Documentation Revitalized: Maximize Reimbursement with Tips for Skilled Therapy, Daily Notes, and Defensible Documentation

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Objectives

1. Justify & document the complexity of your PT or OT skills in such a manner that supports the necessity of your treatment plans. 
2. Develop daily notes that address limitations and their impact on function, complexity of interventions, and state the clinical reasoning for interventions. 
3. Select appropriate data to formulate SMART goals. 
4. Create clinical documentation that demonstrates reasonable and necessary care that is skilled and valuable.
5. Analyze data to update plan of care, set functional and realistic goals, document treatment effectively and update progress to maximize reimbursement.
6. Distinguish effective documentation under the existing standards of Medical Necessity, effectively demonstrating that it requires the SKILLS of a therapist.

Outline

DOCUMENTING SKILLED THERAPY & THE DAILY NOTE

Identify Your Role and Scope of Practice in the Delivery of Services and Documentation

• Demonstrate skill, necessity, and value
• What’s trending in today’s healthcare settings
• The EMR factor
• If it’s not documented, it hasn’t been done
• Investigate reasons for denial
• Establishing roles - therapist or caregiver?

Prior Level of Function

• Set the stage “once upon a time”
• Fundamental components to justify services
• Supportive language for medical necessity

Identify and Write Obtainable Patient Goals

• Select the best plan of care to achieve patient progressions
• Comparison to the goals
• Tackling progress notes
• Treatment selection and effectiveness
• When to make modifications

Clinical and Documentation Expectations

• Purpose of documentation
• Key aspects and common pitfalls
• Select activities and services that are reasonable, necessary and valuable
• Specific expectations and documentation requirements (for inpatient rehab, SNF, home care, outpatient)
• Write effective and accurate progress reports third party payers understand

Create Defensible Documentation

• Provide appropriate documentation of skilled necessity of care
• How to ensure coverage for all payers
• Demonstrate reasonable and necessary/skilled services
• Importance of functional outcomes and requirements

Components of Quality Documentation

• Purpose and expectations
• Body structure, activity limitations, and participation
• Identify patient problems –subjective
• Measure and treat problems – objective
• Assess progress, changes, and recommendations – assessment
• Develop future care – plan

Target Audience

• Physical Therapists
• Physical Therapist Assistants
• Occupational Therapists
• Occupational Therapy Assistants
• Speech Language Pathologists