Skilled interventions
Session notes should include:
______ ________ to intervention
Adverse responses
Session notes should include:
Additional or continued _____________ with other providers
Communication
Session notes should include:
Significant changes in ___________
Clinical status
Session notes should include:
Equipment provided, instructed in ____ or ______
Use or application
Demonstration of skilled intervention and progression/ongoing assessment in daily notes:
____ and _____of skilled assistance given to patient
Type and level
