Release documentation Flashcards
pta
Policy: ALL patients/residents who have physician orders for therapy services will receive an initial and discharge evaluation which includes:
Policy: ALL patients/residents who have physician orders for therapy services will receive an initial and discharge evaluation which includes:
- Clinical and functional findings
- Short-term and long-term goals
- Treatment plan that includes frequency, duration and modalities
Purpose: All patients/residents will have evaluations performed that assess their current clinical and
functional capabilities to maximize the effectiveness and efficiency of service delivery.
Procedure:
Procedure:
1. Therapy evaluations will be initiated within 48 hours of receiving physician orders. MD orders
must be present. For therapy in-house pick ups, supporting documentation must be present
prior to start of evaluation.
2. Each therapy evaluation will include:
a. Demographic information
b. Medical History
c. Insurance information
d. Prior level of care and living situation
e. Therapy appropriate medical and treatment diagnosis. The onset date for the medical
diagnosis is generally the date of admission to the hospital or date of therapy referral. The
onset date for the treatment diagnosis should be the start of care date (evaluation date).
f. Reason for referral
g. Precautions/contraindications
h. Rehab Potential: This should be rated as good or better in order to recommend skilled
therapy services, as this is the potential for the patient to achieve the goals set.
i. Anticipated discharge site
j. Clinical and Functional findings will include:
Occupational Therapy Evaluation: ADL/Mobility status, upper extremity function, visual/
perceptual function, cognitive function
Physical Therapy Evaluation: Mobility, quality of gait, lower extremity function, positioning,
posture, balance
Speech and Language Pathology Evaluation: expressive language, comprehension, dysphagia,
cognition
k. Treatment plan that includes frequency, duration and therapeutic interventions
l. Estimated discharge site
m. Rehabilitation potential
n. Short-term and long-term goals
o. Therapist signature and date
3. The completed evaluation will then require the physician’s signature/date.
4. Therapy clarification orders that include CPT codes, frequency, duration and medical/treatment
diagnoses, will then be placed in patient/resident’s medical record by evaluating therapist for
physician to sign off on. Clarification orders need to be re-written if any changes in these areas
occur.
5. A treatment plan should also be created in the Care Plan, located in the medical record. The care
plan can only be written and updated by a registered therapist.
6. Evaluation Only- as physical and occupational therapists should perform screens only if the
patient would not benefit from skilled therapy. Billing evaluation only to insurance, is considered
atypical. However with speech language pathologists, evaluation only is permitted, but should not
be used frequently. Downgrading of a diet does not require skilled therapy, as it can be done by nursing or the physician.7. Date of Evaluation- the date of the evaluation IS considered the start of care. Evaluation minutes
can be included in the MDS for Med B patients, but are excluded from Medicare A.
8. Whenever possible, a treatment session should occur on the day of the evaluation, in order for the
evaluating therapist to develop a realistic and accurate treatment plan for the patient.
Policy:
All patient/residents will have at least a bi-weekly assessment of their clinical and
functional status, short-term goal status and treatment plan while receiving restorative
therapy. Medicare Part B patients must have a progress note performed weekly.
Purpose: To ensure the patient/resident’s treatment plan is congruent with the patient/
resident’s needs, abilities and goals.
Procedure: 2
he therapist will evaluate the patient/resident’s progress, limitations and treatment
interventions/plan at least bi-weekly. This may be accomplished by the following:
A. Direct assessment of performance
B. Review of daily treatments
C. Team conference and interdisciplinary meetings
D. Therapist/Assistant meetings
2. The clinician grades the patient/resident’s performance in short-term goals on a bi-
weekly basis.
A. Performance is recorded under Short Term and when necessary, Long Term goals
B. Comments should be documented to support patient’s performance
C. Short-term goals are incremental steps towards long-term goals and must be
connected to a LTG. They also must be measurable.
D. Short-term goals may be clinical or functional
E. Short-term goals should be achieved in 2 to 4 weeks
3. The clinician will complete a narrative bi-weekly progress note which may include:
A. Daily treatments which states the number of treatments and
Cancellations, with explanation for missed treatments.
B. Short-term Goal Progress
C. Treatment Plan
D. Frequency is identified in anticipated visits for the following week. This should
be in compliance with the MD order. If the frequency is changed, then a new
order needs to be obtained
E. Recommendations- if the plan is to continue therapy, the therapist needs to
include WHY
4. Re-certification Note
A. Should reflect the patient/resident’s performance in short and long-term goals
B. The long-term goals should be functional and indicate the anticipated
functioning at time of discharge.
C. Treatment Plan/Justification for continued services.
Medicare B Documentation
Medicare B Documentation
A. Progress Notes: All documentation must be authored by a registered therapist. CoSignature
is not sufficient.
B. Treatment: If the assistant is the primary care provider, the registered therapist must
Treat the patient once every 5 visits.
