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Outpatient Physical and Occupational Therapy Documentation: Keep the Money after the Audit

In a recent article we discussed creating a Denial Prevention and Management Plan. The quality of your documentation has a role in that plan. Have you set up your documentation templates to address the following questions?

Display the skill required to support medical necessity?

We all know the old adage, “if you didn’t document it, you didn’t do it.” But we must go one step further in therapy services. We must consistently attend to why it takes a licensed therapist to provide the services. If the therapists documents, “Patient had difficulty getting out of chair and standing,” that could have been written by anyone who had just watched an elderly person attempting to stand. Instead, the therapists should denote something like, “provided transfer training from sit to stand position to improve safety of transfers.” The major difference here is, in the second example, the therapist denotes the need for his/her skill and also the ‘why’. Why did the therapist provide the transfer training? To improve safety. Now we are supporting medical necessity.

Contain all of the required elements in the referral? 

Whether paper or electronic, the referral should include the patient’s name, date, diagnosis, discipline (PT/OT/SLP) and signature of the provider.

Address prior functional status in the evaluation? 

When an auditor reviews a chart to make decisions about taking money back, he/she should be able to clearly see what the patient’s functional status was prior to the injury or illness. If the therapist begins with, “patient presents with ABC functional deficits, but does not give a reference point prior to the date of the injury or illness, the entire episode of care could be at risk.

Capture functional goals in the evaluation?

Outpatient therapy is about improving function. In the plan of care, make sure the therapists are addressing functional goals. The generic goals of improving strength, endurance, etc. without relating them to a reasonable functional goal do not meet the requirements.

Address those functional goals periodically in the daily notes or progress notes? 

Now that the therapists are denoting functional goals in the evaluation, don’t let them abandon them. Periodically, note how the patient is progressing toward the goals.

Capture all skilled minutes in the daily note so that an auditor could equate the service provided with the service billed? 

The minimum requirement is the capture of all skilled minutes for timed CPT codes and all skilled minutes for untimed CPT codes. Why not keep the auditor from guessing and address the specific minutes for each CPT Code?
These are just a few of the elements that you must pay attention to withstand the scrutiny of an audit. Do you have a sound internal audit process/tool that will put you in good standing when the auditor comes? Let us help you develop a process and tool to prevent you from looking at penalties and paybacks!

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Blue & Co.’s Outpatient Therapy Business Advisory Services provides both Assessment and Implementation Guidance to help hospitals understand their revenue and growth opportunities and facilitate changes in processes and behaviors to achieve them. These engagements are not about FTE reduction.
Contact John Britt or your local Blue & Co. Advisor to learn more about Outpatient Therapy Documentation.
John Britt, Senior Manager

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