Tip of the week
Rehab Regs, August 22, 2008
Preventing denials due to insufficient information requires efforts on two separate fronts. First, the person copying the medical records to be sent to the Fiscal Intermediary or carrier must be aware of what documentation he or she should send.
Second, you should ask yourself the following questions to determine whether your documentation will support services billed:
• Is there daily documentation present to support each modality and procedure billed for?
• Does my daily documentation reflect the deficits treated?
• Does my documentation contain objective tests and measures that can be used to reliably chart progress toward the patient’s goals?
• Does my documentation demonstrate different approaches of treatment when progress appeared to plateau?
• Does my documentation mention any medical complications or effects from the patient’s comorbidities that may have affected the patient’s progress toward his or her goals?
This tip is from HCPro’s Pocket Guide to Therapy Documentation.
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