Harmony Healthcare Blog

Part B Therapy Documentation

Posted by The Harmony Team on Fri, Mar 18, 2011

Proactive Approaches to Avoid Claim Denials 


Therapy Documentation/Medicare Part B: The need for comprehensive documentation is essential for reimbursement and to ensure insulation of billed revenue. Harmony has created a list of the key components to support medical necessity of skilled therapy intervention:

  1. Define the need for services that require the skills of a therapist and indicate why the services are needed.
  1. Create a treatment plan that specifies the amount, frequency and duration of treatment consistent with the nature, extent and severity of the illness or injury. Justify the specified intensity of treatment. The patient's medical needs must be considered and the therapy services must meet accepted standards of medical practice as specific and effective treatment for the patient's condition.
  1. Identify the recent change of condition required to warrant an evaluation.  It is important for the treatment, med nurse and/or CNA's to communicate any signs of decline to the nursing staff who in turn should document changes supporting the implementation of therapy services and update changes on the patient's care plan.
  1. Identify the most recent prior level of function (prior to the onset of the episode) and current level of function with objective measurements. Indicate the relationship between the current and prior level of function. Harmony recommends an area to define the prior level of function on a Medicare Part B therapy evaluation.
  1. Define the positive expectation of the patient's potential for improvement in function. Example: The resident has excellent potential to return to his prior level of function due to his ability to follow simple and complex commands, has appropriate attention for completing tasks, and demonstrates good motivation and cooperation during evaluation.
  1. Identify medical diagnosis and resulting rehabilitation diagnosis related to the patient's condition.
  1. Identify the reason for referral. Nursing notes should support the functional limitations identified as the reason for the referral.

Example: From the initial evaluation, the occupational therapist has identified that the resident requires minimal assistance and verbal cues to dress his lower body and his goal is to dress independently to allow his return home without assistance. The long-term goal is for the resident to dress independently in two weeks, however the nurses report that the resident is dependent with dressing and does not participate with dressing tasks. This problem can occur when there is a lack of communication between the therapy and nursing staff. It may require that the occupational therapist provide training to the staff members on proper cueing or sequencing techniques that work well with this resident to allow all staff members to encourage this patient to work towards his goal of independent dressing.


8. Set functional goals

Necessary components of functional goals:

a. Related to a functional activity that is measurable.

b. Must have a qualifier to define when the goal is met.

c. Must be patient centered/patient oriented.

d. Needs to answer who will do what with how much assistance and

why is it important? 


Example: The patient will ambulate 100 feet with a front-wheeled walker independently in two weeks to allow safe gait to the dining room in the facility.


9. Assess whether the resident has made significant improvement (document in the progress notes). Progress notes should be completed minimally every 10 treatments. Progress notes should contain information regarding:  Functional goals; evidence of skilled service; and changes in levels of independence.


Treatment notes should include evidence of skilled service and the patient's response to the treatment. Progress notes should contain all the above as well as comparative data to support gains.


Examples of significant improvement:


a. A change or progression in reducing the level of assistance  required to perform functional tasks.

b. A change in the type of functional activities the patient can perform.

c. A change in the type of assistive device used.

d. Improvement in ratings of reported pain levels and changes in the ability to perform tasks given the reduction of pain.

e. A change or progression of tasks to reflect less intervention by the therapist.

f. Other considerations include gains in strength, ROM, activity tolerance, communication or swallowing abilities with appropriate functional outcomes.

g. Compensations learned or adaptations made that increase the patient's functional level.


10. Evaluate whether other individuals providing care to the resident can see the patient's progress or the impact of the therapy services. If differences or variations in documentation occur, (i.e., between therapy and nursing notes) explain the reason for the differences. Education with nursing staff on specific therapy techniques may be indicated, as well as the establishment of a functional maintenance program when appropriate.

Part B Therapy Documentation

Topics: Part B Therapy Documentation

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