Resource Tool: Visit Note Checklist
References: Guide to PT Practice, 3rd Edition
Recording Available With Purchase
Cost - $129
Defensible documentation to ensure medical necessity and the skilled need of a therapist remains one of the top denial reasons when home health medical records are audited by fiscal intermediaries as well as Recovery Audit Contractors (RACs). The Centers for Medicare & Medicaid (CMS) has made it clear that documentation to ensure reimbursement for skilled services under the Medicare Home Health Part A benefit is the responsibility of the clinician, providing regulatory guidance to assist therapists in meeting coverage criteria for payment. Professional bodies, such as the American Physical Therapy Association (APTA), have clear standards related to documentation by licensed therapists in all settings where care is provided. These standards have recently been updated in the Guide to Physical Therapy Practice, 3rd Edition, incorporating the International Classification of Function (ICF) model as a platform to support utilization parameters. Unfortunately, therapists continue to have difficulty when documenting commonly provided services, such as progressive gait training interventions.
This webinar will provide participants with the GO TO resource for home care therapists and assistants in documenting gait impairments and skilled interventions defensibly. This will ensure that clinicians will meet professional and industry standards rather than personal or industry “expert” recommendations. In addition to this, all participants will receive a Visit Note Checklist for the home health clinician to use as a documentation guide. Additionally, auditors of therapy documentation can enhance current processes by incorporating this checklist into their reviews.
Upon completion of this webinar course, participants will be able to:
1. Define what “skilled, reasonable and necessary” means for coverage of therapy services under the Medicare Part A Home Health benefit.
2. Identify key elements of objective documentation of gait impairments for both restorative and maintenance patients in the home health setting.
3. Identify key elements of defensible documentation of gait interventions for both restorative and maintenance patients in the home health setting.
4. Write thorough and accurate assessment component of visit notes for patients receiving gait interventions.
Target Audience: Clinical Supervisors, Nurses, Physical Therapists, Occupational Therapists, Speech-Language Pathologists
Posted by Steve Peterson on 7th Oct 2015
I am the regional manager(OT) for HH agencies in the western US and I have been working very carefully on claim review from 3 intermediaries. I have found the following: 10 visits or more are up for 'random' review- combination of all disciplines. On reconsideration level of the review, household distances as a cut off is used a lot. It does make me respond with let's look at distance as the enemy. I find that rather than fight for increased distances, I have asked the therapists to document gait quality within a specified distance. Example: Pt will demonstrate normalized gait pattern without observable (+) L Trendenburg, heelstrike at initial contact, and terminal knee extension through stance phase 100% of 5/5 trials for distances >/=150' for improved safety in ambulation within the home environment.
I love the conference you have provided- it is a reminder for some, an upgrade for others about where their skill lies. In documenting that skill, I have often had them write goals that include their eduction efforts. For example: Pt. will progress from swing to gait to swing through gait using front wheel walker throughout the home following 3 instructed techniques without cues 3/3 sessions within 4 wks.
Pt. will perform mobility throughout the home following 4 instructed techniques with no loss in balance including transitions over thresholds, in/out of the bathroom including turns using single point cane 5/5 sessions within 4 wks.
I would share your webinars with every therapist in our company except for the 1000' goals- despite trying to justify their need.
I think along these lines- if the number of reviews are going to go up, I'd rather avoid trigger items altogether. I am still going to have to fight for claim payment- I'd rather fight on the skilled terms than have a gait distance that is harder to justify.