MDS Alert

Published on Tue Jul 24, 2007 PDF

Answer these questions to see if your Part A claims are on solid footing.

True or false? The therapist has to write a weekly progress note for a Part A-stay resident.

If you think that's a tricky question, you're right. Under Part A, Medicare doesn't give specific guidelines for documentation as they do under Part B, says Pauline Franko, PT, principal of Encompass Education in Tamarc, FL.

It's always been a standard of practice, however, that therapists do a weekly progress note, she says. To see if your therapy documentation makes the grade, answer these two additional key questions.

1. Does the weekly note spell out the resident's progress? For example, the documentation might state, "The patient is now able to produce toe touch weight-bearing status for 10 feet with minimal assist for balance or produce a walk through gait instead of a walk to gait," suggests Franko.

By contrast, the therapist's daily note would show what the therapist is working on with the resident, such as gait training, transfer training, etc., Franko says.

The note should also explain why a resident isn't progressing as expected that week, advises Shehla Rooney, PT, principal, Premier Therapy Solutions in Cookeville, TN.  "The onus is on the therapist" to do that, she emphasizes. "For example, did the resident suffer onset of an UTI, pneumonia, delirium, etc.?"

2. Does the documentation justify the level and intensity of therapy services? That's especially important when treating a resident for conditions that wouldn't necessarily warrant a high level of therapy. For example, Rooney has had patients with terminal diagnoses who receive intensive therapy services because the person wants to become as independent as possible to go home and be with a disabled spouse.

Patients who require monitoring and rest during therapy sessions may also end up in a higher rehab RUG. Again, documentation is key to justify the extra therapy minutes. An example would include a patient with end-stage congestive heart failure requiring vital sign monitoring before, during and after therapy -- and rest periods during therapy sessions, says Rooney.

Document this carefully: "Medicare wants to see documentation as to why someone with dementia" is receiving therapy, adds Katy O'Connor, MS, PT, a consultant with Zimmet Healthcare Services Group in Morganville, NJ.

You can keep the person on therapy as long as he's making functional gains, she adds.