C. Functional Limitation: A functional limitation (includes a G code and Severity Modifier)
Must be documented once every 10 visit. This also must include sufficient clinical
Reasoning
POLICY: 3
POLICY: Patients who have a need to be treated by two (2) therapists simultaneously, to improve
participation and achievement of functional goals, will be provided with therapy co-treatment.
Co treatment
PROCEDURE:
1. After evaluating a patient and establishing a treatment plan, the therapist may realize specific
treatment interventions and goals require co-treatments.
2. Co-treatments will generally be Interdisciplinary (i.e., OTR and SLP)
3. Prior to co-treatments, the therapist should:
Review interventions and goals addressed by each clinician during the treatment.
I.E., ® CVA Feeding Program-OTR may be facilitating trunk and head posture and utensil use,
while the SLP will be training in swallowing techniques and impulse control.
4. Review Billing procedure
billing part A and B cotreatment
For Part A patients, when two clinicians, each from a different discipline, treat one resident at the
same time (with different treatments), both disciplines may code the treatment session in full. All
policies regarding mode, modalities and student supervision must be followed. The decision to
co-treat should be made on a case by case basis and the need for co-treatment should be well
documented for each patient.
For Part B patients, Therapists, or therapy assistants, working together as a “team” to treat one or
more patients cannot each bill separately for the same or different service provided at the same
time to the same patient. CPT codes are used for billing the services of one therapist or therapy
assistant. The therapist cannot bill for his/her services and those of another therapist or a therapy
assistant, when both provide the same or different services, at the same time, to the same
patient(s). Where a physical and occupational therapist both provide services to one patient at the
same time, only one therapist can bill for the entire service or the PT and OT can divide the service
units. For example, a PT and an OT work together for 30 minutes with one patient on transfer
activities. The PT and OT could each bill one unit of 97530. Alternatively, the 2 units of 97530
could be billed by either the PT or the OT, but not both. Similarly, if two therapy assistants provide
services to the same patient at the same time, only the service of one therapy assistant can be
billed by the supervising therapist or the service units can be split between the two therapy
assistants and billed by the supervising therapist(s).
All Rehabilitation Program patients may be discharged based on the following criteria:
Patient achieved goals, and no longer requires program services to maintain or improve function.
Most patients are discharged from program to return to the community at a supervisory level.
Progress towards goals has reached a plateau.
Patients’ medical or psychological status makes them unable to participate in individual or group
treatment.
Patient becomes abusive to themselves or others.
Referring M.D. requests termination of services.
Patients or families request termination of services.
No patient may be discharged from therapy without prior approval from the Rehab Director.
PROCEDURE:
PROCEDURE:
1. Discharge planning is part of all treatment plans, and begins when the patient is accepted into a
program.
2. Throughout the patient’s program, the team/therapist review short/long-term goal status;
medical/psychological status; and personal/caregiver safety.
3. In preparation for discharge, determine if the patient would benefit from a maintenance program
or restorative nursing program on the unit. Establishing these programs IS a restorative service.
All training of caregivers, staff members and family members must be done prior to discharge
from services. This includes splints, orthotics, positioning devices, ambulation, range of motion,
etc. Any training should be documented in the therapy progress notes or discharge summary.
4. The therapist/case coordinator gathers discharge information through medical history, family
meetings, Team Conference Reports, Family Contact Notes, Therapeutic Evaluations;
Clinical/Functional Status Reports, Monthly Re-Certifications and discussions with the patient and
family.
5. If a patient is being DISCHARGED SECONDARY TO SAFETY OR COMPLIANCE ISSUES, the
therapist/case coordinators are required to inform the Rehab Director.
The Rehab Director will investigate compliance and safety concerns with the patient, team and/or
therapist, and assist in discharge planning.
The therapist/case coordinator will contact the referring M.D. and discuss discharge
reason/recommendations.
The therapist/case coordinator will meet with the patient (family, if available) to discuss discharge
recommendations.
Discharge services will be arranged base on the therapist, patient, family, and M.D. input.
M.D. orders will be obtained prior to discharge.
- If a patient DISCHARGES AGAINST TEAM ADVISE, then:
The case coordinator/therapist notifies the Rehab Director of the PATIENTS discharge intentions.
The case coordinator informs the referring M.D. and obtains input for discharge planning.
The therapist offers to assist the patient and/or family in obtaining services.
If patient refuses discharge planning, the case coordinator will offer assistance again within 72
hours. - PATIENTS DISCHARGED DUE TO PROGRAM COMPLETION
Are notified of discharge planning throughout their treatment, and given an updated discharge
date based on goal obtainment.
If possible, the patient and family are given seven (7) days notice prior to discharge.
A discharge family meeting with the patient, therapist and family are scheduled within two (2)
weeks of discharge - Acute Hospital discharge-
If patient is gone overnight than therapy needs new orders.
If patient is gone three (3) plus days, significant change in status or D/Ced according to facility
policy, then a new therapy evaluation order is needed.
