Are your therapists including all the crucial criteria?
To hold onto your therapy dollars, you’d better make sure your patients’ records support the services you furnish.
According to a recently revised Local Coverage Determination from HHH Medicare Administrative Contractor Palmetto GBA, here are the elements your therapy evaluations and reevaluations must contain:
1. Reason for referral
2. Diagnosis/condition being treated
3. Past level of function (be specific)
4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress
5. Current level of function
6. Objective measurements such as strength, ROM, pain, ADL level, or edema
7. Treatment techniques/modalities selected for treating current illness or injury
8. Limitations which may influence the length of treatment
9. Short and long term goals stated in objective measurable terms, and their expected date of accomplishment
10. Frequency and duration of therapy
11. Re-assessments must be performed at least every 30 days by a qualified physical therapist. The 30 day clock begins with the first therapy’s visit/assessment/measurement/documentation (of the physical therapist).