Home Health Coding and OASIS Expert

Published on Fri Oct 16, 2015 PDF

Check your therapists’ documentation against this MAC’s requirements.

If you hope to safeguard your therapy claims, your documentation must 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).

Note: The other two HHH MACs, National Government Services and CGS, do not have LCDs for home health therapy.