OASIS Alert

Use these strategies to document for success.

Just showing progress does not prove medical necessity. Show the skills you used.

The HHS Office of Inspector General will continue to require intermediaries to focus on documentation to support the therapy provided in the home, said physical therapist Cindy Krafft, Peoria, Ill.-based consultant with Fazzi Associates. You must be able to defend each therapy visit as reasonable and necessary, she told attendees listening to a recent Eli-sponsored audioconference Survive Your Audits: Therapy Documentation Issues for 2009.

Pay attention to utilization, Krafft warns. Compare your therapy use to that of peers, because the Centers for Medicare & Medicaid Services certainly will. If your agency looks different, be extra sure your documentation is stellar, she says.

Every Visit Must Stand Alone

Remember that medical reviewers from any discipline must be able to get the full picture from your notes, Krafft warned. Don’t assume a therapist will read the record.

Each visit note must include detailed information about what the patient did, what the therapist did, and how the patient responded to what the therapist did, Krafft said.

The assessment must clearly show the patient’s previous functional status to set the stage for your goals. Goals must be measurable and focus on why you want the patient to achieve the goal. For example, “Patient will have better balance to decrease risk of falls.” And documentation must show the therapist provided skilled service.

Bottom line: Goals must match the assessment and visit notes must fit with both of these.

‘Reasonable And Necessary’Hasn’t Changed

When M0826 asks you “what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-pathology visits combined),” pay attention to the wording, Krafft said. Focus on what this specific patient’s needs for therapy are and be sure you can defend your answer as reasonable and necessary. These words provide the most frequently cited reason for denials. You need toshow what is important about your care and “what you did that the caregiver or the neighbor down the street could not do,” she emphasized.

Among the many detailed strategies Krafft recommended are:

1. Focus notes on the therapist rather than on the patient. It’s common to see notes that say what the patient did or what the patient worked on. But to understand why a visit was reasonable and necessary, the reader must be able to see what the clinician saw and what interventions the clinician made. This shows the skilled service.

Example: Include measures of the percentageof time the patient needed cues from the therapist or the instructions on technique the therapist provided.

2. Use the term “independent” very cautiously.When a therapist uses the word “independent” it has a specific clinical meaning: The patient was safe, efficient, and effective in doing a certain task and doesn’t require intervention with that task. “If you call something independent and then go back and work on it some more, you are asking for a denial,” Krafft advised.

Mistake: Just because a patient has no one to help him with an activity, it does not mean he is independent. “Say ‘he bathes when no one is here’ rather than ‘he bathes independently,’” she illustrated.

3. Be careful of orders to extend therapy. When you are adding more visits, be sure there is a clear reason and that you include it in the record. Otherwise the reviewer will think it was just to reach a visit threshold for higher payment.