The Art of Writing Supportive Therapy Notes to prevent Medicare Denials
Denial trending nationally has evidenced that Medical Reviews are focusing on higher functioning patients and conversely, they are also focusing on lower functioning patients. Reviews prone to denial have been noted on patients with documented behaviors or cognitive barriers, which may be perceived as appropriate for restorative nursing management. This type of claim requires documentation to support deficits, potential for further gains and skilled interventions provided. It is critical that documentation of skilled therapy interventions to manage specific deficits be reflected in the therapy documentation. Documentation should establish deficits requiring skilled therapy intervention and through objective measurements clearly state that the patient is making progress toward goals. Frequently Kris B Harmony's chart audits identify rehab documentation of the high level patients and low level patients that does not consistently reflect the need for continued skilled rehabilitation services, progress or functional outcomes.
Weekly progress notes must detail progress towards goals and specify individualized skilled interventions. Kris B Harmony recommends the following format for each weekly therapy progress note:
Current status for each stated goal. Ensure ongoing deficits are detailed.
Specific progress toward each goal. Ensure specific gains within levels of care are documented if a patient does not increase in functional level.
Detailed patient individualized skilled interventions provided (e.g. modalities, progressive exercise and activities, trials of devices and techniques, teaching and training).
Assessments and changes to the treatment plan (e.g. with set-back or new discharge plan to re-establish goals).
Continued need for skilled therapy interventions (consider specific needs to reach discharge goal, risks without skilled interventions and ongoing deficits).
Avoid subjective statements of progress ("no gains").
Kris B Harmony recommends detailed review of therapy documentation for patients continuing at a Rehab Ultra High level after 30 days to ensure that documentation reflects the skilled levels of care provided.
Kris B Harmony can provide facilities with additional information on this topic.