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Optimizing Reimbursement: Weekly tools and tips

Rehab Regs, June 27, 2008

Mastering proper ongoing therapy documentation, including daily notes and progress reports, will help you support the medical necessity of therapy interventions and reduce denials.

The final part of the daily note is documentation of the therapist’s plan for continued intervention with the patient. Most often, therapists write in this section of the note to “continue the current plan.” However, notice that in the PT daily note, there is a check box to indicate to change the treatment, with a reference to the comments sections, where it indicates that the therapist will add unilateral static and dynamic exercises. Items that might fall under this section include:
• Referral to another healthcare professional, such as an OT
• Minor changes in the treatment plan
• Referral to an outside community agency
• Scheduling of a family conference

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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