Eli's Rehab Report

Use this gait training example as a model.

So your SNF has decided to go with rehab therapy instead of restorative care. If that’s the case, your rehab team should make sure it asks this pivotal question: Does the therapy documentation support skilled services? If not, your payer — and auditors — might decide that restorative was more appropriate.

It’s all too easy for a payer to reject legitimate treatment because of poor documentation. Therapy documentation tends to include objective data about the resident and functional outcomes but often lacks information about the skilled therapy interventions that allowed the resident to achieve the objectives. And that can be a problem when reviewers try to connect the dots.

Bad example: A common documentation entry might read, “‘Patient ambulated 50 feet … Patient ambulated 75 feet,’ etc.,” says Pauline M. Franko, PT, CEEAA, owner Encompass Consulting & Education, LLC in Tamarac, FL. But “to Medicare, that constitutes repetition and doesn’t need the skills of a therapist.”

Instead: Document determinations about the patient’s gait disturbance and other problems requiring skilled intervention, Franko suggests. “The therapist has to establish and document the person’s weight-bearing status, balance, and ability to weight shift, etc.”

For the gait training example, important details to include might be that in the swing-through phase, the patient is getting a hip hike rather than a swing-through, or has a flat-foot weight bearing stance instead of a heel-toe push off, Franko says.

In terms of intervention, a nursing aide could make the statement that a “patient ambulated 100 feet with minimal assistance using rolling walker.” But therapy documentation that shows a level of complexity specific to a skilled professional might include, “Patient performed gait training with rolling walker for 100 feet with minimal assistance for weight shifting to facilitate right lower extremity clearance during swing phase.”