OASIS Alert

Published on Tue May 09, 2006 PDF

Protect yourself as the feds turn up the heat on high-therapy use.

When M0825 shows the patient meets the high-therapy use threshold, your therapists' documentation is the key to getting the payment you earned.

Especially important: When physical therapists and occupational therapists are participating in the same case, document how their services are different and don't duplicate each other, says PT Cindy Krafft, director of rehabilitation for Peoria, IL-based OSF Home Care. "Our approach is PT gets them up, gets them moving and works on general strengthening and OT helps them figure out what to do with it," she explains.

Krafft offers these documentation tips:

1. Ask "what is the skilled need?" Then be sure each therapist documents the skilled services provided and the quantifiable progress the patient is making on each visit.

2. Individualize your visit patterns. If you consistently plan for three PT visits for three weeks (3 wk 3), it will be harder to justify medical necessity.

3. Be careful in transitioning to point of care. Clinicians will be in the habit of relying on cues and triggers in paper documentation that may not be available in computer documentation. For example, paper charting may include forms that ask about crucial items a therapist should include in the visit note. If that blank spot isn't there to remind the clinician, she may forget.

4. Provide a monthly "Tip Sheet." Focus each month on a different documentation problem area. For example, you can explain how to write goals or what "independent" really means. Then provide these sheets to clinicians and chart auditors to encourage systematic improvement. 
 
5. Appeal to professionalism. Remind clinicians that appropriate documentation is part of providing skilled care. Make your expectation clear and hold them to it.

Note: For more on successfully using therapy in home care, sign up for Cindy Krafft's June 13 teleconference "Turn Negative Per-ceptions of M0825 into Positive Treatment Plans" by calling 1-800-508-2583.