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Optimizing Reimbursement: Weekly tips and tools

Rehab Regs, November 14, 2008

Therapy documentation develops the patient’s story and justifies the need for therapy. In addition to the patient evaluation and the plan of care (POC), ongoing documentation supports the medical necessity of therapy interventions. 

The assessment is the section where the therapist documents details, including the
• Patient progression in therapy
• Reason why skilled therapy services are still required
• Changes or updates to the patient goals
• Response to treatment received

Avoid writing “tolerated treatment well.” This comment doesn’t tell the medical reviewer how the patient is progressing toward his or her short- and long-term goals. The medical reviewer may read “tolerated well’ and interpret it to mean that the patient no longer requires skilled therapy services, or that the patient was a passive participant in the therapy session.

This tip for optimal reimbursement is from HCPro’s book The How-To Manual for Rehab Documentation: A Complete Guide to Increasing Reimbursement and Reducing Denials.

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