New Final Rule FY 2012 Therapy Documentation Requirements

In the Final Rule FY2012, CMS provided clarification on therapy documentation and expectations in regards to changes in therapy treatment plans.  Harmony recommends facilities are vigilant when documenting on patients that have a change in intensity resulting in increased reimbursement for the facility.  Changes to the mode and/or intensity of therapy must be justified by the changes in the beneficiary's underlying health condition.  In order to demonstrate that such changes are medically necessary, the provider should clearly describe in the plan of care the reasons for deviating from the original plan.  The following statements are examples of documentation that would assist in justifying an increase in therapy intensity:

• Coordination of patient's pain medication and Physical Therapy treatment times has enabled the patient to tolerate BID sessions versus QD. 
• Patient is showing decreased signs and symptoms of depression now that she has regained the ability to ambulate a few steps.  Improved motivation with desire to participate in more therapy in an effort to return home.
• Patient had a follow up orthopedic appointment resulting in increased weight bearing status.  Patient's treatment program has been expanded to include stair training in preparation to return home to a 2-level home. 
• Respiratory status has improved, patient is now able to tolerate increased exercise and length of treatment sessions without complaints of shortness of breath or fatigue.

Telling the story of the patient from medical and functional perspective will support the need for daily skilled care as well as meet the practical matter criteria that the patient could only have received care at the SNF level. Supportive skilled documentation involves education regarding skilled care criteria and practice. Training should be provided on an ongoing basis for both nursing and therapy team members.