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Eli's Rehab Report

Industry Notes:

Reduce Denials Due To Insufficient Documentation

There’s help from Medicare forthcoming on documentation tips. 8 MACs, including Cahaba Government Benefit Administrators, CGS Administrators, National Government Services, Noridian Healthcare Solutions, Novitas Solutions, Palmetto GBA, or Wisconsin Physicians Service Corporation, have made up a task force to create a PDF that gives pointers on what therapists need to watch out for while preparing a plan of care. 

This PDF is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf.

Additionally, these MACs also released a second document, titled “Task Force Scenario: Documenting therapy and rehabilitative services,” which gives tips like:

  • Ensure the medical records provide proof the service was certified and rendered.
  • Ensure the medical records provide justification for medical necessity and need for skilled services.
  • Create a complete plan of care that includes signatures, professional designation, and date.
  • Document when the plan of care is modified and why, including an explanation of why previous goals were not or could not be met.
  • Confirm that the plan of care is certified appropriately with the physician or non-physician practitioner.
  • Clearly document, in minutes, the total time spent on timed-code treatment only and the total treatment time in the patient’s record.

There is help to be had from the APTA Center for Integrity in Practice website too. Check out: http://integrity.apta.org.

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