Eli's Rehab Report
Your Reimbursement Could Hinge On Capturing These 11 Therapy Elements Consistently
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Ensure patient’s records support services furnished.
Build a template ensuring that your therapists are routinely documenting the essential elements without which your claims are likely to be shot down.
According to a recently revised Local Coverage Determination from Home Health & Hospice Medicare Administrative Contractor Palmetto GBA, here are the elements your therapy evaluations and reevaluations must contain:
1. Reason for referral.
2. Diagnosis/condition being treated.
3. Past level of function (be specific).
4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress.
5. Current level of function.
6. Objective measurements such as strength, ROM, pain, ADL level, or edema.
7. Treatment techniques/modalities selected for treating current illness or injury.
8. Limitations that may influence the length of treatment.
9. Short- and long-term goals stated in objective measurable terms, and their expected date of accomplishment.
10. Frequency and duration of therapy.
11. Re-assessments must be performed at least every 30 days by a qualified physical therapist. The 30-day clock begins with the first therapy’s visit/assessment/measurement/documentation (of the physical therapist).
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